On a daily basis, the few questions I get asked more often than “How old are you?” or “How long have you been doing this?” are, “Should I get a steroid injection?” or more frequently, “Why did the steroid injections not help with my ____ pain?” The utilization of corticosteroid injections for musculoskeletal pain management dates back to the 1950s, but recent research reveals that negative effects to surrounding tissues outweigh the trivial benefits. In the clinic, most people are aware of this pain management option and many have first hand experience. However, it is less common that consumers understand how injections work, adverse effects associated with injections, and more importantly, what is efficient at resolving their pain. The goal of this entry is to provide current research to equip health consumers with the knowledge necessary to make confident, informed decisions about their treatment options.
In the literature, steroid injections are documented to treat a broad array of painful conditions: joint pain associated with arthritis, soft tissue pain (muscles, bursas, tendons, and ligaments), and nerve pain like carpal tunnel syndrome (Brinks et al. 2010). Injections are used for a large range of conditions because they serve one purpose: to attempt short term pain reduction via anti-inflammatory processes and immunosuppressive properties at the cellular level (Pekarek et al. 2011). In other words, injections temporarily halt inflammation, which is the first phase of normal tissue healing similar to how band-aids reduce bleeding. Unfortunately, injections do not address the cause or reasons for re-occurring inflammation. Patients typically notice a greater pain reduction, if any, with an initial injection followed by diminishing returns with subsequent encounters. Literature shows that injections have little or no effect on mitigating pain in chronic conditions. This often leads to frustration because injections are frequently administered after a condition has already become chronic (symptoms for 3 months or longer). Unlike band-aids, injections stimulate tissue breakdown with the gamble of having no effect on pain, or even worse, increased pain or sooner surgical procedure. Therefore, corticosteroid injections should only be cautiously considered for pain control during acute conditions (Mittal et al. 2018).
Injections actually cause further damage to the very tissues they are expected to treat. Specifically, a systematic review identified adverse events of extra-articular (outside the joint) corticosteroid injections ranging from minor to fatal infections, numerous tendon ruptures, and local skin and fat pad atrophy (Brinks et al. 2010). A single injection directly into a ligament results in reduced tensile strength for up to a year post injection (Pekarek et al. 2011). Similar findings are evident in cartilage tissue with intra-articular (inside joint) injections. A recent study compared intra-articular corticosteroid injections versus a placebo solution in 140 patients suffering from knee osteoarthritis over 2 years. This study examined the effects on pain and cartilage health measured by MRI. The results were alarming. No significant difference in knee pain ratings between the groups were identified and the corticosteroid group had significantly greater cartilage loss - a sign of progressing osteoarthritis and the very reason people seek injections (Mittal et al 2018). Corticosteroid injections made these patients worse! Clinically, I find that patients get injections to avoid pain and/or surgery, despite the evidence stating the exact opposite.
There needs to be a paradigm shift. Corticosteroid injections should never be a first line of defense to pain and certainly not a “lets just see if it helps” option. There are numerous studies illustrating that exercise alone is superior to injections. Many even prove exercise alone to be equal, if not better, than injections combined with exercise for managing musculoskeletal pain. So why are steroid injection still commonly used for pain management? A meta-analysis by Mohamadi et al. proposed, “their wide use may be attributable to habit, under-appreciation of the placebo effect, incentive to satisfy rather than discuss a patient’s drive toward physical intervention, or for remuneration, rather than their utility (2016).”
Musculoskeletal pain that gradually develops is associated with poor, repetitive movement patterns that apply abnormal stress to muscle, tendon, ligament and cartilage tissues. This is the root cause of reoccurring inflammation and pain. Just as band-aides would never heal a scrape if the scab were repetitively scratched off, injections will not heal tissues in the body if the faulty movement pattern is not corrected. Don’t expect an injection to heal a movement impairment. Stop insulting your tissues, learn to move efficiently, and let the tissues heal.
Here at Austin Manual Therapy, we specialize in soft tissue/joint mobility, specific exercise for tissue healing, and restore efficient movement patterns for a lifetime of reduced pain. If you or someone you know is struggling with pain, work with one of our experienced therapist to stop the tissue bleeding and get you moving in the right direction.
Patellofemoral Pain Syndrome (PFPS)
Patellofemoral Pain Syndrome (PFPS) is a generic term ascribed to vague, and often-times fluctuating, anterior (front side) knee pain. PFPS affects athletes and non-athletes, alike, and can feel like a pretty severe knee ache, like a bruise. It often affects runners and cyclists, but can also affect people whose occupation or lifestyle requires repetitive movements like bending, climbing up and down stairs, sitting and standing repeatedly, or walking over uneven ground.
The onset of the pain is often sneaky, without warning, and progresses gradually with steadily inconsistent pain levels. It can happen without any obvious faulty movement with which to determine the cause of pain. The indeterminate nature of the injury is usually the most difficult to understand, mainly because the dysfunction is a result of repetitive micro-trauma caused by the same movement patterns, even when there was no pain initially.
Over the years, I have heard an old adage that I cannot trace back to a specific resource, but which most clearly reveals why we hurt. “It has been said that we move ‘funny’ because we ‘hurt’, but we really ‘hurt’ because we move ‘funny’.” In fact, in the instance of PFPS, the cause of the knee pain is usually related to poor hip and/or foot control, and the lack of control unfortunately exposes the knee to unmitigated micro-trauma and pain.
Right knee, front view
As you can see from the anatomical image, the positioning of the patella in front of the femur is dependent on what happens with the orientation of the patellar tendinous attachments. The patella is encapsulated in the tendon, and is held in position by the fit of the bony groove on the bottom/front part of the femur (the patella is not ‘attached’ to the femur), and is held in place with fixed tendon attachments. These attachments “pull” in a straight line, expecting the femur and the tibia to remain in their most efficient orientation.
Any positional deviation of the femur or tibia will result in the patella being pulled against the walls of the groove. Enough repetition, especially with the legs, will result in cumulative trauma to the patellofemoral joint surfaces. So, for anyone faced with this condition, there are multiple types of medical and functional interventions for consumers to sift through. There are surgical options, the use of kiniseo-tape is another popular trend, and deep tissue devices (rolls, balls, and Graston instruments) may help manage the symptoms.
