After beginning outdoor softball practices, my young daughter complains of heel pain on both feet. Would a PT assessment be appropriate?

Yes, a PT assessment would be appropriate for your daughter. Adolescent bodies are constantly adjusting to new growth, and beginning a sport may place added stress on the musculoskeletal system. We would assess everything from her lower extremity flexibility and strength, her balance and coordination, her ability to run and jump, to her foot alignment and shoe of choice. All of these factors can contribute to heel pain.

Some typical conditions that can be the cause of heel pain in youngsters are tight heel cords, poor coordination of running or squatting motions, or improper shoe choice. It is important to determine the causative factors and to rule out growth plate injuries by X-ray. 

Growth plate injuries, also called calcaneal apophysitis or Sever’s Disease, usually occur between the ages of 10 and 13. During this period, the child’s heel bone has a gelatinous layer of cartilage where the bone is growing. This layer is called the growth plate, and it undergoes repetitive strain as the heel cord contracts for various activities like running and jumping. Growth plate injuries require immediate rest from the sport in order to heal properly and avoid abnormal growth. Usually they are self-limiting with proper rest, ice, shoe modification, and stretching techniques. Most growth plates have fused by age 16. – Danene Brown P.T., D.P.T.

My running buddies have been talking about toe running. I tried to train this way for an upcoming 10k. Not only is it difficult, but it can be painful as well. How important is it that I learn to run this way?

Over the years there’s been much discussion about how the foot should initially contact ground while running. Should it be a heel strike, a mid-foot strike or a toe strike? There’s plenty of information available on Pose Running and Chi Running techniques as well as a wide array of opinions on which one is more efficient. It can be a bit confusing, but there are some basic principles you should remember. When someone is walking, their gait pattern usually has a deliberate heel-toe progression. In running, the initial foot contact is dependent upon the speed of the runner. During high-speed running events–the 100 meter dash for example–the initial foot contact is usually on the forefoot. During a slow, easy warm-up jog or a long training run, the initial foot contact is usually the mid-foot with a quick progression to the forefoot. If the heel makes contact at all, it is only briefly.

Ideally, you want your turnover speed to be close to 90 RPMs. That means 90 right foot strikes per minute. It can drive you crazy trying to count out 90 right foot contacts in 60 seconds. It’s much easier to try to count 22 to 23 right foot contacts in a 15 second interval every 10- 15 minutes or so during a training run. Warning: it can be difficult to change your running style to this faster tempo, however in the long run you will avoid a lot of injuries. 

Finally, if you can hear your foot make contact, you are probably over-striding or landing with your foot in front of the center of gravity. Your center of gravity is basically a plumb line dropped from the belly button. When your foot contact is in front of this line, you are essentially stopping the forward progression that was just created a moment before. This is a bigger problem to deal with and will lead to injury if not corrected. Working on trying to run quieter with a turnover rate of 90 RPMs will likely change you from an over-striding, slow, plodding runner to the efficient and fluid runner we all wish to be. – Matt Wren M.S.,P.T.

When swimming freestyle, how should your hand enter the water; thumb up or down?

The “thumb first” entry technique may lead to rotator cuff impingement; therefore it is not my personal preference. Some believe that the thumb-down entry method will guarantee a high elbow position in the water, allowing you to catch the water earlier in the pull phase but this is not always the case. By having your hand enter the water with the “ring finger first” technique, you can achieve the same high elbow position and minimize the risk of injury to the shoulder. However, to truly achieve a smooth and efficient swim stroke, after the hand enters the water the swimmer must roll onto their side and glide. Problems occur when the arm pull begins before the body is fully rotated. Swimming with a flat torso in the water and churning the arms like a blender will surely lead to a shoulder injury no a matter whether your thumb or ring finger enters the water first. Remember: enter, reach, roll, glide then pull. Do not rush the sequence. –Matt Wren M.S.,P.T.

I have recently increased my running speed, but I have begun to feel pain in front of my hip. What could be the cause of this?

The pain in the front of the hip could be a result of poor flexibility, improper running mechanics, weakness and/or improper footwear. When increasing running speed, a longer stride length is required. If you do not have adequate hip flexor length, hamstring length, or calf length, it can result in pain. Inadequate hip flexor length can result in a constant strain on the hip flexor tendon when a runner increases stride length leading to anterior hip pain.

Poor running mechanics can be related to poor flexibility, poor body mechanics and/or poor posture. These impairments may revolve around weakness in the buttocks muscles and core, resulting in inefficient body movement. Strengthening may be required for these under-utilized muscles which are necessary for running.
Adjusting footwear may also be an appropriate intervention to control anterior hip pain. This may correct faulty body mechanics–for example, a fallen arch, a high arch, etc. Correcting the foot position can then translate to decreased pressure on the knees, hips and back, resulting in better positioning of the leg and hip and thus creating better posture and running mechanics.  - Chris Thoene P.T., D.P.T.

My daughter is a swimmer who was recently diagnosed with a stress fracture in the lower back. Her physician said she could swim so long as it does not aggravate her symptoms. What should she avoid?

Lumbar stress fractures, or spondylolysis, are common among adolescent athletes such as football lineman, weightlifters, cheerleaders, gymnasts. This type of injury does not occur often in swimmers, but I have seen it before. Lumbar stress fractures occur with repeated lumbar extension, rotation, or a combination of both motions of the lumbar spine.

The motions to avoid are repeated lumbar extension. This would include swimming breaststroke, butterfly, kicking with a kickboard in any stroke, underwater butterfly kick, and starts off a block. Freestyle and backstroke are relatively safe strokes as long as the stroke technique is good. Turns are not a problem if they are performed properly. Any dryland training should be closely monitored and modified accordingly. –Matt Wren M.S.,P.T.

Why do my feet go numb when I’m exercising? Is there something wrong with my shoes?

Improper footwear can cause your feet to go numb when exercising. Numbness can be a direct result of wearing narrow shoes or tying your shoelaces too tight. Cramming your foot into a narrow toe box can cause compression of the forefoot. Repetitive compression of the metatarsals can result in irritation of the nerves that innervate the forefoot. This is commonly known as Morton’s neuroma.

Another possibility is compression of the superficial nerves and vasculature crossing the front of the ankle, which can be caused by overtightening the upper shoelaces. Many people have a tendency to tie the top of the shoes very tight in order to have a snug fit. However, overtightening of the shoelaces for prolonged periods of time can cause the feet to go numb. If this is continually repeated, the condition can become chronic.

Finally, compression in the lumbar spine can cause numbness in the feet with exercise. One sign of compression in the low lumbar spine is numbness and possible pain in the feet. Often, exercise results in compression of the spine either through axial loading or dynamic exercises. If you have a herniated disk or decreased space between your vertebrae, the source of the nerves in your feet can be pinched. 

I would try exercising in a different pair of shoes first to see if the numbness in the feet resolves. Try a shoe that is wide enough in the forefoot that you do not feel like your forefoot is being squeezed. Second, attempt to loosen the lacing system slightly. If symptoms persist, the back may be the source of the trouble. Physical therapy could help address all of these potential problems to get you back to exercising pain-free.
–Chris Thoene P.T., D.P.T.

My 13-year-old daughter plays soccer and complains of pain in the front of her knees. The pain initially occurred during soccer practice and now is troublesome with climbing stairs and sitting in school.

Anterior knee pain is a common occurrence in this age group and can have several causes:

• Bursitis

• Tendinitis

• A mal-tracking patella or knee cap

• Any combination of all three

Dull, aching pain behind the kneecap (patella) is common in active teens. Their exercise or training routine should be adjusted to minimize the pain. The initial symptoms can be controlled by applying ice for fifteen minutes, three to four times a day.

Chronic pain in the front and center of the knee (anterior knee pain) is also common among active, healthy young athletes, especially girls. In fact, adolescent females are six times more likely to sustain a significant knee injury than their male counterparts. This statistic can be reduced with the proper training and pre-season conditioning. The pain usually begins gradually. The athlete might report popping or cracking sounds in the knee when they climb stairs or stand up and walk after prolonged sitting. Pain might flare up when they repeatedly bend the knee (i.e., jumping, squatting, running, and other exercise) or at night.

Consider the changes a young athlete is going through. Often, between the ages of 10-16, athletes undergo several rapid growth phases which lead to losses of flexibility, strength and coordination. These changes lend themselves to compensatory movement patterns which overstress soft tissues, leading to a variety of possible knee injuries. The complex anatomy of the knee joint that allows it to bend while supporting heavy loads is extremely sensitive to small problems in alignment, training, and overuse.

Concurrently, athletes in this age range become more involved in organized sports clubs or leagues with increased intensity and frequency of practices and games. It’s not uncommon to find a young athlete playing for a school team, a recreational team and a travel team all in the same season. With the awkwardness of growing taller, we have an athlete who is getting used to a brand-new body every few months at the same time that athletic demands increase.

The fundamental building blocks of sports skills are mobility, coordination, strength and endurance. Any change to these building blocks will cause an imbalance leading to technique flaws or bad habits that are difficult for the athlete to correct. Before effective correction can occur, the problems in the fundamental building blocks must be uncovered and addressed.

Try these simple tests at home:

1. Can your daughter stand with her knees straight and touch her toes?
2. Can she stand on one leg, bend the other knee, grab that ankle, and pull her heel to her bottom? 
3. Can she squat, run and jump without the knees caving inward or touching? 
4. Can she stand on one leg, reach her hands overhead, reach forward to touch her toes and then reach back overhead again? Can she repeat this five times without losing balance?

