Treating Tennis Elbow (Lateral Epicondylitis) & Golfers Elbow (Medial Epicondylitis)

Tennis elbow and Golfers elbow are right up there with plantar fasciitis as far as the amount of difficulty to resolve especially when you don't have the proper knowledge and patience to treat these injuries appropriately.  

First, lets start with a little bit of anatomy regarding the two pathologies.  Tennis elbow is when the tendons on the outside of the elbow at the bony prominence become irritated and inflamed.  This usually happens from repetitive use weakening wrist/finger extensor muscles.  Golfers elbow affects the tendons on the medial elbow or the inside of the elbow at the bony prominence.  Again, the tendons here become inflamed from repetitive use and weak wrist/finger flexing muscles. In either case these can become quite painful.  The two different terms of tendonitis are quite obvious.  Golfers elbow is termed so because this pathology is common with golfers.  It is the same with tennis elbow.  Tennis elbow is common with persons that play tennis on a regular basis.  

Typically it's not just one specific tendon that becomes inflamed with either pathology.  Rather the "common extensor tendon mass" or the "common tendon flexor mass" are affected.  The extensor tendon mass is relevant to tennis elbow.  The common tendon flexor mass is relevant to golfers elbow.  Both pathologies are related to excessive gripping along with flexing the wrist or extending the wrist.  I think the table below will help give a better picture of the two but similar pathologies.

Tennis Elbow

• Occurs on the outside or lateral aspect of the elbow on the bony prominence
• Symptoms are caused by excessive and repetitive gripping with extension of the wrist or bending the wrist backwards
• Symptoms are also brought on by weak extensor muscles of the hand and of the upper arm
• Can involve multiple tendons which can be referred to as the common extensor tendon mass

 Golfers Elbow

• Occurs on the medial aspect or inside of the elbow on the bony prominence
• Symptoms are brought on by repetitive gripping and flexing or bending forward of the wrist
• Symptoms are often the result of weak gripping muscles and weak muscles in the upper arm
• Can involve multiple tendons which can be referred to as the common flexor tendon mass

Symptoms

Symptoms with Tennis or Golfers elbow are typically the same.  They usually present in the same manner.  Initial symptoms at first can be a medium to sharp ache or stinging pain on the outside or inside of the elbow.  The area initially affected is usually a very small area.  If left untreated and symptoms progress, pain can be present with bending or extending the elbow upon initial movement.  Pain can also be present when gripping or holding an object that may be slightly heavy.  When symptoms worsen, gripping and holding something even of light weight can be quite painful. Often, when the muscle groups warm up with an activity the symptoms can reduce a moderate amount at which time symptoms will not feel so problematic.  However, after use has stopped and the elbow has been in a resting position for a while, initial movement can be quite painful again.  During the early stages of the symptoms, they are very isolated to a very small spot on the lateral or medial aspect of the elbow.  Again, if symptoms are not treated, this small area becomes larger and can refer down the arm towards the hand.  These symptoms can be a dull to very strong aching or burning pain.  Depending on how severe the symptoms are, the area may have symptoms of numbness or loss of sensation.  This is due to swelling at the elbow which can cause pressure on the nerves affecting the forearm.  When pressure is applied on the nerves, this results in the numbness or loss of sensation.  Some symptoms may also be present just above the bony prominence of the elbow.  As symptoms progress, pain at night time can be very intense and can wake a person.  Keeping the elbow bent during the night can increase the intensity of the symptoms, i.e. sleeping with your arm above or behind your head, sleeping on your stomach with your hands under the pillow, etc.  Keeping the elbow bent for a prolonged period can significantly reduce the blood flow and circulation to the involved area causing an increase of the inflammation process and worsening of symptoms.  The involved area can appear swollen, puffy, red, and there may be a skin temperature increase over the tendon insertion area or the common flexor/extensor tendon mass.  When left untreated altogether, the tendon can become so deteriorated that it can tear from the bone or tear from the muscle belly.  This usually requires surgery to repair. 

Treatment

To begin I'm going to give you a progressive list of treatments that will help resolve Tennis or Golfers elbow.  It's very important to know that patience and consistency with avoiding exacerbation of symptoms is going to be extremely important.  Many people are often referred to physical therapy to have treatment.  Some people will have steroid injections by a doctor to help reduce the inflammation and symptoms.  During the time that the injection is working, this is the best time to appropriately treat the tendonitis so that when the injection wears off your symptoms are resolved.  Ok, so here we go:

• Use an over the counter anti-inflammatory medication and rest the arm
• Using ice with the anti-inflammatory and rest is also recommended.  When icing your elbow it's important to avoid icing for too long.  When the ice is being applied directly to the skin via  a plastic bag, the recommended time for icing is 10 minutes and no longer.  This is so you do not cause a nerve palsy of the radial or ulnar nerve at the elbow.  These nerves are very superficial and can be damaged by icing too long with the ice directly on the skin.  If you are icing and are using a towel or some other layer between the ice and your skin, icing may be performed longer.  The rule of thumb to abide by when icing is:  let the ice go through the stages of aching and burning.  Once the ice becomes tolerable it's time to remove the ice.
• Stretching of the involved muscles and tissue can be performed with the above steps
• Cross Friction Massage can be done after being properly instructed with this procedure by an appropriate healthcare provider.  Icing can be performed following the cross friction massage
• Treatment by a competent physical therapist is recommended.  There are modalities that the PT can use which will help speed recovery of the tendonitis.  These modalities include the following:
• Ultrasound while using the appropriate settings
• Iontophoresis
• Phonophoresis
• Electrical stimulation while using the appropriate settings
• Thermal modalities
• ASTYM - Augmented Soft Tissue Mobilization.  This is an extremely effective treatment when performed properly and at the appropriate intervals.  ASTYM can be combined with other modalities, passive and active, to help reduce the pain and inflammation.  Not all physical therapists are credentialed with ASTYM.
• The introduction of passive and active therapeutic exercises should be introduced at the appropriate time.
• Using a elbow strap can also be very effective.  However, I am very picky about which strap should be used.  I do not recommend the strap with the air cushion.  This type is very ineffective.  The strap that I recommend is the Bauerfind Epipoint Elbow strap.  Bauerfind makes very effective and high end braces, wraps, and splints for various injuries.  There is one draw back with Bauerfind.  Their products can be expensive.  The plus to this is, you know that they will work and that they will last a ver long time.  They are of excellent quality.
• Using a compressive elbow sleeve or elbow strap at night can be very effective.  The sleeve or strap will prevent you from bending your elbow to a point in which can increase inflammation and decrease circulation.  This may take some getting used to early on but the benefits are very good.