While these passive approaches to symptom management are popular, the relief is only temporary. The dysfunction is related to faulty movement, so corrected movement is the most reliable method to ensure pain relief. In fact, the research conducted over the years, shows that the best outcomes occur following the combined use of joint and tissue mobilization/manipulation with specific, graded exercise.
Our skill set at Austin Manual Therapy is precisely supported by research. Before you invest in hundreds of dollars in these unproven modalities and devices, come see us at Austin Manual Therapy. We are the experts at movement analysis and correction. Let us show you how we can help you live a more pain-free life.
Contact us at (512)832-9411, or through our website, to schedule an evaluation so we can address your needs right away. Your knees will thank you.
Harris, PT, DPT, OCS, FAAOMPT
Ah 2018, we will miss you! You were fun, stressful, exciting, scary and all of the other adjectives wrapped into 365 days of pure madness! Alas you are gone and a New Year is here! And with that comes new opportunities to grow and change. Most of us use the beginning of the year to reset and reflect. That includes reflecting on our health. The holidays can be brutal on the waistline and on our bodies in general. Just think about it. Once Halloween hits, it’s non stop until after the ball drops on the 1st of January. Traveling, taking kiddos to their extracurricular functions, attending company parties, etc… It’s all so much. It can wear on you can’t it? Of course it can, both physically and mentally.
Take a look at this infographic borrowed from Jeremy Lewis, Consultant physiotherapist at the London Shoulder Clinic.
We will always advocate for some form of exercise for our patients because of the great benefits of taking care of your body and mind. But caution yourselves. The new year is replete with newly signed members to gyms across America that only last up until February 14th (chocolates and champagne can really throw it all off). Doing too much too soon can lead to injury and that’s why we are here; to help guide you in your newfound journey of exercise for the new year (and the next one, the one after that… you get the gist).
So what are your goals for this new year? Hopefully EXERCISE is at the top of the list but remember a few key points going into it:
- Start off SLOW - There is no rush. Take your time to do it right the first time. Teach your body the proper way to do certain things and you could save yourself some agony on the back end.
- Stay Consistent - This is one of the hardest ones but NO EXER-CUSES! The results will pay off you just have to be patient. Rome wasn’t built in a day.
- You Aren’t 21 Anymore (Unless you truly are 21) - Think functional use when you put your body through the paces. Starting your new journey at 40 years of age with a 20 year old mindset may not yield the results you want.
- You Can Still Work Out When You Are Injured - We can help you manage your signs and symptoms while still working towards your goals.
- Keep Your Goals and Expectations Reasonable - This way you aren’t hung up on something unattainable. Instead of trying to hit home runs all of the time, go hit some doubles or triples! The ultimate goal is to WIN THE GAME!
- Trust Your Therapist - We are the Experts in the field! We understand and continue to learn more about optimizing human movement and performance, as well as pain science. And YOUR health and well being are the reason we are fully committed to this profession. This will be a TEAM effort and you would probably want the best teammates on your side. Remember, the ultimate goal is to WIN THE GAME!
This year will be EPIC! Kick it off the right way. If you have any questions, ask us. If you feel like you need some help with mobility issues or if you are having pain that is scaring you from wanting to try any exercise program, call us. We will be a valuable asset on your healthcare team.
HAPPY NEW YEAR 2019!!!
Sarah: Ah, the holidays. A time for family, festivities, and...insurance resets? Looking through different terms and dollar amounts can be overwhelming, especially with the jargon involved. One of the services we provide at AMTA is a benefits check for each patient before they come in for their first appointment, as well as a new quote at the beginning of their plan year. Over the years we’ve received feedback from patients who were pleasantly surprised to have their benefits explained to them before they began treatment and stated their other medical offices didn’t offer that sort of information. We get a patient’s insurance information when scheduling their initial evaluation, make calls to each patient’s insurance companies to get a quote of in-network benefits, and explain said benefits upon check-in at their first appointment, so each patient has an idea of what to expect, billing-wise.
Each of our front desk staff members is trained on insurance terms and the basics of billing insurance claims. Explaining benefit details to patients involves knowing the different types of cost shares for a patient, as well as authorization processes and limits placed on PT in particular.
Crystal: When I was learning how to verify patients’ benefits for them, the first thing I committed to memory was that a medical insurance deductible works the same as that of car insurance: it’s an amount that must be met by paying the contracted amount to all covered medical services combined before the insurance provider starts to pay a portion of the cost along with the patient’s portion, referred to as the cost share. That’s the part that got confusing. The cost share could be a copay or coinsurance. Yikes! What do those even mean?!
The copay is a set amount that will not fluctuate for the same service, for example: Physical Therapy. The coinsurance on the other hand is a percentage and is based on the procedures performed at a PT visit. The coinsurance can fluctuate from one visit to the next by a moderate amount, which we can estimate based on your plan and our contract with your provider.
Sarah: Typically, if a plan has a deductible for medical services, there’s a coinsurance percentage to be paid after the deductible is met. This coinsurance can be as little as 5% of what you would pay towards your deductible each visit or upwards of 50% of the amount. As Crystal stated above, the actual dollar amount for that coinsurance can vary per visit, depending upon what insurance you have. We check your claims before each visit to see how they have processed and will keep you updated should you end up with a credit or balance. In addition to a deductible (if your plan has one for medical services), your plan may also have an out-of-pocket maximum.
Crystal: I bet you’re thinking “I thought I was already paying out of pocket?!” That’s insurance lingo for you; any patient responsibility is going to come out of ‘your pocket’, but the out of pocket maximum is a dollar amount notated in your insurance plan.
