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Saturday, January 21, 2012

A Rant on what Physical Therapy REALLY is...

So, why am I writing this post?  I'm writing it because I want to help get more information out to the world about what Physical Therapy REALLY is.  There are thoughts, beliefs, ideas and misconceptions about what we do as clinicians and where are value lies.  Now for the purposes of this post- I am talking about Outpatient Orthopedic Physical Therapy and not other settings.

Let's start this off with some history behind why i'm writing this with some commonly asked questions:

Question: Why are you not using that magic gel stuff with the Ultrasound machine...
Answer:  I personally have not used Ultrasound in 5 years.  I do not see enough clinical evidence that proves to me it's effectiveness.  I would much rather spend an extra 5 minutes using my hands to manipulate tissue, facilitate movements, etc. 

Question:  Did you have to go to school for this...
Answer:  (I try not to get annoyed when asked this)  Yes, I have my clinical doctorate in Physical Therapy and as well had extensive clinical externships.  PT's go through 7+ years of school routinely and we are Board Certified.

Question: Can you put that stimulation thing with some heat on me to get warmed up and make things feel better...
Answer:  Lets get on the bike (or arm bike) to get warmed up and doing things that are movement based.  While yes, the Electric Stimulation feels good while it's on, it is not fixing your issue; it is just masking your pain.  Let's figure out WHY you have pain and solve that issue.

Question:  Why are you working on my neck and mid back when my pain is in my hand...
Answer:  I'm fixing the source of the problem.  You have "X" problems with mobility in a different area which causes compensation and causes pain where you have it...

Question:  My doctor gave me a shot of cortisone and I now feel better- why do I have to continue PT? OR My doctor gave me a shot of cortisone and I feel great. I wish PT would have helped more...
Answer:  Well, you are continuing PT because the biomechanical problems are still present and we need to fix that so the pain does not come back.  The cortisone took care of the inflammation, now we are fixing the root cause.  OR...  Physical Therapy did help, we fixed the mechanical issues first, you got some cortisone to reduce inflammation and now we can fix some of the higher level movement patterns and you should not have this issue re-surface (as long as the patient listens to instructions)

Those are just some of the questions I get asked quite regularly and while it bothers me, i do realize that there is a common misconception out there in regards to what our profession really is.  Here is my opinion on what a Physical Therapist is:

1- PT's are Anatomy and Biomechanical specialists that focus on movement disorders.  We assess, analyze and treat movement disorders that will help someone reduce pain and return to function.

2- PT's are trained clinicians that can diagnose orthopedic conditions and differentially figure out WHY the injury happened in the first place.  Example- You had a Rotator Cuff repair.  We do the rehab, get you better and figure out WHY it happeend in the first place.

3- PT's understand the body's ability heal, tissue response to variable factors and we get how the body compensates for an injury.  Example- An ankle sprain can cause neck problems simply due to the way gait changes.

4- We are Post-Operative Rehabilitation specialists-  We take the patient through SAFE and effective rehab programs after surgery to improve function without causing harm to the repair tissue.  We dictate to the patient what they can and cannot do and what will happen if they do not listen.  We see the patient multiple times a week and educate constantly.

5- We are relationship driven.  We develope relationships with patients, doctors, trainers, chiropractors, case managers, insurance companies, families, etc.  We make these relationships and gain trust, which in turn will improve outcomes.

6- We work as part of a team!  Teamwork is critical to patient care.  I think that point explains itself.

You can agree with what I am writing or you can disagree but one thing i promise you is that if you are a patient with "injury X" and you go to Physical Therapy where they see too many patients, Electric Stim and Ultrasound everyone and do not individualize your care, you are setting yourself up for failure.

I had a close friend of mine who is a well known Trainer and Performance Specialist say to me, "Because of you and (another PT) I now have a much better understanding of what PT really is.  Before you two, I honestly did not know and had a huge misconception"

Please do not get me wrong- There are thousands and thousands of GREAT PT's out there across the world.  The problem is that there are still lots out there that do not get "get it".  The more we educate clincians and the more we educate the general population, the better it will get.  That is my mission- To educate on what Physical Therapy REALLY is and to make a difference in the lives of others.