When treating Tennis elbow or Golfer's elbow, a combination of the above treatments are usually performed simultaneously.  This ensures better healing and a shorter recovery time.  Therefore seeking out a physical therapist that treats these injuries can mean the difference between a nice progressive successful recovery vs. going under the knife to debride damaged tissue and re-attach the tendons followed by a slow and drawn out recovery with possible loss of function.

As usual, if you have any questions or concerns, please feel free to email me at:  bradsenska@yahoo.com

Happy Sporting!!

What Is Shoulder Impingement Syndrome?

As a physical therapist this is a complicated question and the fix can also be complex.  The shoulder by far is one of the most complicated joints in the body.  It has the greatest amount of movement than any other joint in our bodies.  And do you really have shoulder impingement syndrome?  As a practitioner, if someone comes to me with a prescription or request to treat shoulder impingement syndrome, I'm not going to just look at the shoulder.  I'm going to do an evaluation and assessment on the neck or cervical spine as well.  As I stated, shoulders are complex joints requiring a very skilled practitioner to correctly diagnose impingement syndrome.  Obviously something is impinged.  It's either the shoulder or something coming from the cervical spine.  But for this article, I'm going to just stick with the shoulder joint.  I'm making a firm diagnoses for this article that a person does have  "shoulder" impingement syndrome.

So What Is Shoulder Impingement Syndrome?

From my point of view, this is simply answered.  It is when the tissue underneath the roof of the shoulder gets pinched when the arm is moved in a specific manner.  So now, what's the next question?  

How Do You Resolve Impingement Syndrome?

This is the hard part.  Sometimes it's easy but most of the time it takes some work by the physical therapist and especially by the patient.  Before we go into answering how you get rid of it, we have to look at the anatomy of the shoulder to understand its' mechanics so that the right treatment application can be applied.

The Rotator Cuff Muscles & Shoulder Anatomy

On the left side of the diagram, you'll see the four muscles of the rotator cuff (RTC).  On the right side of the picture you can see that the RTC muscles are what steer the humeral head in that very tiny socket on the shoulder blade or scapula that's called the glenoid fossa.  So, when looking at the size of the humeral head and then looking at the size of the socket that the humeral head sits in, it's quite remarkable what the RTC has to do.  The RTC is responsible for making sure the humeral head sits in that tiny socket.  The attachments of the four RTC muscles are all within the red circle.  The space between the acromium process and the top of the humeral head are where shoulder impingement occurs.  The muscles of the RTC elevate the hummers to a certain point and rotate the humerus inward and outward. 

So why do some people acquire shoulder impingement syndrome and some don't?

Again, we have to look at some more anatomy of the shoulder.  Below are three different types of shoulders.  

Type I Acromium Process

Type I acromium process (AC) is where the bony structure at the edge of the scapula or shoulder blade turns slightly upwards.  Unless there is severe weakness or trauma to this type of shoulder, impingement syndrome does not occur often in a type I acromium process.  These are the people that usually do not have to worry about shoulder impingement syndrome.

Type II Acromium Process

With a type II AC process, the bony structure on the end of the scapula protrudes out laterally or just slightly downwards.  A type II AC process is the most common type.  With a type II process, acquiring impingement syndrome is more likely than a type I.  With a type II AC process, there is usually an aggravating factor that brings about impingement syndrome vs. the type of AC process listed next.

Type III Acromium Process

With a type III AC process, the end of the bony protrusion of the scapula orients itself in a hooked or downward position.  This type of process as you may have already surmised is very common with acquiring impingement syndrome.  Typically if a person has a type III AC process, then some point in their life they will have to tend to resolving shoulder impingement syndrome.

As previously stated, impingement syndrome is when the soft tissue becomes compressed between the head of the humerus and the AC process.  The next question is:

What Role Do The RTC Muscles Have With Regards To Impingement Syndrome?

The RTC muscles are what steer the head of the humerus in that tiny little socket.  So, if one of the RTC muscles becomes weakened then this means that this particular RTC muscle is not doing its job and the humerus is not staying centered in the socket.  When the humerus doesn't stay centered it then begins to "bang" against structures adjacent to the humerus.  This means structures above it as well.  These include the RTC tendons and the lubricating sack called the bursa.  When this occurs, it causes an inflammatory response.  When an inflammatory response occurs this means swelling.  Given the way the shoulder is already built, there isn't much room for any type of inflammation to occupy this space.  There's also no room for extra movement of the humerus outside of the socket or glenoid fossa.  When the humerus moves too much with impingement syndrome, it can also aggravate the bursa that lies on top of the humeral head and just under the AC process.  This bursa is a lubricating  sack that allows the tissues such as the RTC muscles to glide smoothly and evenly under the AC process.  But if the humeral head is not being steered properly by the RTC muscles, this bursa too can become aggravated and inflamed.  When the bursa becomes inflamed, it too swells and takes up space between the humerus and AC process.  So, let's take a look at what's happening now.

1. RTC muscles become weak and do not properly steer the head of the humerus in it's socket.
2. Because of this extra movement of the humerus, it bangs against tissues that it's not supposed to bang against on a continual basis
3. Inflammation begins to occur in the RTC muscle tendons.  This again occupies precious space between the humeral head and the AC process.
4. If the initial impingement syndrome is not addressed, the lubricating sack called the bursa then becomes irritated and swollen.  When this happens you now are dealing with shoulder bursitis (inflammation of the bursa) and impingement syndrome.  By now there is significant pain present even when the arm and shoulder are at rest

In summation:  RTC muscle weakness + Type of AC process + extra humeral head movement + onset of bursitis = A severe case of Shoulder Impingement Syndrome.

  

Symptoms Felt With Shoulder Impingement Syndrome

The initial symptoms felt with impingement syndrome are a pinching sensation on the front or lateral edge of the shoulder when reaching out away from your body, behind you, across your body, or when reaching overhead.  As the impingement syndrome worsens, the pinching pain can become very strong and begin to refer pain down the arm through one or all of the following muscles; the biceps, the triceps or posterior arm, or along the lateral aspect of the arm.  Typically symptoms of impingement syndrome do not refer past the elbow.  However this is not always the case.  This is why an evaluation of the cervical spine is performed as well.  The therapist wants to make sure that the referred pain into the upper arm and forearm are coming from the shoulder and not coming from the cervical spine.