Sarah: Should you meet your out of pocket (OOP) for your plan year, your insurance will then cover 100% of covered services for the remainder of your plan year. The amounts you are responsible for in regards to deductible, copay, and coinsurance payments will typically apply to your OOP; however this can vary from plan to plan. During the benefits call we make to your insurance company, we ask for any deductible, coinsurance, or copay information, as well as the amount you have paid towards your deductible and OOP. This way we can accurately determine an estimate of your responsibility for physical therapy services at our clinic. The example I like to use for deductibles and OOPs when training is that of a person swimming. When you’re paying towards your deductible, you’re swimming on your own in a lake. When you meet your deductible and owe a portion of the charges, insurance has given you a life jacket: you’re still swimming, but you’ve got a little help on the way. Meeting your OOP is akin to insurance giving you a boat; you no longer have to swim and it’s smooth sailing (at least until your plan year resets). In some cases, your deductible and OOP amounts may be the same, so if you meet your deductible, you’re covered at 100% for the remainder of your plan year!
Crystal: Physical therapy can be limited to a set number of visits or a dollar amount worth of physical therapy services. Sometimes, insurances require authorization for PT services. If an authorization is required, we do the leg-work and initiate the authorization, as well as request extensions when necessary. Your insurance may send you written correspondence regarding your authorization. If you have any questions regarding your authorization, feel free to call or bring the letter in and we’ll be happy to go through it with you.
Sarah: Insurance can be a pain, and on top of physical pain, can leave you feeling overwhelmed and out of your element. Our administrative staff is trained on the insurance processes listed above, as well as claims processing and billing, and are always available during business hours to answer any questions you may have. Give us a call at (512) 832-9411 and we will help you get started on the road to recovery!
- Sarah Urias, Front Office Manager | Crystal James, Patient Care Coordinator
Why you should ALWAYS choose physical therapy before surgery
The research is telling: physical therapy is the number one treatment option out there for rotator cuff related shoulder pain. It has been shown to be just as effective as surgery, at a fraction of the cost of surgery. These outcomes have been studied in the short-term (within a year) and in the very long-term (at 2, 4, 5 year follow ups) (Haahr et al 2005, 2006; Ketola et al 2009, 2013). In fact, exercise has been shown to reduce the need for shoulder surgery by up to 80%! (Holmgren et al 2012). Tendon tears in your shoulder relate more to your age than whether you have pain or not (Lewis et Al l 2018). Are rotator cuff tears just a normal part of the aging process, like wrinkles and arthritis? The research has yet to tell us that for sure, but it’s not a bad hypothesis. Let’s go into more detail as to why you should always choose PT before any other treatment out there for shoulder pain.
One of the many things I hear from my patients is this: “I’ve had shoulder pain for years, I went to the doctor and had an MRI, and it shows a tear in my rotator cuff. My doctor says I need surgery to fix it.” I want to talk about why this advice is flawed.
Imaging tells us very little about the condition of a shoulder, and even less about where the pain is coming from. Here’s why: there is a poor correlation between changes seen on imaging and shoulder symptoms (Lewis et al 2009, 2011, 2014, 2015, 2106, 2017). There have been multiple studies done that include people who have no shoulder pain and people that do. What they found was staggering: there was no significant difference in MRI or ultra-sound findings between the two groups. Meaning, people that had NO shoulder pain had visible findings on their MRI or ultrasound (including rotator cuff tears, subacromial bursal thickening, rotator cuff tendinopathy, and labral tears).
In one specific study, they took ultrasound scans of 51 men age 40-70. Here’s what they found: 78% had subacromial bursal thickenings, 65% had acromioclavicular joint degeneration, 39% had supraspinatus rotator cuff tendinopathy, and 22% had a tear in the rotator cuff. That means that 96% of these men had shoulder abnormalities, yet none of them were having pain (Girish et al 2011 AJR). In another study, MRI’s were taken of 14 professional baseball pitchers who had no shoulder pain. Results showed rotator cuff changes in 79% of the throwing shoulders and 86% of the non-throwing shoulders. The study also found that 79% had labral abnormalities in both the throwing shoulder and the non-throwing shoulder. Yet none of these pitchers had any pain, and they continued to function at an extremely high level (Miniaci et al 2002 AJSM). These are just two of the many studies out there that discuss how imaging is not a good tool to diagnose shoulder pain. Unfortunately, this means that many people will have unnecessary shoulder surgery on shoulder tissues that are NOT related to their symptoms. The bottom line: people should NOT be having surgery based on MRI or ultrasound findings.
Then why do people get better after having surgery? Your neighbor told you that his rotator cuff repair fixed his pain, so why wouldn’t it fix yours? Well, multiple studies have shown that improvement may be due to placebo, post-operative physical therapy, or simply, time (Lewis et al 2011, 2015, 2018). I’ll use one study as an example: 118 people were split into three groups. One group of 40 people had surgery for a labral repair, one group of 39 people had surgery for a biceps tendon, and the last group of 39 people had a sham surgery (just an incision that was then sutured up). At all follow-ups including two years down the road, the surgeries were no more effective than the sham surgery in pain ratings and patient satisfaction surveys (Schroder et al BJSM 2017).
If MRI/ultrasound findings don’t tell us anything about the source of the pain, then what is causing the pain? We believe it is simply an over-loading issue. Usually, the problem occurs when there is an excessive or rapid increase in load, beyond the tissue’s capacity, and that’s when pain occurs. For example, your ceiling fan broke and you had to hold a fan above your head for two hours, and you woke up the next morning with severe shoulder pain. Or you haven’t been working out for the last three months and you jump right back in to a CrossFit workout. These are two examples of over-load. Tissues (especially tendons) adapt to the stresses that are placed upon them, and that goes both ways: the less you load, the less your tissues can tolerate load, and the more you load, the more your tissues can tolerate load. What we do in physical therapy is increase your tolerance to load, so that you can handle lifting that gallon of milk, or that fan above your head, without subsequent pain.
So, when that patient who has a rotator cuff tear walks into my office before surgery, I breathe a sigh of relief, because I know they will most likely get better with conservative physical therapy and they will avoid an unnecessary shoulder surgery. These situations always make me think of those patients that didn’t get the chance to make it in my door. Don’t be one of those people. Advocate for yourself, understand the research, and always try conservative treatment first. Don’t hesitate to schedule an appointment with one of our expert physical therapists at (512) 832- 9411.
