Physical therapists see many patients who have sustained orthopedic or athletic injuries and, with a good clinician, the results from rehabilitation are usually excellent. At Pivotal Physical Therapy, the physical therapists are experts in both how to treat the immediate trauma and preventing future injury. Initially, we evaluate the injury and determine the most efficient method of recovery.
44-year-old male runner (15 miles per week) with a 3-month history of right heel pain. Originally the heel was only painful when running. Currently, it is very painful with his first steps in the morning and, the end of the day (after wearing leather soled shoes). He has had to stop running because of the pain.
During the initial evaluation the physical therapist noted:
1. Extreme tenderness of the right medial heel 2. Tightness of right calf muscles 3. Over-pronation of right foot 4. Significant weakness of R hip muscles. 5. Patient’s walking pattern indicated a poor heel strike (especially on right) and excessive medial rotation of the right hip. 6. Running style assessment was deferred due to pain. The patient reported he ran primarily on his toes. 7. A soft gel heel insert was suggested to help decrease the pain with daily walking, and reduce stress upon heel strike. 8. The patient was educated regarding footwear for daily use and running.
1. Ultrasound, ice was applied to the tender spot on his heel. 2. Massage, stretching to his R calf muscles 3. Hip strengthening exercises were taught to begin addressing the hip weakness.
Treatment 5 progress and results
1. The right heel pain had decreased by 50%. 2. Right calf muscles were longer and more supple 3. The hip exercises had begun to feel easier. 4. Deep massage to the heel was performed which helped to alleviate another 20% of his pain.
Sessions 6-8 emphasized lower extremity alignment when standing and walking
1. The patient would practice balancing on his right leg on various surfaces (e.g., wobble boards, trampoline, soft foam pads) with the exercises becoming progressively more challenging.
By the 8th session, he had to squat on his right leg while standing on the foam pad and maintaining ideal lower extremity alignment.
Sessions 9-12 were dedicated to fine-tuning his running style
1. No R heel pain 2. The running style was assessed on the Treadmill and his heel strike had normalized on the R side while he had some residual excessive medial rotation of the right hip. 3. His balance exercises continued to become more difficult (because running, if you think about it, is really a single leg sport, you are never on both legs at the same time). 5. Continue to increase right hip strength.
At the time of discharge, the patient had returned to running 10 miles per week at an increased pace (formerly 8 now 7 minutes per mile)and without pain.
The above case history represents our “typical” patient. Obviously, results and duration of treatment can vary for each patient depending upon their age, severity of the condition, diagnosis, and compliance with their Home Exercise Program.
Low Back Pain
A 57-year-old female who presents into the clinic with lower back pain and stiffness. She states symptoms occurred for no specific reason and have been present for 3 months. Her symptoms gradually were getting worse and now feels she can’t sit or stand for long periods of time. Anecdotally she said her worst activities were placing her dog’s food on the floor, turning over in bed, pain especially at the end of the day or end of the workweek. About 15-20 years ago she had an episode of intense lower back pain, but has not had any pain since. She works full time in the financial sector and takes 2-3 exercise classes on the weekends.
Her goals are to be able to make it through her workweek pain-free so she can enjoy her weekends with her grandkids and dogs.
Upon evaluation, the biggest findings were limited movement and pain in all directions: forward bending, backward bending, side bending, and rotation. The pain was located only in her back and did not travel into her legs.
We discovered along the course of her treatment that stress management and inactivity during the week escalated pain levels. We quickly knew that if we did not address these factors, that her back pain would not decrease. Primarily education about how beneficial movement is for back pain reduction and prevention. One of my phrases is “a healthy spine is a flexible spine”. A lot of times when patients experience pain in their back they develop a fear of moving. Typically introducing movement quicker from the time of pain onset will improve a patient’s outcomes.