If your daughter has difficulty with one or more of these functional tests, then you should consider seeing an orthopedic or sports medicine-oriented physical therapist. A proper knee examination will determine the root cause of pain behind her kneecap and will rule out other problems. –Matt Wren, M.S.,P.T.

My 16 year old son gets abdominal (diaphragm) cramps when he races. He is one if the faster runners on his high school cross country team. He has tried hydrating well before races. Is there anything else he can do?

I believe you are referring to the “runner’s side stitch,” a pain just below the rib cage usually on the right. I used to get these all the time during hard swimming or running training sessions.

Researchers now believe the side stitch is caused by stretching the ligaments that extend from the diaphragm to the internal organs, particularly the liver. Exhaling when the right foot hits the ground causes a greater force on the liver (right side, below rib cage).

The ‘fix’ sounds far fetched, but seems to work. Try exhaling when the left foot hits the ground. Take even, deep breaths when running to prevent side stitches. Shallow breathing can cause cramping because the diaphragm is always slightly raised and never lowers far enough to allow the ligaments to relax. The diaphragm then becomes stressed and a spasm or "stitch" is more likely. – Matt Wren M.S., P.T.

My back pain is hurting my golf game. I have a tournament coming up. What can I do about this?

The golf swing is one of the more complicated motions in sports and requires a great deal of finesse. It demands flexibility, strength, balance, and coordination. Acute injuries can be treated with ice, ultrasound, and electrical stimulation. Once the acute injury is addressed, a physical therapist can then work to prevent it from happening again by determining the cause and fixing it with appropriate exercises and by improving motor awareness.

In the past, pre-golf stretching emphasized the upper body and trunk. Now we understand the role of leg flexibility in terms of maintaining the proper swing plane. The body will find a way to compensate for motion that is not freely available. In other words, if you don’t have the desired motion, your body will find a way to give it to you whether you like it or not. Poor leg flexibility is a strong predictor of recurrent low back pain. If your legs and hips are tight, this inflexibility will be reflected in your swing plane and will lead to lower back pain.

Since golf is a game of finesse, when your club face is off by a few millimeters (because of compensation in the swing plane), you will be unable to accurately place the ball. At PT Works, we can analyze your swing with our video motion analysis system and match this with a physical exam to design a corrective program specific to your needs. – Matt Wren M.S., P.T.


CYCLING. NO PAIN, NO GAIN?
—As seen in SBQ magazine Spring 2008

The only pain you should experience on the bike is from exertion.

Start by using a standard bike fit formula.
Just realize these formulas are designed for a generic person, which you are not. Everyone has asymmetries. Even the smallest malalignment, at an average of 5000 pedal revolutions per hour, can lead to problems. You’re going to need to tweak your ride. Subtle adjustments can mean the difference between comfort and pain. (www.coloradocyclist.com/bikefit is a good website)

Knee pain can result from:
1. Wrong saddle position. Too high, too low, too far forward or back.
2. Wrong cleat position. I see many cyclists with the wrong cleat set-up. Some people naturally toe in or toe out when they walk or sit. The cleat set-up should closely match your natural position.
3. Wobbling knees. Your knees should track straight up and down in a pedal stroke, with no wobble from side to side. Check yourself while on a stationary trainer in front of a mirror.
4. Rapid increase in mileage or intensity.
5. Poor leg flexibility.

Numbness or tingling in your hands can result from:
1. Poor wrist angle. Your hands should be relaxed and in line with your
forearm.
2. Poor posture. A crouched position over the handlebars or a long, stretched-out position are equally problematic.
3. Improper saddle/stem height. Take a 3’ long straightedge, and place one end on the bike seat and the other on the handlebars. The saddle/stem height differential should not be greater than 1”-2.”

Any of these will increase stress on the neck, arms and hands and lead to nerve-related symptoms.

Groin pain or numbness can result from:
1. A seat that is NOT level.
2. A seat that is not wide enough for your “sit bones.”
3. A seat that is too high.
4. Cheap bike shorts. Spend the money for good, well-padded bike shorts.

– Matt Wren M.S., P.T.


My daughter’s soccer coach says she runs oddly but offers no other advice. Can you do anything to help her?

The typical problem I see in runners is that of overstriding. Overstriding occurs when the foot contacts the ground in front of the body’s center of gravity, which essentially slows forward momentum. Overstriding will compromise running balance and efficiency, and a runner will appear off-balance or awkward. This can occur when an athlete is told to “take longer strides” and does so by reaching forward with the legs during the swing phase. The proper way to take longer strides is to deliberately push backward through the hip, knee and ankle during the propulsion phase. This is referred to as triple extension. Some athletes learn this naturally, while others need to be taught this skill. Triple extension can be learned with a series of progressive drills.

I would like to watch her run to assess her technique and then test strength, flexibility, coordination and balance control. – Matt Wren M.S., P.T.

My shoulder aches after swimming. Do I apply ice or heat?

That depends on how the shoulder injury behaves. If your pain level is a constant 7 or greater (scale: 0 = no pain, 10 = severe pain) and worse with activity, I would apply ice. If the pain is 5, and gets worse or better unpredictably, I would play it safe and apply ice. If in doubt, apply ice. If it is 3 at worst and eases with activity, without worsening the next day, I would apply heat. – Matt Wren M.S., P.T.

I’m a recreational swimmer. My doc said I have rotator cuff tendonitis. What is it? Can I swim through it? Is there anything I can do?

I do not recommend that anyone “train through” pain. Realize that pain and muscle fatigue are two different things. It’s OK to get tired while exercising; that’s normal. It’s definitely not OK to feel sharp, burning, tingling or stabbing pain while training. Pain is Nature’s way of telling you something is wrong and needs to be checked out. Pain is a signal similar to the check engine light on your car’s dashboard. Ignoring the ‘check engine light’ and continuing to drive can lead to engine damage. Ignoring pain or covering it up with medication and “training through it” will lead to compensatory movement, altered mechanics and possibly, multiple injuries.
I would need to ask you some questions to determine an answer.

1. How long have you had it?
2. What is your mileage, and how many times do you train per week? ...be honest.
3. What strokes hurt, and which don’t hurt?
4. Do you use paddles or a kick board?
5. What part of the stroke is the problem: the catch, the power phase, or the finish (recovery) phase?

We need to find the why behind the injury. – Matt Wren M.S., P.T.

I got a new bike, and now my first and third fingers, on one hand, are numb?

Gradual progressive numbness, related to cycling, is never good. The first thing to check is the saddle height and lumbar differential. Take a 3’ long straightedge and place it on the bike seat and handle bar. The saddle-stem height differential should not be greater than 1-2.” If the seat height is appropriate for you, it could be that your handlebar is too low. It could also be that the reach is too long for your body. Both of these will increase stress on the neck, and lead to nerve symptoms in the arms and hands. If after making the above adjustments, you still have pain, we can do a dynamic bike fit. Click here to see how PT Works can help. – Matt Wren M.S., P.T.

I added aero bars on my bike. Is the bike fit the same for both aero bars and traditional drop
handlebars?

No. It depends on whether you’re riding a multi-sport bike or a triathlon bike. The multisport bike seat tube will be a laid back 72 to 73° angle. This bike will handle well in a variety of conditions. Using an aero-bar on this bike will change the handling and may be uncomfortable on your lower back and neck. You’ll have to move your seat up and forward to be comfortable and efficient. The extra body weight on the front wheel will make bike handling a bit twitchy at speed. A true triathlon bike’s seat tube will be an aggressive 76-80° angle. This is relatively steep compared to a multisport bike and is only meant to be comfortable at high speeds in the aero position. This bike is an F-14 fighter jet – not your cruise to the bagel shop kind of bike. Click here to see how PT Works can help with a bike fit. – Matt Wren M.S., P.T.

I just changed running shoes and now my Achilles tendons are killing me. Is there any correlation?

I’d have to ask you several questions before I can answer accurately:
1. Why did you change running shoes in the first place?
2. How long did you wear the old pair? You should rotate your shoes every 300 to 500 miles.
3. Did you change the model or the shoe brand? If you were happy and running well with the old model and brand, why did you change?
4. Did you have any hints of injury before wearing a new shoe or was a progressive injury the reason you changed your shoes in the first place?
Some training shoes have a slightly elevated heel for comfort. Most performance shoes however, have a low heel, allowing a faster heel toe transition. Dropping your heel down may irritate the Achilles tendon. Finding a running shoe that works for you is a trial and error process. Our Shoe Fit Program (www.ptworksllc.com/shoe.html) will help save you time and money. Once you find the correct shoe brand and model that works for you, stick with it.
Other than shoe choice, most injuries can be traced to three things.
1. Genetics: a person who is biomechanically challenged. (i.e.: severe flat feet, bowed legs)
2. Training error: too much too soon; not enough rest; dehydration; short warm up or cool down.
3. Environmental changes: too many hills; running when it’s too hot or too cold.
– Matt Wren M.S., P.T.

Should I stretch before or after exercise? I hear conflicting opinions.

