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.
Chronic Knee Pain
A 52-year-old male reports to physical therapy with pain in his R knee. He is a rugged outdoorsman on the weekends which involves a lot of climbing on/off tractors, hauling brush, and working on his classic car collection. During the week he is minimally active and works in finance. He has had several surgeries on his R knee, including ACL reconstruction several years ago. Post-surgery he has had episodic pain in his R and occasionally L knees. His current episode began about a week ago as stiffness which progressed to 8/10 pain and impaired his ability to walk. He is wearing a neoprene knee sleeve which has helped but wants to return to all of his outdoor activities and not worry about his knee pain. He also does not want to have a knee replacement.
Be pain-free with all of his outdoor activities.
Patient was found to lack 30 degrees of R knee flexion as compared to the L. He was unable to fully straighten his R leg and maintained 5 degrees of flexion at his straightest. He had decreased strength in his inner thigh muscles, hip rotators, and quadriceps. When asked to stand on 1 foot, he lost his balance immediately on the R, whereas he could maintain stability on his L leg for a few seconds. During a squat his knees buckled inwards towards each other, and the R knee also twisted inwards. Some swelling was found around his knee. While observing his gait he couldn’t fully extend his knee resulting in a shortened stride and limp.
Our priority was to restore this patient’s knee extension. Full knee extension is integral to restoring walking and quadriceps strength. Once this was achieved, the treatment then progressed to include strengthening exercises of the quadriceps, inner thigh muscles, and hip rotators; followed by balance training.
He was able to regain his AROM after 2 sessions via manual joint mobilizations, soft tissue mobilization, and self-mobilizations at home. He also had significantly less pain (3/10). His program progressed to include strength training at this point focusing on quadriceps strength, hamstrings, and adductors (inner thigh muscles). We maintained his strength program for the duration of his treatment, and in his last 3 visits, we added balance and stability training. By the end of his treatment, he reported no limitations jumping on and off tractors to help clear land on his property.
Despite this patient having a long history of intermittent knee problems and multiple injuries including surgery, he was able to return to a rigorous level of activity. He did not need to wear a brace or knee sleeve once pain and swelling abated. He also stated that it was the most stable and comfortable his knee felt since before sustaining any injuries. All of this was accomplished in 8 treatment sessions with a highly specialized rehabilitation program.
Shelbourne KD, Biggs A, Gray T. Deconditioned Knee: The Effectiveness of a Rehabilitation Program that Restores Normal Knee Motion to Improve Symptoms and Function. N Am J Sports Phys Ther. 2007;2(2):81-89.
Jansen, Mariette J., et al. “Strength Training Alone, Exercise Therapy Alone, and Exercise Therapy with Passive Manual Mobilization Each Reduce Pain and Disability in People with Knee Osteoarthritis: a Systematic Review.” Journal of Physiotherapy, Elsevier, 12 Mar. 2011, www.sciencedirect.com/science/article/pii/S1836955311700029.
A 60-year-old active, female, lawyer reports to physical therapy with limited mobility in her left shoulder that began slowly over a one-month period. Her symptoms started as a low-level ache when she would lay on her shoulder and progressed to pain with reaching over her head or behind her back. She then reports her shoulder felt stiff and had trouble moving her arm. She went to her orthopedist who ordered an X-Ray and MRI. Based on the results of her imaging, she was diagnosed with adhesive capsulitis (frozen shoulder), and the orthopedist gave her an injection of Cortisone. Patient states after the injection she gained most of her mobility and pain decreased, but still cannot comfortably swim or reach behind her back.
Regain ROM in the shoulder to swim.
Patient lacked 10 degrees of motion with reaching above her head. When asked to reach behind her head she reported stiffness and was not able to reach the same point as her right side. When asked to reach behind her back, her R hand could reach the bottom of her opposite shoulder blade, while her L side could only reach halfway to her shoulder blade before the onset of pain and stiffness. Her strength was limited in her rotator cuff muscles. She was found to have a capsular pattern of limitation in her shoulder, which is a defined pattern of loss of motion due to inflammation and sometimes thickening of the shoulder capsule.
Patient had 10 treatments at this facility. We focused on improving joint mobility of the shoulder joint and scapula, muscle flexibility, as well as the strengthening of her shoulder and scapular muscles.
During the first few sessions with a focus on joint mobilizations and self-stretches, she regained her ability to reach above and behind her head. She continued to be limited with reaching behind her back, which impaired her ability to swim the backstroke. These are typically the motions that are most limited with a patient that has adhesive capsulitis. After 4 visits she attempted to swim and found front crawl to be effortless and pain-free due to her gains in ROM. In the next few sessions, we added exercises to improve her scapular mobility, strength, and endurance. The shoulder is the most mobile joint in the body and requires collaboration between the shoulder blade, humerus, and collar bone to achieve all motions. Scapular muscles help control the ROM of the shoulder when we need to use the full breadth of motion, such as swimming backstroke. By the end of her treatment, she returned to swimming all strokes unrestricted.
Adhesive capsulitis can be a tricky diagnosis to treat and we still don’t know what specifically causes the onset of the inflammation and thickening of the capsule. In this case, due to the early injection of cortisone followed by physical therapy, she made a great prognosis. The gains she achieved from the Cortisone (decreased pain and improved AROM) allowed us to achieve our PT goals quickly for her return to swimming. The benefits from the steroid injection are varied by the patient, however physical therapy is always indicated in the successful management of adhesive capsulitis.
Idiopathic Adhesive Capsulitis: A Prospective Functional Outcome Study of Nonoperative Treatment* Griggs, Sean M.; Ahn, Anthony; Green, Andrew The Journal of Bone & Joint Surgery. 82(10):1398, October 2000.
Lorbach, O., Kieb, M., Scherf, C. et al. Good results after fluoroscopic-guided intra-articular injections in the treatment of adhesive capsulitis of the shoulder. Knee Surg Sports Traumatol Arthrosc 18, 1435–1441 (2010). https://doi.org/10.1007/s00167-009-1030-7