What Causes Shoulder Impingement Syndrome?

This is not an easy question to answer.  Shoulder impingement syndrome can simply be caused by the type of AC process one has.  However, most shoulder impingement syndrome is caused simply through weakening of the RTC muscles.  The weakening then allows for improper movement of the humeral head in the socket.  Repetitive use is another way.  One might say though that they are used to working all day long lifting items of weight overhead or in front of oneself.  This thought of being strong through normal daily activity is usually the cause of impingement syndrome.  The most common cause of impingement syndrome is through overuse or repetitive use syndrome.  Just because you are using your arms in a physical manner doesn't mean that this is keeping the RTC muscles strong.  What is happening is that a person will think that they have strong shoulders because of the daily physical use.  Here's the downfall with this thinking.  "Daily use" is a normal daily activity.  And if this normal daily activity is performed in high repetition then the "daily" wear and tear on the shoulder will eventually become "too much daily activity".  The RTC muscles and tendons weaken and then the process of impingement syndrome sets in.

Other causes of impingement syndrome can be:

• Trauma
• Habitual posturing such as the position you might sleep in or sitting in your chair reading a book.  Habitual and prolonged posturing can cause decreased blood and oxygen supply to the RTC which causes weakness and allows impingement syndrome to set in
• Weakness of the shoulder itself such as the deltoids, triceps, and biceps muscles
• A compromised nerve in the cervical spine causing decreased motor signal impulses to reach the muscles of the shoulder and RTC
• Type of AC process
• And again of note, repetitive use or over use syndrome leading to shoulder girdle and RTC muscle weakness
• Specific sports that require a lot of overhead reaching such as tennis, swimming, or being a baseball pitcher.  These sports are very demanding on the shoulder.  If a proper strength regiment is not performed in addition to just playing these sports, then the likely hood of impingement syndrome setting in becomes high
• Age.  Getting older and loosing the elasticity in the soft tissues of the shoulder can cause excess joint play of the humeral head causing impingement syndrome

There are physical therapists that specialize in the treatment of shoulder injuries.  As previously stated, the shoulder is a very complex structure.  In this article, I have just glazed over in the simplest manner about the anatomy of the shoulder and the basics of shoulder impingement.  There are many primary nerves, arteries, and other vessels that are adjacent to the shoulder complex.  In order to isolate the cause of shoulder impingement, the therapist has to rule out pathologies of these adjacent tissues as well as the cervical spine.  It takes patience and compliancy with physical therapy to permanently overcome shoulder impingement syndrome.

In the meantime, enjoy reaching across the table for that last favorite delight!

Always In Good Health!

Brad Senska, PT, DPT, BS, ASTYM

bradsenska@yahoo.com 

Which Physical Therapy Practice Is The Best One To Go To?

The intention of this article is to help educate the patient on the different types of physical therapy practices and then how to decide which one is best for them

Choosing a physical therapist (PT) or physical therapy clinic is like choosing any primary healthcare provider.  Physical therapists are primary healthcare providers in most states now.  You also do not need a referral from a physician to attend physical therapy in most states.  Once you've decided on a PT, you'll most likely stick with this therapist for any subsequent injuries just like a primary care physician.  There are several types of PT practice models that operate in every state.  What I'd like to do is go through these practice models in order to help you decide on how to choose a PT if it ever comes to that for you. I'll then tell you the practice model that I really like and used in my PT practice.

There Are Three Types of Physical Therapy Practices

1. The Altruistic or Original Physical Therapy Practice
2. The High Volume Practice or Clinic
3. The "I Don't Know You" Practice or Clinic (This is my own label)

The Altruistic Or Original Physical Therapy Practice - Physical therapy initially began on a volunteer basis.  In the short of it, physical therapy initially got it's roots during the big polio outbreak several decades ago.  Physical therapy was initially administered by nurses or nursing aides (at that time called restorative aides) in order to restore motion to affected limbs of those suffering from polio.  By performing range of motion activities, this relieved extremity pain and restored, to a certain level, the function of the affected limb and the function of the patient.  Over the years physical therapy extended beyond just treating polio patients.  It was found that earlier movement after surgery provided better recovery outcomes.  Clinical and scientific studies began in depth and found that physical therapy provided much more to patients than one could imagine.  Physical therapy evolved to what it is today - a multi-disciplinary medical practice.  Physical therapy absolutely has it's place in patient care.  

I want to be as politically correct as possible but I also really need to inform you of the benefits of a original practice model.  Original practice models focus much more on the patient vs. how many patients a practice can get in the door (high volume practice & I don't know you practice) as well as their profit margin.  Yes, physical therapy is a business and practices need to make money.  However, patients should not suffer because of a greedy clinic owner.  With an original practice model, you will be the focus of attention.  You will be thoroughly educated with your injury, your plan of care, and what you should be doing and shouldn't be doing at home.  In addition, the therapist will spend a significant more amount of time with you.  You will have a very customized treatment and plan of care vs. a generic treatment at other practices.  The time you spend at physical therapy will be with a PT and not a physical therapy tech or other ancillary staff.  Another benefit of the original practice is that the PT will usually be much more thorough in their documentation with regards of how you are doing and with regards to communication with your physician if a physician referred you to physical therapy.  The bottom line is, the quality of care will be much greater than at other practice models.  

As previously stated, physical therapy is a business.  Physical therapists get paid from insurances just as medical doctors get paid from insurances.  But some physical therapy practices are more concerned about their profit margin (high volume practice) vs. a balance of proper care and profit margin.  This is where the original physical therapy practice once again comes in with high marks.    Ethical care takes priority.  The original physical therapy practice has a very nice balance between making money and giving the best care possible to the patient.  If a patient is able to find more of an altruistic practice model, then that person will see and feel a tremendous difference in patient care and see the difference with ethical billing practices.  However, for the Original clinic owner, keeping open appointments on the schedule becomes problematic due to the patients wanting to get in to the practice.  It doesn't take long for the Original practice model to develop a very good reputation.  It's this need to see patients that many clinic owners will adopt other practice models.  But good patient management, good time management, and adding a like minded PT to the practice can offset the need to morph in to a less ethical practice. 