It’s not so much a matter of when you stretch but how and what body parts you stretch. Granted there are some people who are naturally flexible, who gain sufficient mobility through exercise; these people don’t need to stretch much. On the other end of the spectrum are those who are naturally tight and stiff and must work very hard at gaining and maintaining flexibility; these individuals should stretch before and after exercise. Your exercise prep routine should match your genetic predisposition – whether that is being flexible or being tight. Your routine should also match the activity for which you are preparing. For example, if the activity requires running, cutting, stopping and jumping, emphasize stretching the legs in the sport-specific dynamic patterns you will need on the field. Realize that muscles do not move in single planes of motion but rather in complex movement patterns. Hold each stretch position for 30 seconds before relaxing, and then repeat three to five times. Never produce pain while stretching. The brain will perceive pain as an emergency signal and force the body to tighten the involved muscles. It is impossible to increase mobility while the brain is telling your body to do otherwise. A stretching and dynamic warmup activity should be unique for each person. No two people are alike in terms of genetic predisposition for flexibility and mobility needs. If you’re unsure about which exercises are right for you and your specific sport, click here. PT Works can help. – Matt Wren M.S., P.T.

Spring soccer training recently started, and my son complains of heel pain. Could this be plantar fasciitis?

I need more information:
1. How old is your son?
2. When and in what part of the heel does the pain occur?
There can be several different locations and/or causes of pediatric heel pain. Children and adolescents involved in soccer, track, or basketball are especially vulnerable to overuse syndromes.
Plantar fascia pain is an inflammation of the band of tissue (the plantar fascia) that runs along the bottom of the foot from the heel to the toes. The pain is intense when getting out of bed in the morning or standing after sitting for long periods, and then it subsides after walking around a bit.
Calcaneal apophysitis, also known as Sever's disease, is an inflammation of the heel's growth plate (see diagram) due to repetitive stress. It occurs in those who are very active, obese or who have tight calves and Achilles tendons. It commonly occurs in the 8-14 age range.
Tendo-Achilles bursitis. This condition is an inflammation of the fluid-filled sac (bursa) located between the Achilles tendon (heel cord) and the heel bone. Achilles Tendonitis is usually located 1-2 cm above where the tendon attaches to the heel. This inflammation of the tendon usually occurs in children over the age of 14. Stress fractures or hairline breaks resulting from repeated stress on the bone often occur in adolescents engaged in athletics, especially when the intensity of training suddenly changes. Acute fractures in children under the age of 10 can result from simply jumping 2 or 3 feet from a couch or stairway.
I would recommend your son discontinue playing soccer until he has been seen by his doctor. Physical therapy will help your son by determining and treating any mechanical or alignment dysfunctions that may have caused the strain/stress on his tissues. Apply ice to the painful area for 10-15 minutes as needed for pain. – Terri Berkshire M.S., P.T. and Matt Wren M.S., P.T.

How do I choose the best clipless pedal system for my bike?

That depends on whether you ride a mountain or a road bike. Each situation requires a different set of pedal features. Most cleat systems have a 9° to 20° float or rotation and move with your natural leg motion during the pedal stroke. The critical question is, “how do I adjust the cleats to match my unique biomechanics?” I see so many cyclists with the wrong cleat set-up. Some people naturally toe in or toe out when they walk or sit. The cleat set-up should closely match their natural position. Personally, I toe-in on one foot and toe-out on the other, so my cleat position is set accordingly. Be patient and don’t be afraid to “tweak your ride.” Click here to see how a PT Works Bike Fit can help. – Matt Wren M.S., P.T.

Why do some athletes, especially runners, lie on the ground and elevate their legs up on a tree, wall or fence after a race?

Elevating your legs after a vigorous exercise session or endurance race is an effective way to assist your body in evacuating metabolic waste products created by the effort. These metabolic waste products can collect in your veins and in the lymphatic system of your legs, and if not properly evacuated, they can lead to the delayed onset of muscle soreness.

An active recovery or a warm-down jog, walk or ride, is adequate in most cases to speed the recovery process. However, there are situations where athletes have to exert themselves in back-to-back races with little to no rest interval between the events. Elevating your legs against a wall or fence is a type of passive recovery that can be effective in evacuating metabolic waste products while keeping your caloric expenditure to a minimum.
I also encourage runners to use a self-massage called the THE STICK. You can find it at local running stores or on line at www.thestick.com. Self massage for 5-10 minutes will do your legs a world of good. Personally, I use elevation and THE STICK frequently after training runs and my legs feel much better the next day. – Matt Wren M.S., P.T.

My daughter complains of shoulder pain after pitching in her softball games. Is icing enough to control the symptoms?

Ice is good to control painful symptoms. However, if your daughter has consistent pain each time she pitches, there may be more to it than muscle soreness. In other words, there may be faulty pitching mechanics which are causing repetitive strain to the shoulder. At PT Works, a thorough assessment of her strength and mobility will be conducted. Video analysis will be done to view her mechanics while she pitches. By slowing down the video, the PT can easily watch body alignment during the different pitching phases. This information can shed light on mechanical errors that could be straining the shoulder. Your daughter’s coach and/or physician can be issued a copy of this video to help with proper pitch-training, and her PT would focus on strengthening and mobilizing the correct areas to reduce pain and enhance performance. – Danene Brown P.T., D.P.T.

Tips to return to distance running and cycling training after a sedentary winter.
(As seen in SBQ • Winter 2008 issue)

Build aerobic base:
1. Begin with steady effort runs and cycling rides 60-70% max HR.
2. Use a HR monitor to keep yourself honest. HR monitors run about $100 and are well
worth the investment. If you are a beginner use the formula 220 minus age to
get your HR max and then calculate your aerobic base training range by
HR max x 60% and 70%.
3. Avoid all-out efforts until you build a solid base fitness level. Depending upon how much inactivity you have had over the winter, it could take as long as 6-8 weeks to re-establish a solid fitness base.
Avoid injury:
1. Increase run / bike mileage no more than 10% per week.
2. Train with others who have the same fitness levels and goals as you. It can help keep you progressing at a steady pace. Training with those who are faster or farther along in their training will only encourage you to overdo it, get injured or feel ‘behind’ in your training
3. Avoid “spring knee.” Cyclists should start by using low gearing on the bike for 6-8 weeks; it’s not hammer time. Got a stiff lower back? Raise the stem 1 inch; you can lower it again later in the season.
4. Watch road conditions. Look for pot holes, cracks, loose sand on the side of the road and around turns. Look out for the unaware drivers who have not seen cyclists and runners on the road over the past several weeks. Dress to be seen while running and cycling.
5. Hydrate. Although it’s not hot outside, you will lose fluid with respiration even on cold days. Drink up.
6. Upgrade. Update your running shoes (rotate shoes every 300 to 500 miles), and get your bike tuned up.
7. Dress for success.
a. Wear tights when the air temp dips below 60° to protect the knee ligaments, tendons and cartilage from wind chill on the bike. In the spring, a warm sunny day can change to cloudy cool, windy and back again very quickly. It doesn't have to be bone-chilling cold for an athlete to get into trouble. Hypothermia can occur on what might otherwise be considered just a cool spring day.
b. Carry gloves, hat and shoe covers; you can’t wear it if you don’t have it. Why do you think cycling jerseys have pockets in the back?

My 13 year old son is getting into weightlifting. I’m concerned that he does not know what he is doing. Is there anything he should not do at his age?

Why does he want to begin weightlifting? Typically, as adolescent sports programs become more competitive, the practice schedule increases in intensity and frequency of training sessions. An exercise program should be customized to his needs and administered by an experienced professional with a background in youth sports training program and design. Close supervision is needed at age 13, so an instructor to student ratio should not exceed 1:4. Avoid situations where training instruction is performed by a friend, by watching a DVD or video, or by reading a wall poster. Sit in on a few sessions and observe the training sessions. Be a nosy parent; that is what I would do.

What most people consider to be Traditional Weight Training (TWT) was developed for/by bodybuilders. This method often isolates one muscle at a time for maximal size and symmetry development. The range of motion and speed of each repetition are carefully controlled in order to eliminate momentum and to isolate the stress to a specific muscle or group. This muscle isolation method of training is contradictory to the normal coordinated effort used to complete most sporting or daily activities. TWT can lead to strength gains but, at the same time, is more likely to lead to muscular imbalances, flexibility loss, restriction of movement patterns required for sport technique, and overuse injuries. Carryover into sports is limited.

Olympic Style Lifting (OSL) is another type of strength training. Since most sports require a combination of strength and speed. This type of strength training has become popular over the past several years. In this style of training, the weight is lifted as quickly (with control) as possible with a single or a combination of explosive movements. OSL is a highly technical skill, and is difficult to learn. It is neurologically demanding, requires excellent leg and arm mobility and should not be performed when tired. This style of training requires the utmost attention from spotters as well as adult supervision. Most OSL lifting patterns are in single planes and do not account for triplaner motion (cutting, pivoting, direction or change) and therefore may have limited carryover into “direction change” sports, such as soccer, basketball, football, etc.

Functional Strength Training (FST) originated with injury rehabilitation programs and emphasize exercises that are relevant to the movements of everyday life and sport skills. FST takes into account the desired movement pattern, including the muscle force, power and muscle firing sequence specific to a sport (tennis, swimming) or activity (squatting and lifting the grandchildren). Movement pattern weaknesses, mobility, power and coordination problems will be uncovered and corrected by the supervising professional. This type of training will provide the best carryover to improve an athlete’s sports-specific skills, power, coordination and endurance. 