Did you know that you can see a physical therapist in Texas without a referral? But there is a catch; you cannot be treated without a referral. Are you confused yet? Well, welcome to the party. Under current Texas law, a physical therapist in Texas may do an evaluation without a referral but cannot treat without a referral from a qualified healthcare provider that includes a physician, a physician assistant, dentist, podiatrist, nurse practitioner or chiropractor. Evidently, our fine Texas legislature feels that these qualified healthcare providers know more about physical therapy and who should or should not be receiving treatment than your actual physical therapist. Go figure!
Direct access to physical therapy is the ability to go see your physical therapist for evaluation AND treatment without a physician referral or prescription. Currently there are 47 states that allow evaluation and at least some treatment. That’s 47 other states plus the US military, Washington DC and the US Virgin Islands that have significantly better access to physical therapy services than we do here in Texas. Every state that borders Texas has a Physical Therapy Direct Access Law that includes both evaluation and treatment. Yes, even Oklahoma! Seriously Texas, Oklahoma beat us to direct access. Well good for them. Let’s hope our state rivalries get into the heads of our lawmakers on this one.
While the Texas Physical Therapy Association (TPTA) has been pushing for direct access for evaluation and treatment for well over a decade, sadly we have been unsuccessful in convincing our state legislature to change the current laws.
Why is that, you ask? Well the simple answer is politics. Several large physician-lobbying groups have been lobbying against our bills and have traditionally had a stronger influence down at the State Capitol than we have. These groups argue that there are public safety concerns with direct access and a lack of education on the part of physical therapists to be able to treat without a referral. The truth is that in every state that allows direct access evaluation and treatment, there has been no evidence of increased risk to patients. And some of these states have had direct access for many years. In fact, there is even significant evidence of lower cost and improved outcomes for patients that were seeking physical therapy first. Why wouldn’t everyone want that?
As for the education and qualification of a physical therapist to be able to treat without a referral, the current education standards and curriculum for physical therapy is better than it has ever been. Upon graduation from a three year doctorate-degree physical therapy program, each physical therapist in the state of Texas is required to pass a national licensing exam. In fact, every PT in the country takes the same national licensing exam, and the only determination of whether you are allowed treat without a referral is the state you end up living in and working in. Because of this reason, many physical therapists graduating from Texas programs decide to move to other states that allow them to practice without restrictions. We need to keep our hard-working physical therapists practicing in Texas.
So what can we do about it? Please don’t drive to Oklahoma for physical therapy. You can at least start with your local physical therapist for an evaluation. They should at least be able to get the ball rolling a bit faster for you to actually get treatment. You can also contact your state representative to voice your opinion on this issue. Remember they technically do work for you, and if we are able to get enough constituents bringing up the direct access issue, we can hopefully make a change, sooner rather than later. One thing is for sure; we at Austin Manual Therapy Associates will continue to advocate for our profession and for you, our patients.
And don’t forget- you can still come see us without a referral. We will then help you jump through all the hoops to get you started on treatment.
- Benjamin Keene, PT, DPT, OCS, FAAOMPT
Back pain is one of the leading reasons people seek medical care in America. However, per this article, a staggering number of people will continue their lives without seeking professional help for their issue possibly causing further harm later on down the road. Often, people come to see us for their back pain and I just love it when they say, “my back is out and I usually just go to the chiro and they put it back in.” I used to get wide eyed and shocked at this statement. I would often respond to the patient, “what do you mean your back is out? It looks like it’s inside your body.” Sometimes I would get a chuckle, other times I would get a look of disdain from my rebuttal. I just thought that it was a silly thing to say out loud to another person that something that is inside of you is now outside of you and someone has to put it back in your body. Especially something like your spine. Use of these terms often come with the fear that doing anything active will cause further damage but they have been walking around and doing ALL of the things up to this point without their signs and symptoms worsening.
Take a look at this picture:
The first slide shows obvious discogenic issue and compromise to the nervous system. The picture next to it are the effects of effective, physical therapy intervention without surgical intervention performed. And no one had to put the back “in” for this to happen. Even more shocking is that this patient was still working out with minimal discomfort and intermittent lower extremity signs and symptoms. After feeling some low back discomfort, this person decided to seek medical attention and had this imaging study performed only to reveal this. Imagine the instant fear from looking at that first pic. Remarkable isn’t it?
I know, I know. You are probably reading this and saying to yourself, “good for that person, but my back goes in and out all of the time and my case is different.” Absolutely correct about the latter, your case is different. But to use terms like “my back is out” or “I was told my disc slipped out” seems to be misleading. The message trying to be delivered here gets muddled. Your body is injured. It’s important as clinicians to use effective verbage to describe what is happening inside your body. Often these “pictures” just show one side of the story anyway. It’s a still shot of what may be causing your pain. I’d much rather see how you move first, improve that dysfunctional movement pattern and teach your body to adapt to something like this. Often this will allow the body to do what it is supposed to do which is heal itself. Think about that scratch on your arm that scabbed up. Your skin isn’t out and you don’t have epidermal prolapse. (Doesn’t that sound like a hot mess?) You have an injury and your body, when put in the correct environment, will heal itself. That’s why scabs go away and you have normal, healthy skin after awhile.
By now you are probably saying, “Ok, fine. My back isn’t out. But I do have pain so what does that mean?” It means you’re normal just like the rest of us. Congratulations, you have an injury! How can you manage it? Well that is where we come in. Let’s sit down and talk about it. Let us see how you got here and how we can get you back to a happy place which is moving pain free and going back to the activities you want to do without pain. Let us help you get your body back into a position to heal properly, move better and get stronger! We understand that pain can definitely be annoying and limiting, but always remember, “Pain is inevitable. Suffering is a choice.”
P.S. This blog has some interactive hyperlinks in it. Feel free to enjoy them!
Do you have pain when you squat? Are you afraid to squat because you are afraid it’s going to hurt or afraid you don’t know how to do it properly? Have no fear! We, the movement specialists, are here to the rescue.