Something that is very noteworthy and of great importance with an altruistic or Original PT clinic is that more responsibility is put on the patient with regards to compliancy with their treatment and plan of care.  This is because of the customization and Education that a patient receives in a Original practice.  The  Original PT practice is one that spends more time with a patient one on one.  This one on one time is to be able to educate the patient about their condition.  This isn't just a story telling time.  This information is meant for the patient to use during their recovery and be responsible for their recovery. If a patient is going to receive this kind of care then this patient needs to reciprocate and be responsible for their home care instructions.  However, being responsible with home care should be the case no matter the type of practice a patient goes to.  A patient should always follow through with the educational instruction from the physical therapist.    With other practice types, the so very important education of the patient is left out.  The patient goes through their physical therapy process without knowing why they are doing what they are doing.  So without further explanation here is an itemized list of the pro's for seeking out an altruistic or Original practice model:

• You will always see the same physical therapist
• You are held responsible for following the instructions by the PT for proper recovery.  Non-compliancy with this can mean discharge from physical therapy whether you have recovered or not.  Non-compliancy is often referred to as "waste of resource" by a patients insurance company if the patient is using insurance vs. cash paying patients
• Because you will always have the same therapist, problem solving of your injury is performed in a much more competent manner
• Your plan of care will remain consistent
• Progression of your care will occur at the right intervals and will be communicated in a timely manner to your referring physician
• Of great importance, you will be fully informed of all aspects of your injury and pathology.  So education regarding your care and recovery will be covered thoroughly
• This type of practice most often does not use ancillary staff such as PT techs, aides, or athletic trainers.  If ancillary staff are used, then they too will be educated fully on your plan of care.
• Discharge will be performed at the appropriate time.  
• The therapist does not see as many patients in a day as does a high volume clinic or an "I don't know you" clinic.  This results in better documentation and very ethical billing practices.  
• On the downside, these clinics are harder to get into.  Once you do get on the schedule it is up to you to maintain your schedule, limit deviation of your schedule time, and absolutely do not miss your appointments.  A good altruistic clinic is hard to find and often even harder to get into.  The best care comes from these clinics!

The original type of practice is absolutely my preferred method of practice.  Persons who do attend the high volume clinics do receive care that improves function and healing but the quality of the care is often questionable and of poorer quality.  So, if you ever have to attend physical therapy ask the clinic how many patients a therapist will see in a day.  If the number of patients exceeds 12 - 14 in a day, then you're looking at more of a high volume clinic and ancillary staff are most likely used.  Also make sure you will be seeing the same therapist each visit.  Clinics that treat patients with varying PT's are typically hospital based outpatient clinics and high volume clinics.  

The High Volume Clinic - The title already does a good job of describing this type of practice.  A high volume clinic is one in which a patient is seen more or less for just a few minutes by the PT.  Once the PT has checked in with you, you are then handed over to a PT tech, exercise physiologist, or an athletic trainer.  A high volume clinic is one that mostly benefits the owner of the clinic vs. benefitting the patient.  The more patients seen then the more money the clinic owner can claim in billing.  Often high volume billing practices are unethical.  

Education of the patient in a high volume clinic with regards to their injury or plan of care is minimal.  Because the PT comes and goes so quickly in a high volume clinic, the education of the patient is significantly bungled or left out all together.  What I mean by this is, the patient goes through the motions of physical therapy but they have no idea why they are doing what they're doing.  Nor does the patient get a thorough explanation of their pathology that brought them to PT in the first place.  

Next, with a high volume clinic, therapeutic exercises or activities are prescribed and then it is up to the PT aide or tech to perform these activities with the patient.  Once again, the PT aide is going through the motions with the patient but doesn't know exactly why the patient is performing a specific routine.  A huge downfall with this is that the tech doesn't know what signs or symptoms to look for that might be contraindicated for the patient.  The next thing to mention is, with a high volume clinic, prescribed exercise routines become the mainstream for everyone.  

Quick Editorial - Most times "filler" exercises are added to a routine just to keep a patient busy and  to accumulate time in the clinic.  These filler exercises are often not even related to the patient's injury.  They are added in order to accumulate the time you've spent in the clinic so that the clinic can bill you for this time.  

The mainstream exercise routines are because the PT doesn't have the time to customize a proper therapy protocol for a specific patient.  I have seen this first hand in several clinics and it ruins my whole concept of what physical therapy is supposed to be.  I have seen someone with a shoulder injury performing the same exercises and therapeutic activities that a patient with a total knee replacement is performing.  This does the patient no good at all.  It is also a very unethical practice.  Why would someone with a shoulder injury be performing exercises for their hip or knee?  Again, the answer to this is that the PT is too busy to customize and then educate the patient on a proper therapy protocol.  So instead of taking the time, the PT will hand the PT tech an generalized exercise flow sheet and have the tech perform this generic routine with the patient.  In addition to this, as the patient heals, the protocol needs to be changed or progressed in order to match the rate of healing of the patient.  With a high volume practice, the progression of a therapy protocol is not maintained.  Again, this leaves the patient in a "healing" limbo.  Of significant importance with this healing limbo, the patient's insurance only allows so many visits to physical therapy.  So each time the patient goes in to physical therapy, they are paying for something that is useless and something that the patient has a very poor chance at recuperating.    

Next, what happens when the patient has met the ability to perform the initially assigned therapy protocol?  They are usually discharged and are discharged prematurely.  The strength and function that was supposed to be acquired in order to go back to their regular work and recreational activities was not acquired.  This leaves the patient very susceptible and prone to subsequent injuries and poor long term healing.