At PT Works our Train Smart program http://www.ptworksllc.com/train.html is based on Functional Strength Training. –Matthew Wren M.S.,P.T.

I’ve heard the term “RICE” for injuries but do not know what that is.

The RICE protocol is often advised for acute injuries. It is an acronym for Rest, Ice, Compress, and Elevate. It is the simplest, safest, and most effective method to reduce muscle spasm, pain, and swelling associated with a new injury.

Rest: Relative rest from activity for 1-2 days after your injury is important to reduce further stress and to stabilize the affected area. This will also allow time for you to seek medical attention depending on the severity of symptoms.

Ice: Icing the affected area for 10-to 15-minute intervals is imperative to reduce swelling. It is the swelling that can delay healing by blood clot formation, tissue damage, muscle spasm, and pain. Ice application should cover the affected area, but have one layer of cloth between the ice and skin to prevent frostbite. Ice should feel cold, then burning/pricking, then aching, and then ultimately numb. When numb, you should remove the ice.

Compression: Slight compression over the injury with the use of an ACE wrap can also limit swelling. To apply, begin the ACE wrap at the most distal end of the injury (eg, start at your toes for the ankle) and circumferentially wrap toward the heart. If you sense throbbing or increased swelling below the distal end of the wrap, re-wrap with less compression.

Elevation: Elevation of the affected area above the heart also limits swelling. Theoretically, elevation can reduce fluid retention by allowing gravity to assist blood circulation back to the heart.

Physical therapy can be helpful during this acute stage of injury as well as in returning you to your previous level of activity. –Danene Brown P.T., D.P.T

I just finished my first marathon and want to begin training for the next race, but I’m really sore. Any suggestions on how to build up my mileage again?

Congratulations! Completing your first marathon is a huge accomplishment. Your hard work and mileage on those legs have paid off. Now let your legs rest and recover. My advice is to not run during the month following a marathon but rather to try other non-impact aerobic exercise, such as swimming or cycling, or try using an elliptical trainer or a Nordic Trac X-C skier. Get a massage (or two), use a massage STICK http://www.thestick.com/  (local running stores carry them), try a yoga or Pilates class or other gentle non-impact strength training exercise. Don’t forget a healthy diet; nutrition and hydration are important and often overlooked during a recovery period. After at least a 4-week recovery training period, begin a walk –jog program (long walks with a little bit of jogging) and build up the running no more than 10% per week. This program works well for many people. Often I see runners with persistent, nagging injuries that last for months which can be traced back to a lack of recovery training.

Bask in your personal glory, but do not run for several weeks.  –Matthew Wren M.S.,P.T.

My friend says excessive running can cause knee problems later in life. I say no. Can you settle a bet?

There is much debate whether running early in life will cause arthritis in the later years. First you must know what arthritis actually is and what can be done to reduce its impact on your joints.

Osteoarthritis (OA) is the most common type of arthritis and is often referred to as “degenerative arthritis.” It is described as the mechanical breakdown of the cartilage which lines our joints. Healthy cartilage acts as a cushion to reduce stress to the joint, but as we age the chemical make-up of our cartilage becomes more brittle. This can cause pain, swelling, and reduction in activity level. The best way to reduce the impact of this is to maintain or improve your strength, flexibility, and coordination around the joint. An appropriate ratio between rest and exercise is crucial to make your joints work for you; thus the debate stated in your question.

Studies are currently investigating your question. Most cannot find a direct correlation between running and the progression of OA. One study followed over 1,200 healthy adults over 53 years of age. They underwent X-rays and provided information regarding exercise regimes, body weight, and knee pain for 10 years. No link was found between OA and running. Another study showed that men and women between 50-79 years old, who completed vigorous physical activity for 10 years had healthier, more robust knee cartilage upon MRI versus sedentary folks.

Overall, the current consensus is that running is appropriate and that it does not directly cause OA. Keep in mind that running is a great form of exercise, but it is not for everyone. You need to find what works for you and that may be swimming, yoga, or some other form of exercise. You may also have specific physical issues that need to be addressed. The physical therapists at PT Works can give you a formal assessment of your abilities and advise you on what steps you should take. –Danene Brown P.T., D.P.T.

I have been lifting heavy weights and now have pain in both elbows when doing bicep curls. What can I do?

It sounds like this pain could be the result of two possibilities. 

1. Bicep tendonitis. The biceps tendon connects the muscle to the bone. Tendonitis usually occurs due to overuse. The demand on the tendons with lifting heavy weights results in irritation and inflammation of the tendon. Tendonitis is associated with tenderness over the tendon, pain with movement of the joint, and inflammation at the tendon. To decrease the irritation of the tendon, you must avoid the aggravating movement. Ice and anti-inflammatory medication are useful to decrease irritation. Using proper techniques and taking breaks are important for returning to activity.

2. Nerve impingement within the cervical spine. Bilateral symptoms are often a sign of spinal cord compression. Lifting heavy weight causes increased inter-abdominal pressure. This increased pressure can result in herniated disks in the lumbar spine and/or the cervical spine. It is important to exhale during the exertion portion of lifting. Another suggestion would be to decrease the amount of weight you are lifting in order to decrease pressure on the disk.

–Christopher Thoene P.T., D.P.T.

I’ve heard that core stabilization exercises are the key to preventing back injury; yet some exercises that I do hurt my lower back. What am I doing wrong?

Properly executed core stabilization exercises should not cause back pain. Core stabilization exercises are nothing new in the world of physical therapy. In the 1970’s we referred to them as spinal stabilization exercises. In the 1990’s the fitness industry referred to these exercises as core stabilization or core exercises. By definition, you may move the arms and legs but the spine must be held stationary during the exercise if it is to be considered spinal or core stabilization exercise. If the spine is flexing, extending, rotating or side bending the exercise is no longer a core stabilization exercise. For example, sitting while flexing forward, extending backward or twisting the spine against resistance is not a core stabilization exercise and could cause potential damage to the spine. Core stabilization exercises should not be performed while sitting due to the excessive pressure on the spine that occurs in that position. Beginner level core stabilization exercises may be performed in supine, prone or side lying positions. More advanced exercises may be performed during standing, squatting or lunging motions. Most of my patients perform basic exercises in supine or prone and then transition to standing, semi-squatting or lunging motions as timely as possible. Considering most daily and athletic activities are performed with standing, semi-squatting or lunging motions then stabilization exercises should be performed in a similar manner. If performed properly, core stabilization is an effective way to train the abdominal wall to work with the muscles of the trunk, legs and arm without causing back injury. 

–Matt Wren M.S.,P.T.

What are the major differences between yoga and Pilates? Do physical therapists have an educated opinion of which is a better overall exercise regime?

Yoga and Pilates exercise regimes have been hugely popularized over the last several decades. So which is best for you? When performed correctly, both yoga and Pilates can be fantastic choices for regular exercise.

Yoga, developed over 5,000 years ago in India, is still widely practiced. That speaks for its longevity! Different styles of yoga have been developed (e.g. Vinyasa, Hatha), but all focus on the connection between the mind and the physical body. The emphasis of yoga is to align the body in different postures, called asanas, while practicing proper breathing technique, called pranayama. Yoga requires little equipment; a mat, strap, and blanket are all you may need. Your body acts as the only resistance, and modifications to the asanas can be used to improve form or to ease tension. The benefits of yoga are relaxation, breath control, flexibility, body awareness, and trunk and extremity strength.

Pilates was developed during WWI in order to improve rehabilitation for the many returning veterans. The program gained early popularity in the dancing community. The focus is on the abdominal, buttock, and back musculature as the “powerhouse” of the body. Once the powerhouse is stable, the limbs can move freely in rapid, controlled movements to build trunk strength. Most exercises are completed on a mat; however, Pilates specific equipment, such as a Reformer, can be used to add more resistance to these exercises. The benefits of Pilates are trunk strength, postural control, and toned musculature.

As a physical therapist who practices both forms of exercise, I believe both are good choices if practiced correctly. Both should be taught by certified instructors who should be informed of any particular injuries or weaknesses you may have. For instance, you would avoid inverted yoga poses if you have a history of neck injury. Yoga and Pilates will challenge you in terms of strength, flexibility, endurance, and balance. But as with any exercise please keep in mind that pain is a warning sign. If you experience pain with any exercise, you should discontinue it. –Danene Brown P.T., D.P.T.

I like using aquatic gloves when I swim but they seem to make my shoulder hurt. I don’t understand why.

Aquatic gloves–basically webbed gloves–are used to add extra resistance while swimming. Although similar to a swimmer’s paddle, aquatic gloves are smaller, more flexible and form-fitting and are more comfortable for some people. Both are useful training tools if used properly and if the shoulder has enough strength and coordination to control the extra resistance they create. If your stroke technique is flawed then the aquatic glove or paddles will exaggerate that flaw, possibly leading to a shoulder injury. Exercising to fatigue will also exacerbate technique flaws and certainly can lead to injury as well.

I suggest that you focus on perfecting your stroke technique and use your aquatic gloves sparingly. –Matt Wren M.S.,P.T.

Last year several of my volleyball players were sidelined with ankle injuries. What can I do
differently this year to prevent ankle injuries?