Squats as an exercise are a beneficial way to build lower body strength and improve core stability. Squats are also a movement that everybody does on a daily basis without even realizing. Think about every time you get into and out of a chair, on and off a toilet, in and out of your car; you are actually performing a squatting movement. These repetitive movements, if done incorrectly, can eventually lead to break down of your joints.
The point of this post is to briefly talk about proper squat mechanics and to mainly give tips and cues on how to properly perform a pain-free squat.
The squat is a compound movement that involves movement at the hip, knee, and ankle simultaneously without allowing the spine to either flex or extends.
The initial movement of a squat is actually a hip hinge; the hips glide backwards without allowing the spine to be involved as the chest comes forward. Following the hip hinge, the knees flex and the ankles dorsiflex to complete the first half of the squat. The second half of the squat initiates with an extension from the hips and then the knees follow as you bring your chest back up to a neutral position. Break down in the squat usually occurs at two different points; during initiation of the squat and coming up from the bottom of the squat. The following are a set of cues and tips I give my patients to allow a pain-free squat.
Set-up Tips :
Feet should be about shoulder width apart, core engaged (throughout the whole movement), and head in a nice neutral line with the spine (chin down, back of the head up). Some people prefer a wider than shoulder width stance which is okay.
Initiate the squat by keeping the back nice and straight and allowing your hips to glide backwards. It is okay to allow your chest to come forward, but keep your head in a neutral line with your spine. I usually cue to “sit your hips back”. Once you have initiated the hip hinge you can allow your knees to bend. Do not allow those knees to buckle in and try to keep those shins vertical. I cue people to “drive those knees out”. The knee-cap should track in line with the 3rd toe. If this is hard for you with your toes completely straightforward you can angle them slightly outward.
Bottom of the Squat Tips:
Only go as low as your body will allow. For the general public, this will probably be above parallel which is okay. I would you much rather work on proper mechanics than to try to break parallel. Do NOT bottom-out or do the dreaded “butt-wink”.
The “butt-wink” usually occurs when the core stops being engaged and the hips stop gliding backward. If you notice this happening, stop your movement before you get to that point. Once you get to the bottom of the squat, your core should still be engaged, the head is still in line with your spine, and you want to initiate the movement by extending your hips. I cue people to “push through your heels” to get the posterior chain to fire. Once the hips begin to extend the knees can then follow to allow the return to neutral.
If you are having difficulty or pain with performing squats I would recommend coming in and seeing one of our highly trained physical therapists at Austin Manual Therapy Associates for a movement screen and assessment. We know SQUAT and can get you back into pain-free squatting!!
Check out this video for a quick demo.
Elaine Tsay, PT, DPT, FAAOMPT
For anyone who has ever laced up a pair of cleats, running shoes, or as my boys like to tease me, “sneakers”, then almost all of you have probably suffered an ankle sprain at some time in your life. The most common variety: Inversion ankle sprain, which is more casually referred to as “rolling your ankle” (where the foot turns in while all the weight goes to the outside of the lower leg). Other ankle injuries can occur, but let’s stick to the more common type.
First priority: determine if it is simply a low grade type of ankle sprain, and not something more serious. One of the classic signs of a serious injury is the inability, or refusal, of the individual to bear any weight immediately after the injury. This may indicate the need for more formal diagnostic imaging and medical care.
Second priority: control the swelling. This is most likely caused by small vessel damage and subsequent bleeding. This is the best time for ice, compression, and elevation to be used. Once 2-3 days have passed, and more serious conditions are eliminated, switching to heat and gentle movement is probably best. But the swelling and soreness from the initial vascular injury are not the only causes of ankle pain.
Third priority: assess for joint dysfunctions and nerve irritability. Some ankle pain may linger for a time after the initial bruising and swelling have cleared. Causes could be the joint is stuck out of position, or shifted. In fact, a one-degree deviation from the normal resting position of the ankle increases the forces in the ankle by 42% when your full weight is on it (ACSM, 2017). Manipulation to restore proper alignment and mobility may be needed.
In base level orthopedic physical therapy, nerve pain is often overlooked when treating the ankle. The Intermediate Dorsal Cutaneous Nerve, a branch of the Superficial Fibular (peroneal) Nerve, travels directly over the front of the talofibular ligament, and may also be what is tender when pressed (see bottom left portion of image). Austin Manual Therapy Fellowship-trained Manual Physical Therapists are specifically trained to examine and evaluate every potential source of pain for a “simple” ankle sprain, including nerve pain.
At Austin Manual Therapy, we provide a uniquely thorough and holistic evaluation for every patient, every time (no two ankle injuries are the same). We have the highest expertise, the most advanced specialized training in Orthopedic Physical Therapy comprehensive examination and diagnosis to get to the root of the problem, the “cause of the cause”, if you will. Whether you wear sneakers or not, our treatments will address your immediate needs, and add preventative measures to help reduce likelihood of a recurrence.
Ask yourself the next time it happens, if your “simple” ankle sprain is just that; simple. Come see us at Austin Manual Therapy and we’ll help you figure out what the problem is, correct it, and help you protect the ankle in the future. You can reach us at (512) 832-9411, or www.austinmanualtherapy.com.
One of the unexpected “benefits” of being a physical therapist is that family, friends, and strangers ask your advice on all sorts of health related topics:
“What kind of exercises should I do for my back?”
“Why does my knee hurt right here?”
“Should I use heat or ice?”
“What medication should I take for pain?”
“Does this look normal?”
While I love that people trust my opinion and want my advice, most of the time there is a lot more to answering those questions than just a simple recommendation. Often times, my answer begins with, “Well it depends…” and after a few follow up questions the person who wanted a simple answer is no longer that interested because I have made the situation more complex. But here’s the thing, it should be complex and also comprehensive.