As in typical fashion in my articles, I'd like to give you a simple summary of a high volume clinic:

• Minimal time is spent with the PT
• Proper education of the patient and the ancillary staff are not met
• A proper therapy protocol is often not met
• Proper progression of the therapy protocol is not kept up to date
• Unethical billing practices occur and this translates over to the patient paying for something they didn't receive
• The patient does not receive the care that they are paying for
• Discharge is often premature leaving the patient susceptible to unfinished healing or subsequent complication of the current healing
• There is poor documentation of the patients status.  Proper documentation is what dictates how much a clinic is reimbursed.
• Often unnecessary "filler" exercises are added to your physical therapy protocol so the clinic can justify the time you spent in the clinic and bill for that unnecessary time

The "I don't know you" clinic - This is a clinic in which is very similar to the high volume clinic except that the volume isn't with patients.  The volume is with PT's.  An "I don't know you" clinic is one in which a person has a different therapist each time a they go in for a physical therapy treatment.  The patient is usually not informed at the time of scheduling that they will not be seeing the same therapist on a subsequent visit.  Imagine that you chose a primary care doctor.  When you go to the doctors office you know that you'll be seeing the doctor that you were expecting to see.  By seeing the same doctor you're able to build a relationship with the doctor.  By doing so, the doctor gets to know you well and is able to meet your needs in a very specialized way and in a very consistent way.  A relationship with confidence and trust is built.  This is the same way that physical therapy in my opinion should be practiced as well.  However, many clinics do not do this.  Instead, the patient is often placed on the schedule just to get you back in the door for your next visit at the clinic's convenience, not yours.  When you're placed on the schedule, you're also put with a different PT.  Here is an example.  A patient has been coming in at 10:00AM Monday, Wednesday, and Friday for the past 2 weeks.  Now all of a sudden for some reason, this time slot that they are used to is taken after two weeks out.  However, there is an option for the patient to stay with the current PT.  This is to schedule with the same therapist but at a different time.  But often times, the scheduling staff will keep you at the same time so that the rest of the schedule is not upset and when they do so the patient is scheduled with a different therapist.  In many cases, the patient will see a different therapist each subsequent visit.  This "I don't know you" method also benefits the clinic or clinic owner vs. accommodating the patient.  

The downfall of seeing a different PT each visit is quite obvious.  As with a patient's primary care doctor, a relationship is built.  Doctor and patient get to know each other and become comfortable with each other.  Same as with seeing a PT, trust and confidence are built as is a good plan of care for the patient.  Patient education is established with the PT, consistency with treatment is maintained with your PT, and good communication is established between you, your PT, and your referring physician.  When a new PT is tossed into the mix, it's like going to see a stranger and your plan of care is disrupted.  In addition, the PT does not know you or your status and your plan of care again is disrupted even further.

Here is a summarized list of con's with seeing an "I don't know you" clinic:

• Most importantly, a patient's plan of care can be disrupted
• Poor consistency of treatment
• There is a chance of multiple diagnoses and change in philosophy of treatment
• Education of ancillary staff regarding the patient is poor
• Mixed educational messages often occur due to a PT's philosophy of practice
• The patient's treatment can suffer due to the PT not having the full history of the patient prior to treatment
• Of the different PT's, who will decide the progression of treatment and who will decide the appropriate discharge date?
• Often unnecessary "filler" exercises are added to your physical therapy protocol so the clinic can justify the time you spent in the clinic and bill for that unnecessary time

My advice to you is to insist on the same therapist from each treatment session to the next!

Here is what you will want to know and ask when attending physical therapy:

• Will I be seeing the same therapist each session?
• How much time will my therapist spend with me?
• Will I be under the care of physical therapy techs or aides during my treatment?
• What part of treatment will the ancillary staff (PT techs, PT aides) be administering?
• Ask to be scheduled out as far as possible so that you can stay with the same therapist and keep your therapy consistent
• Pay attention to how much time you spend at your physical therapy clinic.  Then make sure that your bill matches the amount of time spent during your PT treatment.  Often times there is over billing.  Insurance companies do not have nearly enough time or manpower to audit physical therapy practices or medical practices in general 

On another page in my website, I mention that physical therapists do specialize in specific treatments or pathologies.  This is something else you will want to consider when choosing a clinic.  You will want to inquire about whether or not the clinic in question treats your specific injury.

As Usual, Good Health & Spirits To All

Brad Senska, PT, DPT, BS, ASTYM.

bradsenska@yahoo.com

When Is The Best Time To Eat In An Endurance Event?

I believe this article will help most with people of whom are just getting started with their adventure in endurance sports.  I've not ever discussed nutrition in my blog and there's a reason for this.  The intake of nutrients during an endurance event is different for each individual person.  Nutrition is very customized.  A person will go through a period of trial and error with several different types of energy gels and bars before settling on one or two that work best for them.  So what I'm going to do in this post is give you the basic breakdown of the different types of nutrients or fuel that is used during a endurance event.

Fuel intake during endurance events seemed to become of strong interest in the early 80's.  The default fuel intake during this time were bananas.  Why bananas?  Bananas contained essential electrolytes and the right type of sugar that could be quickly converted to the appropriate type of fuel for the muscles without disrupting the gastrointestinal (GI) system during high physical output.  This was great!  The problem however was that the energy the banana supplied was short lived.  In addition, carrying enough bananas with you during a long event wasn't practical.  So what was needed was a compact lightweight fuel that would provide a person with enough energy for a sustained period of time and a fuel that didn't disrupt the GI system.  Another consideration for the right type of fuel is one that wouldn't pull too much blood from the working muscles to the stomach in order to breakdown and digest the fuel.  So what did the researchers come up with?  Here's the answer:

"Monosaccharides and Disaccharides" along with other nutrients such as electrolytes, anti-oxidants, amino acids or proteins, caffeine, vitamins, and flavoring.  Each energy company has their own secret recipe.  Because of the varying ingredients from one gel to the next is the reason why a person may have to go through a trial and error of which gel is the best one.  One gel may have too high of a concentrate of one or another sugar or caffeine for a particular person's digestive system.  Using a gel or bar that doesn't get along with your digestive system can cause cramping, diarrhea, and the inability to absorb any type of nutrient because of the current digestive system upset.

Monosaccharide and disaccharide?  What the heck are these?  No worries.  They are just fancy names for sugars that we consume in our everyday foods.  Let's start with a monosaccharide.

Monosaccharide (one sugar by itself):  This would be the same thing as glucose or dextrose.  This is a single molecule sugar.  Single molecule sugars breakdown in to useable energy very quickly and is very easy on  the GI system.  Glucose is the sugar that our muscles and brain use as energy.  This sugar is the most easily digested sugar and is most readily available.  

Disaccharide (two sugars bonded together):  Fructose is a disaccharide.  A disaccharide is a two molecule sugar and therefore slower to break down into useable energy.  Fructose is a sugar that is found in fruits and vegetables.

Maltodextrin:  This is the most common sugar found in energy gels.  Maltodextrin is a more complex sugar because it is made up of more than one or two molecules.  Maltodextrin breaks down in an optimum manner to provide you with the right flow of fuel or energy to the bloodstream without disrupting the GI system.  