There can be several reasons for your players’ ankle injuries. What to do about them is straightforward. Ankle injuries can be related to weakness, coordination and agility problems of the ankle, knee, hip and trunk. Preventive exercise should address all of these areas.
Dynamic Single Leg Swing: Stand on the right leg with the knee slightly bent, rapidly swing the left leg forward and backward 20 times and then side to side, in front of right leg, 20 times. Swing the leg as fast as you can without losing balance. Repeat 5 times while standing on each leg.
Single Leg Toe Touch: Stand on the right leg while holding a volleyball overhead. Now slowly reach forward as far as you can, then downward to touch the toes, reach forward again and back over your head. Repeat 10 times, on each leg, without losing balance.
Bump Practice Against a Wall: many players will practice bumping against a wall. Try doing so while standing on one leg. Count the controlled contacts without losing balance and compare the right leg to the left.
These drills will help you and your players discover agility and coordination deficits between the right and left legs as well as fix the underlying problems. – Matt Wren M.S., P.T.


Is plyometric training safe for children?

Plyometrics is a method of conditioning originally reserved for adult athletes. The American College of Sports Medicine considers plyometric training a safe, beneficial and fun activity for children and adolescents provided that the program is properly designed and supervised.
Plyometric exercises start with a rapid stretch of a muscle (eccentric phase) and are followed by a rapid shortening of the same muscle (concentric phase). Plyometrics are a natural part of most movements such as double and single leg jumping, hopping and skipping. Common games and activities seen on any school playground such as hopscotch, jumping rope and jumping jacks are considered plyometrics.
As with any exercise, there is the potential for injury if the level of difficulty and volume of the training program progresses too rapidly. Children should be supervised and instructed in proper exercise technique and rate of progression. Participants must wear supportive athletic footwear and exercises should be performed on surfaces with some resilience; grass, mulch bed, rubber floor mat….not a concrete floor. A good resource: Progressive Plyometrics for Kids by Falkel, Faigenbaum and Chu available at Amazon.com. – Matt Wren M.S., P.T.


I’m a high school coach; many of my football players have problems with recurrent lower back pain. We have a good strength and conditioning program, and these are strong, powerful kids but something is missing. What can we do differently?

First, we would need to assess the athlete for a lumbar stress fracture which is common in football linemen, gymnasts and cheerleaders. If an athlete complains of increased low back pain with a standing back bend, he will need to see a physician and get a lumbar spine X-ray, a CT or a bone scan to rule out a stress fracture.
If the tests are negative for stress fracture, then we next would need to assess how the athlete moves.
For an athlete to move efficiently on the field or court, he / she must develop:
a) mobility (flexibility across multiple joints as with squatting or lunging);
b) stability (balance control, body awareness);
c) sports skills; and finally
d) strength and power.
Without mobility and stability an athlete will not be able to develop efficient movement patterns for sport skills such as running, cutting, jumping and lunging. This will lead to compensation by the foot, ankle, knee, hip and lower back. These compensations are inefficient movement patterns and may lead to injury. To layer strength and power training on top of these compensations would be a mistake. The result will be an over-powered, under-mobile, clumsy athlete and injuries will likely result. This is a common situation I see in the teenage athlete where weight room statistics and body image are a concern, and mobility and stability are not a priority.
Without mobility, dynamic stability is not possible. Without mobility and stability, efficient sport skills are not easily developed. Athletes must develop mobility, stability and efficient sports skills BEFORE adding strength and power training. – Matt Wren M.S., P.T.


CONGRATULATIONS!!

To our Train Smart client, Dr Robert Singer, age 78, for accomplishing his goal of climbing Mount Kilimanjaro–19,341 feet–which he reached January 14, 2008. We look forward to helping you train for your next climb!



I have “crunches” and “cracking” in my neck… what is that? Should I?be concerned?

Actually, there is a debate about the noises our joints make…

One form of noise is an audible pop. Some believe it is a release of pressure within a joint occurring during joint movement after being sedentary for a period of time. This release is often followed by a feeling of relief and increased motion and cannot be replicated for about 20 minutes. The science of it is confusing. It is thought that the pressure of a joint’s synovial fluid drops when we stretch the joint capsule as we move. The synovial fluid contains some gases which, under decreased pressure, cause ligaments surrounding the joint to be pulled inward toward the joint. This causes formation of a carbon dioxide bubble. The popping noise occurs as the bubble comes out of the joint capsule; this is called cavitation. Subsequently, the synovial fluid has more pressure, resulting in the ligaments being pushed away from the joint capsule, causing a second popping noise. This happens so fast that we can only detect one pop. Research hasn’t definitively agreed with this theory, but in general, “popping” your joints is not recommended as it may overstretch the soft structures surrounding the joint.

Another joint noise indicates degenerative changes and sounds more like “grinding” or “crunching.” This is called crepitus. As our joints age, the cartilage tends to become irregular instead of smooth. When these irregular joint surfaces move across each other, crepitus may occur. Another theory is based on degenerative changes of the joint’s surrounding ligaments. The ligaments may become fibrotic or thickened due to wear and tear, causing noise when joints are moved. Crepitus is not always pathological or painful, but it commonly occurs with degenerative disc disease or degenerative joint disease. –Danene Brown P.T., D.P.T.

Our pediatrician just diagnosed our baby with congenital torticollis and told us to see a PT. What exactly is torticollis? What causes it and how can physical therapy help?

Congenital torticollis, aka “wry neck,” refers to muscular tightness of the neck which causes the baby to prefer turning its neck in one direction over the other. The theory is that the baby’s neck becomes tight on one side due to positioning in the womb or by the trauma of birth. The good news is that it is treatable.

The particular muscle involved is called the sternocleidomastoid (SCM) muscle. The origin of the SCM is behind the ear, and the insertion is at the top of the sternum. Normal tensioning of the SCM allows us to turn our heads to the opposite side and to side-bend toward the same side. With torticollis, there is too much tension on one SCM, causing the baby to prefer turning to one side only. Parents and pediatricians usually begin to see this behavior by 2-3 months of age. The baby may also show a flattened area on the back of the head or changes in facial symmetry due to the biased positioning.

About 1-16% of infants are diagnosed with congenital torticollis. In 90% of cases, the condition resolves within the first year as the baby develops better neck control.

Be sure to consult with your pediatrician if you think your baby may have torticollis so that treatment can begin early. Physical therapy helps speed up the recovery by showing parents positioning techniques that will encourage their baby to turn his or her neck in the opposite direction. This allows the SCM muscle to lengthen gradually and without pain to restore the symmetry of the baby’s neck. –Danene Brown P.T., D.P.T.

I’ve got swollen ankles and hear that “light” therapy can help reduce swelling. What is light therapy and do you offer it?

Infrared light therapy (ILT) has been receiving attention as a treatment to promote healing of damaged tissue, e.g., diabetic ulcers or torn muscles. It involves exposure of the tissue to light via laser or LED. It is proposed that ILT can actually stimulate production of collagen, which is the repair protein that binds cells together, as well as production of adenosine triphosphate (ATP), the energy source of cellular activity. Other purported benefits include increased lymphatic activity, cellular reproduction, and scar maturation. All of these benefits are thought to occur without any known side effects.

Sound too good to be true? It may be. Some research shows no significant improvement in pain or function after ILT application. Also, most insurance companies do not reimburse for ILT application, leaving you with the bill. The physical therapists at PT Works have tried ILT and have had mixed results. We do employ a variety of other modalities and manual treatments supported by research that yield consistent and favorable results for our patients. –Danene Brown P.T., D.P.T.

I just spent a fortune on new MBT Sport walker shoes. Now my feet are killing me 
and I can no longer walk without pain. What did I do?

The MBT Sport shoe is a rocker bottom shoe. The company claims that the shoes reduce strain on the lower back, activate the gluteal muscles, and reduce shock to the foot. The design of the shoe facilitates a rolling motion from the heel to the forefoot. However, the sole of the shoe is very rigid and does not flex. As a result, the normal mechanics of the foot are not allowed during walking. When walking, we land on the heel and as we progress forward, the heel rises off the ground as the foot supinates. The MBT does not allow the normal foot mechanics. These shoes require increased dorsiflexion at the ankle, which many people lack. Due to all of these factors, the shoes can cause increased stress and strain to the foot and ankle complex. If you do not have the accessory range of motion necessary for these shoes, there is a potential for painful feet. 

In the end, if your shoes are causing pain to your feet, they are not the right shoes for you. Choosing the right shoe can be difficult. You should never feel like you have to “break in” your athletic shoes. If you just don’t know what to do, PT Works offers a Shoe Fit program where we can measure your feet, watch you walk, and evaluate your foot mechanics to put you in the correct shoes. http://www.ptworksllc.com/shoe.html

- Chris Thoene P.T., D.P.T.

I notice my elderly father can no longer get out of a chair without a great deal of effort. He says this is normal for his age. Is he right?

I am a firm believer that, no matter the age, one should be able to rise out of a chair safely and independently. Decreased ability in this skill has been associated with risk of falling. With that in mind, many factors play a role in this movement, and one or more may be limiting your father in his ability to rise from a chair.
• strength of the core stabilizers and lower extremities
• flexibility of the trunk and lower extremities
• confidence (or lack thereof)
• balance and coordination
• chair dimensions (eg, height or availability of arm rests)
• mental state (eg, depression or conditions such as a stroke)
• activity level (eg, sedentary versus mall walker)
• medicine side-effects (eg, lightheadedness, dizziness)

If you see your father struggling with basic mobility skills, physical therapy will benefit him. Learning a few basic exercises can increase his confidence, independence, and potentially, ward off a future fall. This alone is worth its weight in gold; a fall could cause a head injury, a fractured hip, or ultimately, result in the need for assistive care. – Danene Brown P.T., D.P.T.