There’s a reason that becoming a PT requires 4 years of undergraduate education, 3 years of a clinical doctorate, and in the case of Austin Manual Therapy Associates, 3 years of advanced training in manual therapy to become a credentialed Fellow of Orthopedic Manual Physical Therapy. Bodies are extremely complicated; it takes a lot of knowledge, experience, and training to properly evaluate, diagnose, and treat the complexities of the musculoskeletal and nervous systems. I’d be doing someone a disservice if I answered their questions with a simple response without taking the time to ask specific questions and gather more information. That’s also why I advise people not to rely on google, instagram, facebook, and other social media for self-treatment approaches; a one-size fits all approach to treating injury and pain is not always the best option.
The benefit of going to a PT with advanced training and experience is that they will take the time to ask the right questions, get a comprehensive history of your injury and pain experience, identify your goals, assess and evaluate the body as a whole system working together, address any soft tissue or joint dysfunctions, and develop a personalized and achievable treatment plan. A good PT can give you advice on how to treat that shoulder pain that you developed while doing yard work last weekend, but a great PT will take a comprehensive look at your movement system as a whole and work with you and educate you to prevent that injury from reoccurring.
So if you’ve been dealing with aches, pain, injuries (new or recurring) or have had similar questions like the one above for a PT or consulted “Dr. Google”, give us a try at Austin Manual Therapy Associates and let us show you the benefit and difference of being treated by highly qualified PT’s. After all, we are the movement experts!
Jacqueline Stine, PT, DPT
Hiya! My name is Sam. I am a patient coordinator and a PT tech at the Barton Springs clinic. My blog entry this month won't offer any technical PT advice because I would feel as though I were breaking the law if I did. It will, however, talk about my experience with a personal injury and how the battle to be won extended further than the physical pain. Essentially, this is an account of how a new physical limitation can upset the balance in one's personal life, and how it can sour our happiness. The goal of it: To relate to those of us who feel the twinge of depression when we feel the twinge of our pain. So I'd like to start the story with a few words that I needed to hear myself:
You are not your injury.
I say this, though I had become mine. I was a sprained ankle, a burning knee, a crooked back. I was held hostage indoors; fearful I might make myself worse and full of pity because I could not see beyond the imprisonment of a physical limitation. I was to be this way forever. Life sentence, man.
Here's the thing, I was wrong. Of course I was wrong!
So I write my story as an easy little lesson I learned difficultly over a long time, as silly stubborn folks often do. Here's the mantra, and I'll say it again, you are not your injury.
Prior to my injury I would spend a lot of my free time bumming around the out of doors. I also enjoyed jogging as my evening catharsis and I exercised daily. Let's say I was "active-ish." I enjoyed freedom of movement. I could climb rocks, sprint, jump, and swim without worry. I was armored and carried kiddish energy at the hilt. Open fields or dense woods or muddy mud were invitations for me to rush across and investigate what lay there and beyond.
It was out there in my own jam, exploring the great Appalachian Trail when I badly sprained my ankle. Ah, the AT had claimed another one.. or so it thought! Yessiree, I hiked another 2 full days with an 80lb backpack. I had to see this hike through, plus I could handle the pain after the swelling filled my ankle when my body began to realize it was walking another 7 hours or so (not a good idea, do not do that.) So if you recall me mentioning something about being stubborn, it was that stubbornness that set all of this into its terrible motion.
This fool writing to you knew nothing about how the body worked. If he had, he may have sought treatment immediately. Since he hadn't, 8 months of walking around on a clubbed foot had not only knocked his knee out but rotated his hips and weakened his lower back. I didn't know this, of course. All I knew is that I was in too much pain to go for a half-mile walk. My knee started to click and my back started to tighten and my ankle swelling hadn't gone down in a few months. Everything was becoming worse. Top it off with the enervating fact that I was currently in between jobs and had no income, I became smothered with the feeling of a total loss of self-worth. It was depression. The rot of my future spread unencumbered, and my mind asked itself sad questions. How could I promote myself to employers if I struggled with the loss of what made me happy? How could I enjoy time with my friends who all love the same activities I could no longer do? How could I feel good about myself when what made me feel good was moving around?
I felt left behind, and it was consuming what seemed like any sanity there was left. With the mind dark, limits only grow. Dr. Seuss said it well in the best book ever written!
Oh the Places You'll Go!,
You can get all hung up
in a prickle-ly perch.
And your gang will fly on.
You'll be left in a Lurch.
He can sum it up in 4 lines. He's a darn genius, but those words only confirmed my feelings. They didn't offer any advice! I was surprised at how easily I lost myself in this mindset, but even more surprised that I couldn't get out of it. The pain became the definition of who I was to myself and everything around me. I was what I could not do. I was my injury. But I must tell you, it gets better. As it turns out, the Seuss does proffer some encouragement:
On and on you will hike.
And I know you’ll hike far
and face up to your problems
whatever they are.
Gosh he just gets it. I didn’t, however. Fortuitously, I found myself employed by our very own Austin Manual Therapy. It was not long, perhaps a week, before I was forced to do physical therapy by my coworkers. I was showing off my lumpy ankle too often I suppose, but it was all for the better. Immediately after the first day I could feel the depression lessen. It wasn’t gone, however. I was just glad I knew what was wrong with me. I became consistently conscious of where the pain was and how to help prevent it throughout my day. In about a month I could walk as long as I wanted. Eventually I could do some light jogging. Then I could hike, I could swim, I could climb. All of these activities were moderated, of course, but I was getting back to my old self nevertheless. Little by little did my injury stop affecting the way I thought about who I am.
I am better now. I am not perfectly put back together just yet, but I am better. Since I had waited so long to help myself, my progress will take me awhile. So far, the journey has been about a year and a half. However, this firsthand experience has taught me that pain is not only physical. Pain is debilitating to us in a myriad of ways. Pain creates limitations to our relationship with the world and with ourselves. We can, unfortunately, be felled by the sword of our injuries. I hope that anyone reading this can relate, and at the very least is encouraged to not waste time like I had. It took me getting a job at a physical therapy clinic to begin healing myself. So if you are reading this, you are way better now at taking care of your body properly than I was. You are on the right track. Always remember, you are not your injury.
Also, it is never a bad idea to readOh the Places You’ll Go!