Sucrose:  This too is a disaccharide.  This molecule is made up of one glucose molecule and one fructose molecule.

There are other sugars used in energy gels and bars but the above listed are the most common.  You notice how I just breezed over the names and definitions.  To say more about them would be getting into the chemistry of each and this can become complicated.  Here's an example of the chemistry and considerations when creating an energy gel:

• If you noticed, sucrose is a disaccharide (glucose + fructose).
• Glucose by itself is a monosaccharide.  Same as fructose.    
• Maltodextrin is varying lengths of glucose chains, i.e. glucose + glucose + glucose... up to ten or more molecules combined together.  When many sugar molecules are bonded together then the sugar becomes a polysaccharide.  These too are used in energy gels and bars for sustained energy release.  The more bonds in a sugar chain that need to be broken down, then the slower the release of energy into your system.
• But in any gel or bar, the main ingredients will be a combination of sucrose, glucose, fructose, and maltodextrin.

Energy gel and energy bar manufacturers go through a tremendous amount of combinations of these sugars as well as vitamins, amino acids, electrolytes, etc. so as to get the energy gel or bar just right.

What Does "Just Right" Mean?

Just right means that the gel will absorb at just the right rate and release just the right amount of energy to keep the GI system working just right.  The sugars listed above are simple and not complex sugars that break down in the stomach and are either absorbed via the stomach or as they just enter the small intestine.  If the gel or bar contained a more complex sugar then it would take longer to be absorbed, require more blood to be pulled from the working muscles, and could cause an upset stomach as well as muscle cramping.

So, When is the best time to ingest the energy gel or bar?

This really is the question now isn't it?  Now that the gel has been properly formulated, when is the best time to consume the gel?  Most manufacturers give a general guideline of when and how to consume the gel.  The general guideline is 15 minutes prior to your activity and then 45 minutes to one hour after you've begun your exercise and then every 45 minutes until you've completed your exercise.  Remember, this is a general guideline.  This absolutely does not work across the board for everyone.  Each person burns through calories and fuel at a different rate as they exercise.  However, this is the link as to when it's best to consume a bar or gel.  

Exercise exertion plays a big factor in the timing of when to consume an energy gel.  Your fitness level also plays a role in when to consume an energy gel.  Generally, the more trained and conditioned you are, then you have greater lee way of when to consume a gel and how much you need to or are able to consume.

Fitness level aside, physical exertion or the intensity of the exertion is the factor on when to consume energy fuel.  The intensity of work being done will determine how well and how quickly the energy will be absorbed and then used by your body.  This is one of those factors that fall into the trial and error category.  To get straight to the point, it's best to consume energy gels/bars when you are not exercising or racing at a high intensity.  If you've ever watched professional cycling, the feed zones are usually placed along the course in which the cyclists are not cycling at their highest intensity.  There is a reason for this.  When exercising at a high intensity, blood and oxygen are diverted into the working muscles.  When you consume an energy gel, blood is called away from the working muscles to the stomach in order to digest the gel or bar.  The amount of blood that is diverted is also relative to how much of the gel or bar is consumed and how dense the nutrients are in the fuel.  If too much energy fuel is consumed at one time this can cause GI distress and even muscle cramping.  This is one reason why energy gels come in small packets.  Gels are meant to be taken in smaller amounts so that GI distress does not occur.  

There are several reasons why energy gels and bars are designed the way they are.  And I'm not talking about the shape or size of the energy fuel.  I'm talking about the chemistry of the energy fuel.  Here are the most important reasons.  They are designed:

• To be digested with minimal blood being diverted from the working muscles to the stomach
• To be absorbed by your digestive system as easily as possible and as quickly as possible
• To not create a blood sugar spike and then low.  This is where the "chemistry" of energy gels really come into play.  Energy gels need to release energy into the blood stream in a even and fluid manner.  If too much sugar and electrolytes are released to quickly, then the possibility of GI distress becomes a risk.
• To release the right amount of energy over a designated period of time.  This is where monosaccharides, disaccharides, and polysaccharides come into play.  The longer the sugar chain is, then the longer it takes to digest.  However, the long chain sugars will provide energy over a longer period of time.  A good example of a longer releasing energy fuel would be a Power Bar or Cliff Bar.

In summary, an energy gel or bar is best taken when not exercising or racing at your highest intensity.  It's also best to consume several ounces of water with the gel or bar to aide in proper digestion.  Energy bars and gels are created for specific purposes so read the labels and make sure you are consuming the proper gel or bar for the specific activity that you are performing and at what intensity.  Personally, I don't feel I've done this article justice.  There is a lot to consider when fueling up during high intensity activity.  As previously stated, it takes a period of trial and error to get the right energy fuel that works best for you.  Some gels are much more concentrated than others.  Some contain high amounts of caffeine and others high amounts of electrolytes.  Often, more than just one specific gel is consumed so that all bases are covered during training or competition.  

As usual, if you have any questions, thoughts or concerns, please feel free to contact me.  In the mean time, Bon Appetite!


Brad Senska, PT, DPT, BS, ASTYM.
bradsenska@yahoo.com

Long Term Use of Opioid Pain Medications In The Endurance Athlete

In preface, there has not been enough said here in this post to fully clarify the effects of long term opiate use in endurance athletes.  One difficultly with publishing precise information is that opiate usage and endurance athletes is more or less oxymoronic.  However, there are a few of us (myself included) that have lived with the ability to train and compete while on a more than moderate amount of daily narcotic consumption over a very long period of time (> 2yrs).  But with time, training let alone competing became more and more difficult.  The motivation was present but the body was no longer willing.  I speak from experience and I am using my own experience to write this post - as a narcotic free athlete!  

I've been pondering this topic for a long time.  So, using myself as a lab rat, I began to problem solve my training and competing issues.  But first, to get straight to the conclusion, opiate pain medications will eventually hinder physical performance in an endurance athlete.  

Let's look at a specific scenario.  A competitive cyclist has had an accident and has injured his pelvis or back.  The injury is so severe as to require surgery.  Pelvis injuries are quite painful and take longer to heal than other parts of the body.  Because of the prolonged healing, the athlete may be required to consume narcotic pain medication for an extended period of time.  In many cases, the athlete will begin to compete again while still using the pain medication.  While being re-introduced to vigorous physical activity, the consumption of narcotic pain medication is not so uncommon.  Pain medication is taken prior to the activity in anticipation of neutralizing any residual pain from the injury and healing process.  Often the athlete will make a generalization of performing better with pain medications on board.  The thought process is that "I will be able to perform better due to being able to tolerate a higher threshold of pain during harsh physical activity".  Again, this assumption is wrong.