Hippocrates and Galenus are believed to have been the first practitioners of physical therapy as they created and advocated for manual techniques, exercise and aqua therapy to treat people in 460 B.C.  They GOT IT.  They treated people with their hands and with their knowledge on movement and the human body.  Now we look at people like Gray Cook, Gary Gray, Tim Tyler, Terry Malone, Christopher Power, Shirlie Sahrmann, Mike Voight etc...  They all GET IT.  They are at the forefront of taking Physical Therapy to the next level and educating people across the globe.

I encourage patients to ask their PT's questions such as: Why am I doing this particular exercise?  Why are you working on that area?  What is the reason for my having this issue in the first place?  If the clinician cannot give you a good concise answer, you are probably in the wrong place.  There should be an answer to all of those questions and it should make sense.

And that concludes my rant on what Physical Therapy REALLY is.  Is there more I can say, yes, but you get the jist.  This is how i function on a daily basis with any patient who walks through my door-  Evaluate, assess, educate and treat the person that is right there in front of you.  Decide what needs to be done based on the information right in front of your face.  Treat them with respect, have fun and when all is said and done, you have gained their trust for life and probably made a new friend.  Isn't that what it's all about?  Helping people and making friends?

Monday, January 16, 2012

Flexor Hallicus Longus and Plantar Fasciitis...

Do you have plantar fasciitis?  Do you have a patient or a client who has plantar fasciitis?  Does the fasciitis keep coming back time after time?  If you answered yes to any of these questions you will find this post extremely helpful.

Ok, so you have properly diagnosed that patient X has Plantar Fasciitis (PF for the purpose of this post).  Winner Winner chicken dinner!  What does this diagnosis tell you other than their plantar fascia is inflammed?  Not much...  We need to figure out WHY they have developed the PF in the first place.

Here are some thoughts/suggestions/ideas.  The only one below that you must do first, is #1 (in my opinion)

Step 1- Look at their gait and watch them MOVE.  You WILL find some faulty movement patterns that are leading to the increased stress on the planar surface of the foot...

Step 2- Look at their Gastroc/Solues Complex for facilitated muscles and restricted fascia (This should not be rocket science)

Step 3- Look at the distal tib-fib joint.  If this is restricted and leading to decreased dorsiflexion, something has to compensate and usually the PF will become irritated

Step 4- Flexor Hallicus Longus!  This is a major key to treating PF.  With PF, the FHL will almost always become facilitated and we cannot cure the PF without releasing the FHL.  Rememembet that the FHL Originates at the Posterior surface of the distal 2/3 of the fibula and as well the interosseous membrane and associated fascia.  FHL inserts at the base of the distal phalanx on the plantar surface of the great toe.  Bascially the tendon of the FHL travels directly along side of the plantar fascia, which can and will directly alter the mechanics of the PF.  Don't forget to treat the FHL both where it travels posterior to the medial malleolus AND where it travels parallel to the PF.

Step 5- Go look at the knee and go look at the hip.  Take a look at their glutes first...  Do we have a weakness of gluteus medius causing a trendelunberg gait?  Is this gait abnormality causing extra stress on the PF?  Bingo, yes it is...  Do we have a restricted iliopsoas?  Is this restreicted iliopsoas?  A restricted iliopsoas migh now cause the hip to slightly internally rotate which will change the mechanics of the lower extremity and possibly increase pronation of the foot. (And thats just scratching the surface)

Step 5- Based on your movement pattern assessments- treat and fix the dysfunctional movement patterns.

Treat the mobility issues manually with your tool box and make sure once you have fixed the mobility issues you fix the stability issues.  Use the KISS principle (Keep It Simple Stupid).  Make sure you start simple and dont progress until they are ready.  Fix the core, fix the foundation and then move to the more complicated patterns.  And dont forget to treat in ALL planes of motion:  Frontal, Sagittal and Transverse Planes.

And that's my two cents on Plantar Fasciitis...  Remember, figure out WHY it's there in the first place.  If you just treat the foot, the issue will return. Promised.

Sunday, January 15, 2012


Welcome to Game On Physical Therapy:  When function meets medicine...

My goal with this blog is to keep you up to date with the wide wonderful world of medicine and relating it back to human function.  Movement and function are 2 of the keys we need that opens doors to a healthy, happy and successful lifesyle.

My specialty is Sports Medicine rehabilitation and specifically Post-Operative Rehab of the Shoulder and Elbow.  I'll be discussing with you common shoulder pathologies and why they happen in the first place.  You will learn how an Ankle sprain can cause shoulder impingement and you will also learn why I tight hip flexor can cause elbow injuries in a thrower.

I hope you all enjoy!