Sam Jaklich, PT technician
I first heard this saying spoken by Dr. Laurie Hartman, DO at the annual conference provided by The American Academy Of Manual Physical Therapists in San Antonio, Texas, about four years ago. I have subsequently discovered it is a widely-known phrase that has been used in many instances and by many individuals in various contexts. Nevertheless, it gave me a renewed interest in striving to further help our physical therapy patients accept this concept: Experiencing pain without truly suffering.
For a lot of people, orthopedic pain is an experience as common as breathing. What to do about this pain is the driving force behind countless analgesic pharmaceutical commercials, as well as seemingly endless infomercials about the latest gadget that will make pain disappear without any real effort. The heart of this axiom in deciding whether to attempt to relieve the pain itself, or to seek to discover the primary cause of the pain.
Manual Therapists, Physical Therapists who are fully credentialed Physical Therapists in the specialty of Manual Therapy, strive to find what we frequently call finding the “cause of the cause”. The designation ‘Manual Therapist’ indicates this is someone who has received the highest level of Orthopedic Physical Therapy training available.
What does this mean for the general public attempting to proactively determine their best course of action to fight pain? As a fully credentialed Manual Therapist, I am partial to recommending you come to our clinic, Austin Manual Therapy Associates. We have some of the very finest Orthopedic Manual Physical Therapists in Austin. The level of training is more than most Orthopedic Physical Therapists will seek, as it is equally as grueling as it is time-consuming to complete.
Regardless of whether you choose Austin Manual Therapy Associates, I would like to offer a little advice when seeking the best physical therapy care for your aches and pains.
Do your research.I know it is easier to get word-of-mouth advice from social media forums, as well as public review sites, but you can also look for the credentials of the therapist you are seeking through the Texas Physical Therapy Association, including any disciplinary issues of any particular therapist. Also, I would recommend to seek a Physical Therapist that has the FAAOMPT credentials…the best of the best. In any case, find out as much as you can about that therapist before proceeding.
Be RealisticEspecially about promises made by a practitioner offering to have you pain-free within 2-3 visits when you have had this dysfunction and pain for years. Usually, if it seems too good to be true, it is. Instead, seek consultation from a number of therapists until you find the one who seems to understand your pain and has a plan that is unique to your needs. You deserve that consideration.
Be actively vested in your recovery.The details you provide to your Physical Therapist will enhance the rationale for their recovery plan for you. The behavior of pain is often one of the most telling aspects in leading to the best treatment method.
Finally, be strong.Pain is designed to get your attention that something is not right. Physical Therapy has been shown to be the first choice for pain control. If you want the best care, you have to search for it. Manual Therapists can provide the highest quality of Orthopedic Physical Therapy care, and we assure you that we offer the best Orthopedic Manual Physical Therapists at Austin Manual Therapy Associates. Give us a call at (512) 832-9411. Remember, “Suffering is a choice”. Choose wisely.
Spring is in the air, birds are chirping, the sun is shining, and Texas is showing off its bright blue skies and sunny days. What does this mean?? IT’S GOLF SEASON. Winter has come and gone and it’s time for you to hit the links!
Golf has always been a passion of mine, and is something I enjoy on a weekly basis. It is one of the few sports that people of all ages can enjoy; grandparents and grandchildren can play right along-side one another, and it’s a sport that you can continue to play as you age. The real kicker is… how do we keep your back safe as golf season ramps up?
There are 2 occasions where keeping your back in a strong, stable position is important:
- The golf swing is a very fluid motion and is based heavily on your ability to rotate into your backswing, pause, and then change direction rotating down into contact with the ball. Rotation of your lumbar spine places a higher stress on your intervertebral discs, as only 1/2 of the collagen fibers that make up the disc can resist rotation in one direction at any given time. THEREFORE, it becomes very important to place your back in the most optimal position when setting up to begin your swing, so you can keep your back safe and stable.
- Another time it’s crucial to protect your back is after you make that ever elusive hole in one, and you bend down to grab that golf ball out of the bottom of the cup.
HOW CAN WE KEEP YOUR BACK SAFE?? Here’s a quick tip to help keep you out on the course week after week… BEND AT THE HIPS!
When setting up for your next shot, or when bending over to grab your golf ball out of the cup, think of keeping your back “straight” as you hinge at the hips. For most of us, it will feel as if you’re sticking your bottom out to sit back into a chair. Don’t let your back curve in the shape of a “C”! If your hamstrings feel a little stiff when you do this, don’t panic, just bend those knees a little when bending over. If you can do this, you can keep your back nice and safe, feeling strong for that next round!
Having difficulty figuring out how to hinge at the hips? Fighting off some low back pain, stiffness, or tension? Contrary to popular belief, back pain/stiffness/tension isn’t normal, so come on in to Austin Manual Therapy and one of our highly trained physical therapists would love to help get your back feeling strong, get you hinging at the hips, and back out on the course again!
When Should I Go See A Physical Therapist?
As physical therapists we often hear patients ask questions such as, "why didn't I come in before?" or "if I had come in right after this happened I'd have been better by now, right?" Most folks dealing with an injury have usually waited for several weeks employing the age old adage "I can work IT out" or my personal favorite "when I was younger these things would go away with rest." Unfortunately this has led patients to possibly hurting themselves even further and making matters worse.
When we get injured, a physiological process occurs right away to protect us from further harm. As a part of this process, adaptation occurs and can create faulty movement patterns. Often times it was the faulty movement that set us up for the injury in the first place. When we ignore this we tell our body that it is okay to continue these poor mechanics and episodes can reoccur. If you’ve ever experienced multiple episodes of back pain or have sprained the same ankle over and over again, you are probably nodding your head yes to this explanation. But it doesn’t have to be this way.
Current research in our field has shown that early intervention following episodes of injury tend to show favorable outcomes for patients, including quickly decreasing pain, improving movement, and helping people return to performing activities they enjoy with little to no limitations. There are other benefits as well including the cost-savings of dealing with your injury. Often, early intervention will require LESS treatment visits and can also decrease the likelihood of having to undergo expensive surgical procedures.