I’ve got degenerative disc disease. I can’t decide whether to see a physical therapist or a chiropractor. How would a physical therapist differ from a chiropractor?

Degenerative disc disease (DDD) refers to the loss of normal structure or function of the spine. It is related to normal aging or misuse. The discs between the vertebrae begin to lose their water and protein content, which leads to their inability to withstand stress. Symptoms are often localized around the spine, but since the spine carries a considerable portion of your body’s weight, DDD could be associated with disc bulging and referred pain into a limb.

The medical community agrees that episodic low back pain associated with DDD should be treated with rest and ice for only 1-2 days, followed by a progressive therapeutic exercise program. Who should design this program for you? Whichever avenue you decide to pursue, you should feel results and learn how to care for your spine in the future.

Physical therapists (PTs) receive either a doctorate or masters degree, are licensed through the state medical board, and are experts in the assessment and treatment of biomechanical disorders. Your PT will take a thorough history to include cause of injury, your health history, family history, work postures, current activity level, etc. A physical examination will include observing your body’s movement and assessing your strength, flexibility, and coordination. A treatment plan will be designed to meet your particular needs and may include education, therapeutic exercise, manual techniques applied by your PT, modalities to reduce pain, and a home exercise program to continue the healing process. The goal of physical therapy should be to teach you what to do (and what not to do) to alleviate symptoms now and in the future.

Chiropractors receive a doctorate degree from a chiropractic school and are licensed by the state. A chiropractic assessment should be similar to a PT’s, though most concentrate on the spine. Treatment varies, but spinal manipulation or adjustment is often used in an attempt to restore joint motion and, therefore, spine motion. Because manipulation cannot be replicated at home, frequent visits may be necessary to achieve the desired results. Modalities, nutritional advice, and therapeutic exercise may or may not be offered.

At PT Works, our physical therapists place a strong emphasis on education and awareness, so that you will know from day one how to take care of your spine for years to come.– Danene Brown P.T., D.P.T.


I have, on occasion, heard a “pop” in my knee. The orthopedic surgeon says I may need surgery if the knee is unstable. Can you help me avoid surgery?

An audible “pop” can be caused by a few musculoskeletal conditions: an ACL tear, a torn meniscus, or friction from a tendon against a bone within the knee joint. In all cases, the knee may feel unstable, swell, demonstrate restricted movement and be painful. A physical therapist can assist you in reducing these symptoms by providing pain relief and range of motion and leg strengthening exercises. A physical therapist can also provide gait analysis and postural assessments, incorporating the whole body, to provide you with an overall assessment of movement. Surgery may be avoided if strengthening and range of motion exercises decrease pain and improve stability of the knee. However, if you are an athlete, a weekend warrior, or a generally active person, surgery may be beneficial to return you to your prior level of ability. After that, we’ll be happy to assist you in your recuperation and training. – Christopher Thoene P.T., D.P.T.


I first sprained my ankle as a teenager and have sprained it many times since. I seem to sprain it so easily now and don’t understand why.

When you sprain your ankle, the ligaments and soft tissue are stretched beyond their normal limits. This leads to pain, swelling and difficulty walking for several days. But there is also injury to the joint proprioceptors. These proprioceptors send a message to your brain to tell you where your body is in space.

Your foot and ankle need to adjust to uneven surfaces such as walking on gravel or a grassy, bumpy yard. When a joint is injured, the sense of position is altered, so your brain does not receive the appropriate message to avoid reinjury. This can lead to problems with balance and coordination, which can cause recurrent ankle sprains. Physical Therapy can retrain the joint proprioceptors by using exercises and activities that challenge the balance and reaction time of the injured joint. Thus strengthening your ankle and reducing the risk of recurring sprains. – Matt Wren M.S.,P.T.


Sometimes I develop a headache in the back of my head after sitting at the computer. Am I sitting too close?.

It’s very likely that your sitting posture at the computer can cause an occipital headache (at the back of the skull). Several muscle groups attach to the base of the skull and can actively push your chin forward toward your computer. This sustained tightening of muscle fibers, over long work hours, can fatigue them, triggering a headache.

Think of holding a bowling ball with your arm extended straight in front of you versus down at your side. By holding it in front of you, your arm muscles will fatigue and you’ll likely have muscle soreness for a day or two. Holding the ball at your side is more efficient, and the ball could easily be held for a longer period of time, without muscle soreness.

This plumb line concept is crucial for your seated posture at a work station. Try this.
• Starting at your feet, place your ankles at right angles or flat foot position.
• Your knees and hips should be no less than right angles; they may do even better at angles up to 120 degrees. This limits the amount of slouching that may occur at the low back and sets the foundation for your upper spine.
• Your keyboard should be placed over your lap to encourage elbows resting beside your waist.
• Finally, the monitor should be placed slightly below eye level to limit chin forward postures.
• Also, using a phone headset and taking standing/walking breaks often will help.

If your headaches persist, your Physical Therapist can help evaluate your posture and give you detailed exercise and stretching techniques. – Matt Wren M.S.,P.T.





Last week, I awoke with intense vertigo especially when I turn my head to the right. I’ve been diagnosed with vestibular neuritis. What should I expect in terms of recovery?

Vestibular neuritis is an infection of the inner ear (labyrinthitis) or the vestibular nerve (neuritis). It disrupts the signal to the brain that gives us our spatial awareness or equilibrium. Symptoms include sudden onset of vertigo, nausea, imbalance, and possibly vision or hearing difficulties. It can be of bacterial or viral origin, so a doctor’s diagnosis is important in initial treatment.

Initially, the symptoms are intense, but they decrease over 1-2 weeks. Symptoms can completely resolve in this timeframe, though some can linger and become chronic. Often you will “look healthy” but find that simple daily tasks can be fatiguing or uncomfortable due to persistent disorientation. This is the time when physical therapy can help. Your physical therapist would assess the three sensory inputs that give you equilibrium: your gaze stabilization or how your eyes track targets; your balance or how your feet sense the ground; and your inner ear’s ability to orient you. A program will be developed to retrain the inner ear to respond appropriately through exercises which challenge your equilibrium. Most of the exercises are done at home, with periodic check-ups to modify your exercises and monitor your progress as you heal. – Danene Brown P.T., D.P.T.


I have a pain in my right buttock and my doctor says I have piriformis syndrome. What is it and what can I do about it?

The piriformis is a deep muscle behind the hip joint. It aids in controlling hip joint rotation during walking and running. The piriformis muscle lies in close proximity to the sciatic nerve.

Pain can stem from muscle spasm or irritation to the sciatic nerve due to:
• overuse (running without adequate arch support)
• sustained pressure (prolonged car travel)
• sitting on a hard surface (or a wallet)
• direct trauma to the area
• strength or flexibility imbalance

Other causes of this type of deep buttock pain include spinal problems such as herniated discs, spinal stenosis, sciatica, and tendonitis. The diagnosis of Ppiriformis syndrome is often given when all of these diagnoses are eliminated as possible causes of hip and sciatic pain. Typically in piriformis syndrome, the muscle is tight and exquisitely tender to the touch.

Physical therapy can assist in assessing the root of the problem and in prescribing proper stretching and strengthening. Deep soft tissue mobilization may also be necessary. – Matt Wren M.S., P.T.


I cannot lie on my left side because of hip pain. I notice it as I go up stairs too. Is this bursitis and what should I do?

Bursitis is a term to describe inflammation of a bursa. A bursa is a fluid filled sack which lies between layers of muscles to lubricate them during muscle contractions against each other. We have many bursae throughout the body, and the hip has several. Bursitis symptoms include localized tenderness to the touch and discomfort with large movements of that particular joint.

Trochanteric bursitis refers to the bursa just behind your hip bone on the side. Often it is difficult to lie on that side, and larger hip movements such as stair-climbing or brisk walking can be painful. It can be caused by general hip weakness, which allows the surrounding musculature to work inefficiently over the bursa, thus irritating it. Also, poor core stabilization can cause repetitive strain to the musculature over your posterior hip. Other factors include sedentary lifestyle, leg length differences, and lumbar disorders. At PT Works, we can determine the root cause of the bursitis and prescribe a program unique to your needs. – Danene Brown P.T., D.P.T.


My physician told me I have a frozen shoulder and that it will go away on its own… but my friend did physical therapy and got better.

Your physician and friend are BOTH correct. Frozen shoulder, aka adhesive capsulitis, is a metabolic condition afflicting the shoulder joint lining. Its etiology is often unknown, but those having a previous shoulder injury are more prone. It occurs most often during the fourth and fifth decades of life. The lining of the joint becomes inflamed and restricted, causing pain and immobility of the shoulder. Interestingly, frozen shoulder usually resolves in about one year without treatment. However, most can benefit from PT to reduce pain and improve mobility for daily activities in less time. PT would include modalities to reduce pain, hands-on techniques to increase joint mobility, and therapeutic exercise to restore functional abilities. – Danene Brown P.T., D.P.T.


My mother is aging and has had several falls in the last few months… can anything be done?