This patient was treated in the office for 9 visits. We tiered her return to movements based on what she was comfortable with so that her pain would not be triggered or flared. Her home exercise program mirrored the exercises we performed in the clinic. Allowing freedom of movement in one plane until the body is comfortable builds confidence (achieved by repetition of safe movements) within the neuromuscular system. More confidence will help the body decrease its threat response. When the body feels safe doing an activity it will decrease the inflammation in the tissues, thereby decreasing a person’s pain.
After the first 3 visits, this patient reported an improvement of overall pain intensity. She started to report improvements in sitting and standing and pain did not wake her while she was turning over in bed. After 5-6 visits she reported she regained the ability to get out of bed in the morning without pain and played with her grandkids all weekend. She stated that the Monday after she played with her grandkids she had some pain and stiffness, but she didn’t feel discouraged with her progress. At visit 9, this patient was able to engage in most of her normal activities and was experiencing pain at most 2-3 days per week which were relieved by her home exercise program.
Hip and Groin Pain
A young, elite soccer player presented to our clinic with pain in his left hip and groin. He was sprinting and felt a sharp pull in the left leg. He took some time off to rest but every time he started to play soccer again, his pain returned.
Return to playing soccer with his team this season.
Upon evaluation patient presented with altered walking patterns, decreased ROM at his hip, decreased core (oblique) strength, and decreased adductor strength. When attempting to squat, he required additional stability making him shift his pelvis to the L and his knee to bend inwards.
Over the course of 10 weeks, this patient worked through progressive strengthening exercises focusing on his body weight mechanics and strength of his leg and obliques. As with most hip injuries and pain syndromes, balance is compromised and affects how the weight from the trunk and torso is loaded onto the leg. Considering his high level of athletic performance, his balance and agility are integral parts of a return to playing. He required proper loading mechanics to improve his balance and agility. For high-level athletics, all the joints need to function together.
The patient was able to begin running after 6 weeks of physical therapy. By 8 weeks, he returned to practices with his teammates and was participating in all drills with the exception of scrimmaging. By 10 weeks, he was fully participating in all practices and working on additional conditioning exercises outside of soccer practice. By week 11, his coach allowed him to play a few minutes of a game (the last of the season).
I was able to follow up with this patient a few months later and was happy to hear that he had fully returned to competitive play. He had been part of an international soccer team and had been competing in some of the international tournaments, all pain-free and without injury.
A 33-year-old male was biking 20 miles 10 days ago and felt a “pop” in his lower back after bending down to get his water bottle. As he dismounted his bike, pain radiated into his left leg. During the initial 3 days the pain was severe and sitting, standing, sleeping, and walking were excruciating. He had been sent by his primary care physician for an MRI which revealed a herniated disc. The patient was scared that he may need surgery. He came into the office 10 days after he initially experienced pain.
Wishes to avoid surgery and return to running and biking
He could only bend a little bit forward and backward before reproducing his pain down into his leg. To avoid pain during walking he favored his left leg and kept more weight on his right side. He also reported the reproduction of pain down his left leg during a straight leg raise test.
Because his onset of pain was recent, we tried using the McKenzie method of repeated extension which decreased his pain and allowed him an improved ability to bend forward and backward. He was instructed to continue the exercises that decreased his pain as his home exercise program. When he returned for subsequent visits, found he had tight muscles in his lower back, hamstrings, and hip flexors as well as a lack of core strength. We made recommendations to engage his core and take stress off of his back while bike riding. The treatment during the next two physical therapy sessions focused on improving his flexibility and core strength.
This patient was completely pain-free after three physical therapy sessions. Running and biking are activities that place a lot of stress on the lower back. These activities, however, do not guarantee anyone will experience back pain. They also are not “bad” for your back. When pain is acute but resolves quickly, surgery typically isn’t warranted. Intense pain levels are always a trigger to let you know something is wrong but can be mitigated by movement and exercise. MRI findings can be scary but do not necessarily dictate the need for an invasive treatment. Because his pain resolved very quickly, he didn’t require additional office visits. He was given instructions on how to safely return to biking and running.