So to answer the question, you should seek treatment from us immediately following injury for every episode. Our fellowship trained and experienced manual physical therapists at Austin Manual Therapy Associates are here to help get you back to the things you love to do most. Contact us today or simply stop by any of our locations to speak directly to a physical therapist about your needs!
Have you ever taken a step first thing in the morning and felt like you had a sharp knife stabbing you in the heel? Have you gone on a long walk to find hours later you have a burning or aching pain along the bottom or backside of your heel? Heel pain is by far the most common foot problem we see in the clinic. It can be debilitating and can greatly affect your quality of life. Differential diagnosis of heel pain is essential, as treating the correct tissue is incredibly important to ensure proper healing and faster results.
More often than not, patients with heel pain come into the clinic with a diagnosis of “plantar fasciitis.” However, this is not the only cause of heel pain. The plantar fascia is a fibrous tissue that runs along the bottom of your foot, originating at the inferior surface of the heel and ending at the toes. Typically, when this tissue is involved, the pain is sharp and intense, located directly at the bottom of the heel and sometimes into the arch of the foot. Pain is usually only present when weight-bearing through the foot and almost always painful with the first few steps in the morning.
The inferior calcaneal nerve (ICN), otherwise known as “Baxter’s Nerve,” also runs in the same area as the plantar fascia. Baxter’s nerve can cause burning, aching, or numbness and tingle in the heel or foot. Initially, this pain is present hours after activity, but when highly aggravated, the pain can be constant. Baxter’s nerve will also be painful at rest, unlike the plantar fascia, which will be painful only when the foot is in use.
If you have heel pain, call Austin Manual Therapy Associates to make an appointment today. Our expert physical therapists are fellowship trained and can help correctly diagnose the underlying cause of your heel pain.
The Science Behind Pain
Pain is a common occurrence. Except for those rare individuals who have no sense of pain, everyone else will experience some sort of physical discomfort in their lifetime. According to data synthesized from information provided by The Manual Therapy Institute and Physiotherapist David Butler, the simple concept that tissues must be injured to cause pain is the most commonly held belief as to its source and has been around for centuries. But recent research shows that the source of pain may be from a multitude of other factors, rather than automatically associating it with tissue injury.
Sure, tissue injury in the body causes physical pain, but it is hardly the entire spectrum. When information is sent from the injured area of the body to the brain, it is simply received as “danger”, or “no danger”. It is not necessarily perceived as what we think is “pain”. The brain analyzes the significance of the signal and then “decides” if it warrants further attention, or if the signal can be dismissed.
Prolonged and repetitive pain experience over time causes the spinal cord to get more efficient at sending this “danger” signal to the brain, instead of simple sensory information. This means the “threat” message is more easily and frequently delivered, even if there is no threat. If this process goes on long enough, without being checked, any type of touch stimulus may eventually be perceived as a danger, even if the stimulus is intended to be comforting and soothing.
The brain then has a hard time keeping up with the demand for more and more endorphins to be released to control this ever-increasing “threat” surplus. The brain is overrun by this constant influx of nociception. This phenomenon can be part of the clinical picture of many physical disorders such as Fibromyalgia, Complex Regional Pain Syndrome, and other autoimmune disorders. The vague pain distribution (sometime subtle and sometimes intense) is characteristic of what is now identified as Central Sensitization Syndrome.
As Fellowship-trained Manual Therapists, we at Austin Manual Therapy have the training and skill to help most everyone manage these often intrusive and unrelenting pain symptoms. Give us a call at (512) 832-9411 to discuss ways we may be able to help anyone whose life is interrupted by any type of pain experience.
Crossfit and Manual Therapy
How can Manual Therapy benefit Crossfit City Limits’ members in their quest for “ultimate fitness”? And what is Manual Therapy? These are sample questions many people have about our physical therapy practice at Austin Manual Therapy, and why we show up at Crossfit City Limits every few weeks with a table set up for injury screening.
In principle, Manual Therapy is a philosophy inasmuch as it is a set of manual techniques. According to the American Physical Therapy Association, the definition of Manual Therapy is the skilled passive movement of joints (joint mobilization/manipulation) and soft tissues (soft tissue mobilization/specific localized massage). This also includes movement analysis and restoration of appropriate movement patterns. OMPT (Orthopedic Manual Physical Therapy) is currently the only certified therapy recognized by the American Medical Association. The training for Manual Therapy specialization is very similar in nature with didactic and residency training for a Medical Doctor specializing in a particular medical domain.
In essence, Manual Therapy is a treatment philosophy which treats the whole patient, utilizing the most advanced cutting-edge techniques with the highest order of orthopedic physical therapy problem-solving. Simply stated, it is the most effective holistic approach to Orthopedic Physical Therapy. What does this mean to Crossfit City Limits? It means that our training and attention to detail mirror that with which you strive in every workout.
Crossfit City Limits fundamentally is focused on generating exceptional fitness, while at the same time improving efficiency of movement with every front squat lift, muscle-up, and power clean, etc. To that end, it is evident that you must perfect your form before progression in workout volume and intensity can be achieved, most especially to avoid injury. But we all know that, even in the best of attempts, injuries are part of the process. Usually, these injuries are related to lapses in small details of particular dynamic movement, not a weakness in the larger muscle groups. Learning from the mistakes that lead to these particular injuries is what ensures progress more consistently.
We at Austin Manual Therapy strive for the same movement mastery you do with your Crossfit program, beginning with establishing a strong base of stabilization control and aerobic capacity of the working tissues, then progressing to more challenging dynamic movements to more closely mimic and correct the activities in patient’s lives which caused the breakdown and injury in the first place. Ultimately, we at Austin Manual Therapy are after the same things that you at Crossfit City Limits pursue. Everyone needs a little help and coaching along the way, and that is the help that we provide with our injury screenings and subsequent treatment approaches. We would assert that asking for help is a sign of strength. Ask yourself if you are strong enough to ask for this help.
We are always ready to answer your questions and provide relief of your symptoms. Contact our office at (512) 832-9411, or simply stop by to speak to us at our exam table during the next Saturday morning open-gym workout. Your health will thank you!
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