Number one, falls should be taken seriously. One in three, over the age of 65, fall each year, and of those, 20-30% will lose mobility and independence. Can you believe that 87% of all fractures occur from falls? Half of those with hip fractures cannot return home!
First, it should be determined why your mother is falling. Falls can occur from many factors, ie, developing weakness with sedentary living, inner ear disorders, or being over medicated. Consulting with her family physician and possibly a balance specialist/ENT may diagnose the root cause.
Physical therapy can definitely help to prevent falls by strengthening the muscles associated with balance and stabilization, assistive device prescription (cane, walker), home modifications, and gait training. – Danene Brown P.T., D.P.T.


I’ve been told I have plantar fasciitis… what is it and can PT help?

PF is an overstretch injury of the arch, or plantar fascia, from it’s attachment at the heel bone. This creates local inflammation and pain on the bottom of the heel, typically upon first rising in the morning and with prolonged standing or walking. It is often persnickety and can linger for a year or more. Physical therapy can assist in pain reduction, shoe or orthotic prescription, proper stretching of the calf musculature, and ice application techniques—all which can get you back on your feet quicker! – Danene Brown P.T., D.P.T.


I was in an awful car accident last week. I felt ok for a day or two, then the pain got really bad
on the third day. X-rays are normal. How long can I expect to feel bad?

Initially after an accident you may feel fine because of adrenalin in your system. As this wears off the soft tissue strain will become noticeable causing pain and stiffness. You may feellousy for a couple weeks. It is important during this time to allow your body rest periods through the day and to avoid static postures, as possible, to keep
the tissues from stiffening which will cause more pain. Gradually you will begin to feel better with some set back days. In the clinic we would perform a thorough exam and develop a program to meet your specific needs to aid in your healing process. We can help you manage your pain through education in posture, function, positioning, use of modalities (ice, heat, e-stim, massage) and exercise. – Terri Berkshire M.S., P.T.


I have a bunion and my podiatrist recommended surgery to relieve the pain I have when
walking. Is physical therapy an option?

Yes, physical therapy may be able to relieve your pain; and therefore, improve your quality of walking. Even if you’ve already had the surgery, PT can reduce the recurrence of bunions.
First, I would ask you what type of shoes you wear on a regular basis: for exercise, for work, and for going out on the town. More women than men tend to form bunions as they squeeze the forefoot into the narrow toe box of high-heels. Second, I would determine if you’ve been wearing the correct size, including the width. You can easily do this at home by tracing the outline of your foot while standing, then tracing the outline of your favorite shoe over top. Your shoe should be the larger outline!
Your PT should examine your foot posture while you stand and walk. Pronation is a movement pattern where the arch lowers excessively during stance or walking. This can cause undo stress to the first metatarsophalangeal joint, creating pain and further malalignment of a bunion. An over the counter insert or an inexpensive, heat moldable orthotic may be prescribed by your PT to reduce pronation of the foot. Other biomechanical factors would also be assessed, such as leg length discrepancies or restricted heel cords. – Danene Brown P.T., D.P.T.


One Doctor said I had tendonitis in my elbow, and another doctor said I had tendonosis. What’s the difference?

A tendonitis is an acute inflammation of a relatively recent injury. This type of injury responds well to ice application of 15 minutes, 3-4 times a day; reduced exercise time and intensity; resting. A tendonitis should resolve within 4-6 weeks. A tendonosis is an inflammation that has continued for six months or longer. In a tendonosis, the tendon has undergone a degenerative change and it is actually weaker than it was the day of the initial injury. To heal properly, a tendonosis needs two things:
1. Increased blood flow which will provide oxygen and nutrition to the injured tissue.
2. Controlled, progressive exercise to promote healing.
Applying heat, combined with a slow progressive warm-up and exercise plan, should help the elbow heal. But this will take time. If you don’t address a tendonitis early, it will progress to a tendonosis, which is much more difficult to heal. – Matt Wren M.S. P.T.


My three-year-old son is a toe walker. What do you recommend?

Two words: blinky shoes! Most types of light-up shoes or blinky shoes only light when the heel is on the ground. Excellent motivation and immediate gratification for a 3-year-old to walk with a heel-toe pattern. Not all blinky shoes function that way so make sure the shoe lights up when the heel contacts the ground before you buy. You can also encourage your son to play with playdough or other manipulatives in the squatting position. This is an excellent calf and heel cord stretch. Super-duper slow-motion running forward or backward is another choice that comes to mind. Make it fun at all costs. You will also need to stretch the heel cords manually, and we can show you how to do this as well. – Matt Wren M.S. P.T.


What is spinal decompression therapy? I saw an ad in the paper for spinal decompression
therapy as a new and revolutionary treatment to cure low back pain.

Simply put, decompression therapy is mechanical spinal traction. This type of modality can be effective at treating neck and lower back pain, but I hesitate to say that traction can CURE a specific problem. Be leery of any practitioner who wants to charge you out of pocket for traction, as most health insurance plans cover the cost of mechanical traction. Furthermore, there are a few good products that can be used in the home setting as well.
I assure you, spinal decompression therapy is not new, revolutionary or exclusive. Spinal traction was originally employed for the treatment of spinal deformity (scoliosis) dating back to 4000 B.C. The father of modern medicine, Hippocrates himself, designed and effectively used a traction device in 400 BC. For 20 years, I have treated patients who have neck and lumbar pain with spinal traction, and I am confident in saying that you cannot cure everyone with this treatment modality alone. – Matt Wren M.S. P.T.


I have two friends who have had total knee replacements with very different results. One is back to work and walks two miles per day without pain; the other can barely go grocery shopping due to pain and stiffness. I am concerned about the outcome of my pending surgery—do you have any advice?

The goal of knee replacement is to reduce pain during daily tasks and walking. Several factors can predict the outcome after a knee replacement. First, your overall health and your knee function prior to surgery play the biggest roles. Having adequate range of motion (0-120 degrees or more) and good quadriceps strength are favorable. Being in good health is a benefit for obvious reasons; however, having a concurrent illness may slow your recovery. Also, consider your current level of activity and frequency of exercise. Rehab following this type of surgery requires daily exercise; this is done in a rehabilitation hospital, in your home, or in an outpatient facility depending on your progress at that time. The type of hardware the surgeon chooses for your knee is also crucial. Some hardware resurfaces three separate parts of the knee joint (two for the long bones, one for the knee cap); others have an actual hinge between the two long bones; and some surgeons opt to resurface just one compartment of the knee (medial or lateral portion of the long bones). Your surgeon will choose the best fit for your knee. Post-operative considerations include swelling, pain, and scar tissue formation- these are unique to the individual.

So you see, many factors go into deciding if knee replacement is for you. We suggest meeting your potential physical therapist prior to surgery to discuss your goals, learn the basics of rehab, and get a pre-operative exercise program to familiarize yourself with what’s ahead. Your physical therapist will customize your rehab to meet your needs and goals. – Danene Brown P.T., D.P.T.


I have had foot pain for several years, and someone suggested that I look into custom orthotics. Custom orthotics can cost between $300 and $400. Do you have any other suggestions?

First of all, I know little about the nature of your foot condition or why you’re having pain. I can, however, offer some suggestions. Not everyone needs an expensive custom-made orthotic to solve their foot and ankle problems. I recommend you start with an over-the-counter or prefabricated product to see if that helps. Currently there are several excellent over-the-counter products available which cost between $25 to $40. With that said, those products may need a bit of customization to meet your specific needs. We can help you find the right product and adjust it for you. I have found that a customized over-the-counter arch support will often do the trick and is much more cost-effective as well. – Matt Wren M.S., P.T.


After I do yardwork, I often cannot stand up straight because of back pain. Is bed rest my best option?

Bed rest and ice application (10 minutes at a time, with one layer between ice and skin) are appropriate for 1-2 days following a back strain. After that, it’s imperative to get moving to avoid stiffness. Walking on flat surfaces for 10-15 minutes several times a day is a good way to start. Avoiding positions in which you are bent forward (eg, folding laundry or picking up small children) can prevent flare-ups.
Most back strains are self-limiting and resolve within 1-2 weeks. If you find that your symptoms persist or seem unreasonable, you should consult your doctor. Physical therapy, anti-inflamatories, or muscle relaxers may be prescribed to ease your symptoms.
Your physical therapist would assess your symptoms and prescribe appropriate treatment and exercise to get you back on your feet. Simple, regular back exercises can promote back health for years to come. Also, your physical therapist can educate you on proper lifting and yard work mechanics to avoid this injury from happening in the future! – Danene Brown P.T., D.P.T.


When I roll over in bed, I become extremely dizzy. My doctor explained that I have “loose rocks” in my ear and that physical therapy is the best option. Can you explain this?

About 20% of dizziness is due to Benign Paroxysmal Positional Vertigo, or BPPV. The symptoms include a brief sensation of vertigo (spinning) with position changes and possibly lightheadedness, nausea, and imbalance between those episodes. Calcium carbonate crystals (ie “the rocks”), become dislodged from one part of the inner ear and then collect in the semicircular canals. Normally, the fluid of the semicircular canals swishes with head movement, giving the brain a signal of spatial awareness or equilibrium. The fluid viscosity changes with those dislodged calcium carbonate crystals, thus confusing that signal. This results in brief vertigo lasting a few seconds. The cause could be normal aging of the inner ear, head trauma, mild stroke or a viral infection, and can even be unknown.
The good news is that it is completely benign and treatable! First, your PT would assess for the problem and then treat you with a simple head turning procedure to reposition the calcium carbonate crystals. Your PT may repeat this procedure as often as necessary and issue you home exercise instructions. – Danene Brown P.T., D.P.T.