Narcotic Pain Medication Is Not An Ergogenic Aide or Performance Enhancing Drug (PED).

It Does Not Improve Performance But

 Hinders Performance

This topic became a strong interest of mine due to the fact that I have had several spine fusions and following the spine fusions (lumbar & cervical) I returned to competitive cycling.  I did stay on narcotic pain medications for quite some time.  I returned to my usual training schedule and began to compete.  But no matter how hard I tried, my performance plateaued well below where I should have been performing.  I was bouncing off of the walls trying to figure out why I couldn't improve my fitness and reach a competitive level.  Finally a light came on and I began performing a very in depth literature review regarding how opiates affect different aspects of the body including physical performance.  Let me tell you, there is certainly not a plethora of information on this topic, but what I did find was extremely enlightening. After becoming educated on this subject and applying physiological and medical principals, I went straight to my doctor and asked to be taken off of the narcotics.  The withdrawal off of the chronic use of narcotics alone is a very difficult and painful process to go through.  This can easily take several weeks to several months to complete.  You'll understand why later on in this article.  But what helped me through it was that exercise is mandatory during withdrawals in spite of how horrible you feel!  And it's not just me, it's anyone that is struggling with opiate withdrawals.  Moderate to vigorous exercise will speed your recovery and reduce the pain of withdrawals!  

HOW NARCOTICS WORK IN THE BODY TO REDUCE PAIN

First of all, an understanding of how opiates work in the body is essential in order to understand how opiates affect physical performance.  

Opioids and the Central Nervous System (CNS) 

Opioids attach to specific proteins called opioid receptors, which are found in the brain, spinal cord (AKA the central nervous system or CNS), and gastrointestinal tract. When the drugs attach to certain opioid receptors, they block the transmission of pain messages to the brain.  Opioids relieve stress and discomfort by creating a relaxed detachment from pain, desires, and activity. Opioids tend to produce drowsiness, reduce heart rate, cause constipation, cause a widening of blood vessels, and depress coughing and breathing reflexes.

Nerves carry information through the spinal cord to the brain about what is happening inside and outside of the body.  The brain processes the information and sends messages back through the nerves that control how muscles and organs respond.  This being said, I think we can all agree that the CNS controls our voluntary muscle contractions and involuntary muscle movement.  This means that our balance, fine motor skills, gross motor skills, and our ability to stand and sit without having to think about how to stand and sit or even walk are controlled by the CNS.  This touches on just a very small portion of what our CNS controls in the body. 

Consider the function of our CNS with the following and it's relevance to physical performance.  The CNS Controls (amongst a myriad of other functions):

• Blood pressure when at rest or when exercising
• Heart rate when exercising or at rest
• Muscle recruitment for a specific task, i.e. whether to recruit fast twitch or slow twitch, and how much recruitment is necessary for a task.
• With reference to this post, the CNS also decides which fuels in our body are to be used during a specific activity.  The CNS controls the use of adipose tissue for fuel, the conversion of liver glycogen to blood glucose for fuel, and the ability to utilize the necessary amount of oxygen to convert these fuel sources for muscle contraction (remember, opiates suppresses the respiratory system).

The CNS controls the conversion of food to absorbable nutrients and energy in the gastrointestinal tract.  Hormone production and regulation.  After mulling over the above mentioned specifics of the CNS, many of you can speculate on just how opiates will affect physical performance.  There is slower absorption of fuel in the gastrointestinal tract, respiration and blood oxygen saturation is less, muscle recruitment is being affected adversely, and heart rate and blood delivery can be affected.  Hormone production such as the feel good hormones like dopamine, endorphins, and enkephalins are violently affected!  Endorphins and enkephalins are small peptide molecules that are naturally produced and are important regulators of bodily pain.   In men, testosterone production is negatively affected and sex drive is significantly reduced.  

The Specifics of How Long Term Opiate Use Affects Physical Performance

Long term opioid use can have a very detrimental effect on physical performance.  The reason for this is that:

• Opiates interfere with peripheral nerve transmission.  In other words, opiates reduce electrical activity in the body.   This in return reduces synaptic activity in the brain which causes signal reduction from the brain telling the muscle to work.  This causes significant muscle recruitment.  Over time this causes muscle weakness and atrophy.
• Naturally occurring hormones in the body cease production.  This is because the opiate acts as a specific hormone.  Since the body senses the presence of the "supplied hormone", the body stops producing that specific hormone.
• Opiates cause a reduction in appetite.  Therefore, prior to or after a hard workout a chronic user of opiates will typically not provide themselves with the appropriate nutrition needed to continue participating at a high level in endurance sports.
• Chronic users of opiates usually have a very high anxiety level due to their dependence on the opiate.  Chronic users of opiates typically need to steadily increase the amount of medication just to maintain normal daily activities.  If that increase in opiates is not supplied, a person can become clinically depressed and develop generalized anxiety disorder.
• Cortisol is a product of high anxiety and stress.  High cortisol levels in the body act as a catabolic hormone breaking down healthy muscle tissue.

The above listed are just a few affects that opiates have on an endurance athlete.  One could also argue that since the brains ability to send signals to working muscles is lessened, then the nerve to that muscle can atrophy as well.  The myelin sheath around the nerve can become thinned and only a weak or slow signal will reach the intended muscle.  

Earlier I mentioned how horrible a person can feel during immediate withdrawal and during the days or months following.  Depending on how long a person is on opiates is directly correlated with how long it will take a person to recover.  The damage done from opiates, fortunately, is not permanent.  The key to reversing the effects of long term opiate use is Moderate to Intense Physical Exercise.  It is a well known fact that vigorous exercise causes a sharp increase in the "feel good" hormones.  This includes those that were listed as being depleted by opiates - dopamine, endorphins, and enkephalins.  No matter how crappy you feel following detox from opiates, exercise is a major component for an absolute cure!  

All in all and with what is known, opiates will eventually hinder athletic performance, the ability to develop muscle, improve muscle strength, train fast twitch or slow twitch muscles, produce necessary hormones, and maintain training motivation and focus.  I am not a sport psychiatrist but I think that a study or several performed by an appropriate institution would give great insight on this topic. 