I’ve got jaw pain and have a night guard. A friend said physical therapy could help. How?

Jaw pain often can be the result of Temporomandibular Joint Syndrome (TMJ). TMJ is associated with a combination of the following: difficulty opening the jaw, popping and clicking in the jaw, locking of the jaw, neck and shoulder pain, and a bite that feels off. There are many contributing factors to TMJ, but the most common cause is oral dysfunction such as excessive jaw use, clenching teeth, and grinding. 

Physical therapists see patients with TMJ symptoms – usually those symptoms include radiating jaw, neck and facial pain; jaw stiffness; or limited or painful jaw movement. Physical therapy interventions aim at changing the cause of the jaw pain. We begin with education on how to eat – decrease chewing, cut food into small pieces, bite with the front teeth, eat softer foods. We educate patients in posture dysfunction, which can put added stress on jaw and facial muscles, and in stress management. Finally, we address muscles and joints in the region which contribute to the pain.  – Christoper Thoene P.T., D.P.T.

My doctor says I have calcific tendonitis in my shoulder, but don't need surgery. It hurts. Anything else I can do?

Calcific tendonitis results from the formation of tiny calcium deposits within the tendons of the rotator cuff. These calcium deposits usually resolve within 1-4 weeks. The first line of defense is always conservative non-operative care. Treatment for calcific tendonitis is similar to the treatment of shoulder impingement syndrome. Treatment begins with shoulder stretching, shoulder strengthening, and application of moist heat for pain control. Anti-inflammatory medications are also useful to decrease symptoms. –Christopher Thoene P.T., D.P.T.

I’m due to have knee surgery and my surgeon referred me to physical therapy BEFORE surgery. Why is this necessary?

Physical therapy can be very helpful prior to knee surgery to improve your outcome after surgery. Physical therapists (PTs) are the healthcare providers you can rely on for this service. Your PT will evaluate your current abilities and help you establish your post-surgical goals. Having this discussion is important so that you and your PT are on the same page from day one. You may be prescribed a home exercise program to optimize your flexibility and strength pre-surgically—this may improve your post-surgical knee function. This also allows you to become familiar with the exercises you’ll be performing during your recovery. Your PT will train you to use walking devices you may need, such as a cane or crutches. Preparing your caregivers on how to assist you is also valuable. This can include wound care technique and the best way to safely assist you in/out of a chair. Your PT will offer advice on how to set up your home, from installing a grab bar in the shower to removing scatter rugs to avoid trips and falls.

The PTs at PT Works are knowledgeable about the type of surgery you’ll be having and have extensive experience in the rehab process. We’ll be here for you from day one through the completion of your rehab. –Danene Brown P.T., D.P.T.

When I am driving I get a burning sensation near my shoulder blade and sometimes my thumb goes numb. What could this be?

The pain you are feeling could be the result of compression of the sixth cervical nerve at its origin, the cervical spine. This is commonly called a “pinched nerve.” In particular upper body positions, e.g., when the arms are outstretched for driving, the intervertebral space between the fifth and sixth cervical vertebrae is compressed. With certain underlying conditions, this natural compression can be enough to squeeze the C6 nerve root causing referred, neurologic symptoms to the thumb, forearm, and around the scapula. These conditions include relative muscular tension around the cervical spine, arthritic conditions of the cervical spine, or a bulging disc. Of the nerve roots in the cervical spine, C6 is the most commonly involved in referred symptoms. 

Your physician can determine the cause of your problem with a physical exam and diagnostic tests. No matter the cause, your physical therapist can teach you ways to reduce cervical compression and relieve the associated symptoms.

–Danene Brown P.T., D.P.T.

You say to ice an inflammation, but what exactly does ice do and how does it help?

Any acute injury is followed by inflammation at the site of the injury and its neighboring tissues. The inflammatory process occurs naturally, begins soon after injury and can last for several days. Natural healing consists of a series of carefully choreographed steps.

Inflammation brings increased blood flow to the injury, resulting in an accumulation of fluid or swelling. Think of it as your body’s way of placing a protective cast around the injury. Increased blood flow also provides the injury site with oxygen and nutrition for the tissue repair process. However, excessive swelling can lead to significant pain and stiffness and delay the natural healing process.

By applying ice to an acute injury you can control the swelling and pain and help keep the healing process on course. Ice should always be used immediately following an injury because it decreases blood flow to the tissue, and will thus lessen swelling, numb pain and control bleeding. Wrap ice cubes—or a bag of frozen peas or corn—in a thin towel and place the pack on the injured area for 20 minutes of each hour you’re awake. If your skin turns blue or white, discontinue icing for a few hours. Two cautions: Never apply ice or frozen bags directly to your skin, and never leave an ice pack on your injury while you sleep. The rules of RICE should be followed: Rest, Ice, Compression, and Elevation of the body part with the inflammation.–Chris Thoene P.T., D.P.T.

When I try to walk for more than an hour there is numbness/tingling and pain in the ball of my right foot. When I sit down and rub my foot for a couple minutes it goes away. I want to be able to walk for an hour or more but this is preventing me. What can I do?

We would need to do an exam to find the root cause of your pain. Symptoms of numbness and tingling indicate irritation or inflammation of a nerve. The source could be in the foot itself or in the back where the nerves exit the spine to feed into the legs and feet. A Morton neuroma occurs in the ball of the foot, causing pain, numbness and tingling with walking. A neuroma is a thickening of nerve tissue that results from compression and irritation of the nerve. In this case, I would try unloading / decompressing the area using of a pad that provides support for the metatarsal arch. Also try to wear shoes with a large toe box and ice the area for 10-15 minutes as needed for pain. Another cause of numbness and tingling could be caused by spinal stenosis. Leg or foot symptoms can occur with or without symptoms of low back pain. Symptoms are often worse with prolonged standing or walking. Bending forward or sitting increases the room in the spinal canal and may lead to partial or complete symptom relief.

You should have this checked out by your doctor. A Morton neuroma is treated with ultrasound, massage and a correctly placed metatarsal pad. Spinal stenosis can be treated with stretching and lumbar traction. –Terri Berkshire M.S.,P.T

Are there specific physical changes that occur during menopause that can cause joint pain?

Joint pain may become more apparent during your pre-menopausal and menopausal years. Research shows that more than half of all post-menopausal women have joint pain. Knee, elbow, and shoulder complaints are the most common. Often it is referred to as “menopausal arthritis.”

One theory is that normal aging of the body leads to degradation of cartilage and the decreased ability of joints to self-lubricate. Symptoms include joint stiffness, aching/pain, and loss of mobility. Another theory involves the body’s natural depletion of estrogen during menopause. This is thought to generally increase sensitivity to pain in joints. This was discovered when investigating breast cancer treatments which are designed to decrease estrogen levels in women. While on the drugs, women had generalized joint pain. When the drugs were stopped, so did the joint pain.

Regular exercise is crucial during these years to maintain joint health and muscular strength. Regular exercise can also slow progression of osteoporosis, decrease obesity, and prevent cardiovascular issues. Women who have a regular exercise regime report less menopausal symptoms overall. Those using hormone replacement therapy (HRT), in combination with exercise and calcium supplementation, show greater bone density than those using HRT alone. – Danene Brown P.T., D.P.T.


Running is my favorite form of exercise, but I have had to stop running, and other activities that involve jumping, due to problems with urine leaking out. A friend suggested seeing a physical therapist; how can this help?

What you are describing sounds like a specific type of urinary incontinence; stress incontinence. Stress incontinence may occur when you sneeze, cough, laugh, jog, or do other things that put pressure on your bladder. This is the most common type of bladder control problem in women. Because incontinence can be a short-term problem caused by a urinary tract infection, a medicine, or constipation you should always consult your doctor before seeing a physical therapist. Stress incontinence can be caused by childbirth, weight gain, or other conditions that stress the pelvic floor muscles or other urinary structures. When the pelvic floor muscles cannot support your bladder properly, the bladder drops down making it difficult to tighten the muscles that close off the urethra. Most bladder control problems can be improved or cured. Specially trained physical therapists can assist in your treatment for stress incontinence. PT can assist through education, biofeedback training, and functional exercises for the pelvic floor so you can get back control and return to your previous level of activity. – Terri Berkshire M.S.,P.T


I had a mastectomy 4 months ago. Now I feel tight and stiff on that side and can’t reach over
my head or behind my back.

After breast surgery, women often keep their arms at their sides in a protective position usually due to pain at the incision site, and /or body image concerns. This position promotes muscle guarding, particularly in the pectoralis major and minor muscles and stiffness in the shoulder. Muscles such as the levator scapulae, teres major and minor and infraspinatus often become tight and this can also restrict active range of motion in the shoulder. In severe cases, you might even develop a “frozen shoulder,” with flexibility greatly diminished in all directions and daily activities severely limited. Soft tissue restrictions in the anterior (front) chest wall, particularly in the pectoralis group is common, and some women lay down more scar tissue than needed in the healing process. Adhesions and tightness in these muscles will interfere with shoulder motion and contribute to poor postural habits. Physical therapy will help to decrease adhesions and restore soft tissue mobility and muscular balance between the anterior and posterior (back) chest musculature. We also help to reinforce good postural and movement habits for activities of
daily living. – Terri Berkshire M.S.,P.T