As usual, I can be reached at:

bradsenska@yahoo.com

Happy Locomoting!

Brad Senska, PT, DPT, BS, ASTYM.

Spine Fusion & Hip Extension During Running

Spine Fusion & Hip Extension During Running

Throughout this blog, I speak of ways to improve efficiency of running.  Recently, I became acquainted with Jeff Gaudette of Runners Connect.  On his website he has a great tutorial about the importance of hip extension during running.  As with all aspects of running, there has to be purpose, intent, and proper execution behind it to maximize the benefit of this one aspect of running.  So, with this post, I've decided to cover a couple of different aspects of hip extension and running.  As usual, I want to provide information that is unavailable anywhere else with specifics to injury and running or sport in general. 

Proper hip extension is a key component with efficient running.  As with all aspects of running and its' mechanics, there needs to be intent and purpose behind a specific aspect of a specific phase of the running cycle.  With this post, I'd like to emphasize the importance of the incorporation of the abdominal muscles to check anterior pelvic tilting and it's effect on checking hyper extension of the hip during running.

As with anything used in excess or in a "too much" mode, bad things can happen.  Without the braking motion of the rectus abdominus muscle and psoas muscle during running and active hip extension, you increase your chance of overuse injuries in the form of lower back pain, psoas muscle tendonitis, and even greater trochanteric bursitis (hip bursitis).  Hip bursitis by itself can be extremely debilitating if treatment is not strictly adhered to.

For persons that have undergone lumbar spine fusion, the tension in the abdominal muscles is extremely important with regards to limiting anterior tilting of the pelvis and compression of the compromised spine segments.  Because of the attachment of the psoas muscle on the lumbar spine transverse process, the action of active hip extension is like using a chisel to break down the inter body fusion hardware.  For those that remember the mechanics of the spine, an anterior pelvic tilt is the same thing as bending backwards.  All of us that have had a lumbar spine fusion know that bending backwards is an action that you want to avoid at nearly all costs.

For Those Without Spine Pathology

Hip extension is an active motion that provides us with potential energy ready to be turned in to kinetic energy for the forward advancement of our thigh and leg.  The stored energy in the hip flexors via the hip extending is the potential or stored energy.  The resulting and forward motion of the thigh is the stored or potential energy turned in to kinetic energy.  It's basic physics.

Now, lets ad a support system to the hip extension.  To maximize the amount of energy being stored in the hip flexors there has to be a strong support system or base for the hip flexors to work from.  The act of hip extension is like cocking the trigger on a gun.  Another analogy is if you want to acquire height in a vertical jump, it would not be wise to jump off a soft cushy surface.  The force developed to propel you upward would be absorbed by the soft surface you are launching yourself from. You would want to jump up from a hard firm surface to provide as much propulsion upward as possible.  This law or rule of physics is based on Newton's Third Law of Motion:

Third law: When one body exerts a force on a second body, the second body simultaneously exerts a force equal in magnitude and opposite in direction to that of the first body.

Given this information, it would make sense to provide a strong base in which stored or potential energy can be maximized.  So, to provide a strong base of support, an antagonistic muscle body would have to be employed to maximize the energy return of good hip extension during running.

The Anatomy & Physiology of Good Hip Extension

Image I shows a side view or sagittal plane view of a torso.  The bony structure of the pelvis and lumbar spinous process' are visible too.  Also visible are the rectus abdominus muscle and transverse oblique muscle.  For our purpose, I'm going to be focusing on the rectus abdominus muscle.  In the case of hip extension and the actual elongation of the hip flexors, the rectus abdominus is the antagonist of the hip extension muscles.  When the hip is at full extension, it's the contracting or shortening of the rectus abdominus that provides the base structure or launch pad for maximum kinetic energy from passive hip extension to active hip flexion.  It gets a little confusing huh?  No worries, we'll fix any confusion.  If the abdominal muscles do not contract and engage, then the slowing and reversing of the hip extension motion is left up to maximum congruence of smashing together of bony surfaces and maximum elongation and tension on the supporting ligaments and tendons.  Over very high repetition, this can cause over use injuries in several areas of the torso, lower back, and hip. 

So, when the hip or thigh goes backwards (extends) there has to be a brake to stop it's backward motion.  This brake is the psoas muscle and the supporting contractile structure is the rectus abdominus muscle.  Let's look at Image 2.  

                                                                                Image 1 

Side View of Torso, Lumbar Spine, & Pelvis

Image 2

Overview of the Mechanics of the Torso, 
Lumbar Spine, & Pelvis During
Running and Hip Extension

The gluteus maximus, medius, minimus, and hamstring muscles are the major hip extension muscles.  If the action of these muscles are left unchecked, the pelvis tilts forward very hard.  Subsequently the small joints in the back become compressed in a very harsh and violent manner.  This is indicated by the black arrows.  The hard forward tilting of the pelvis is indicated by the blue arrows.  When the top of the pelvis tilts forward, this is referred to as a anterior pelvic tilt.  The green arrows indicate the elongation of the abdominal muscles when the pelvis tilts forward.  Basically, with an unchecked and strong hip extension moment we are literally bending ourselves backwards.  

Now, if we reverse the direction of the green arrows and contract the abdominal muscles to just the right amount, then this reduces the amount of extension in our spine and reduces the amount of passive anterior tilting of the pelvis.  This accomplishes three major events.

1. This increases the amount of stored energy in the hip flexors for a much quicker hip flexion moment and forward advancement of the thigh and leg.  This is done by the abdominal muscles providing a solid base of support to turn this stored energy into kinetic energy.

2. This significantly decreases the amount of joint compression in the spine and tensile forces on the passive stabilizers of our hip and lumbar spine.  These passive stabilizers are our ligaments and joint capsules.

3. This reduces the amount of unwanted anatomical events such as compression in the lumbar spine segments, unwanted "yanking" of the psoas muscle on the lesser trochanter of the femur, and unwanted yanking motion of the psoas muscle on the transverse process in the lumbar spine.

By checking active hip extension with the right amount of contraction in the abdominal and psoas muscles, the stored muscle energy used for efficient hip flexion will be significantly increased.

All of this translates into more efficient running and enjoyable running.

As usual, I can be reached at:

bradsenska@yahoo.com

Happy Bipeding!