Geaux to Physical Therapy » Orthopaedic

Peas and Carrots: Carpal Tunnel Syndrome and A Stiff Neck

MoniquePT — Mon, 11 Jul 2011 12:25:27 +0000

Image by IronHide via Flickr

An article^[i] in the The Journal of Orthopaedic and Sports Physical Therapy (JOSPT) recently discussed a possible new hallmark of carpal tunnel syndrome – a stiff neck. Carpal Tunnel Syndrome (CTS) is a condition in which a nerve in the wrist is compressed, causing symptoms of numbness, tingling, and weakness in the hand. It can cause considerable pain and debility in the hand and many patients complain of it waking them at night or causing them to drop objects. Carpal Tunnel Syndrome is most commonly thought to be caused by compression of the median nerve within the “carpal tunnel” in the wrist. Or so we think. In the JOSPT article, neck mobility was assessed in women with CTS and a second healthy group. The research showed that women with CTS had less neck mobility, essentially a stiff neck, compared to the healthy counterparts. The research also discussed previous studies that also found the presence of abnormal posture, arthritis, spinal stenosis, and pain in the neck and shoulder in individuals with CTS. Apparently, CTS and conditions of the neck hang out well together like peas and carrots. Hmmm. One of my patients made a relevant comment this week, “You mean one part of the body is connected to another?!”

The carpal tunnel is a space within the wrist. In this space lies a nerve, the median nerve to be exact, as well as 9 tendons. If you can correctly comment below the names of the 9 tendons, you get a cookie, or maybe one of those mashed potato cupcakes. During cadaver dissection, nerves look like little white strings. The median nerve arrives from the brachial plexus, a bundle of nerves in the neck and shoulder region that look like a complicated braid. The brachial plexus arrives from nerves that shoot off from the neck. When you pull one side of a string, does it make the other side of the string move? I’m simplifying something that is much more complex than that, but can you see how movement of the neck might affect a string or strings that come from it?

Physical therapists are trained to assess adjoining joints to get a more global picture of what might be contributing to a condition. In a physical therapy evaluation of a patient with CTS, I screen range of motion and strength in the joints all the way up from the wrist and hand to the neck. I also assess mobility of the median nerve along its entire course from the hand to the neck, in what I like to call “flossing.” Whatever impairments I find, treatments are incorporated to address them. If CTS is not managed well with conservative treatments of physical therapy, splinting, and injections, then surgery may be suggested. If you have or think you have CTS, be sure someone takes a look at your neck.

Although this study points out that a stiff neck may be a common feature in CTS, more research needs to be done to see if this may indicate it contributes to CTS or if CTS contributes to neck pain and associated conditions. We don’t fully understand our body’s nervous system. I have a feeling it’s more than just peas and carrots.

Is all this talk of vegetables making you hungry? Try this out.

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References

De-La-Llave-Rincon, et al. (2011). Women With Carpal Tunnel Syndrome Show Restricted Cervical Range of Motion. JOSPT, 41(5): 305-310.

Tennis elbow… or is it?

MoniquePT — Tue, 01 Mar 2011 23:55:44 +0000

Image via Wikipedia

Tennis elbow is a painful condition in which pain is experienced on the outside of your elbow with lifting and gripping (especially when your elbow is straight) and can lead to weakness in the elbow and hands. The condition can be attributed to poor technique related to tennis, however, more people suffer from tennis elbow than just tennis players. If you’re reading this, you may fall into this category. In fact, the condition is attributed to playing tennis in only 5% of the cases!

Tennis elbow commonly occurs in those who are middle-aged. Although many believe tennis elbow (also known as lateral epicondylitis) is an inflammatory condition (“-itis” means inflammation, right?), research shows that in many cases little to no inflammation is present. More recently, tennis elbow has been described in terms that do not suggest inflammation is present, such as tendinopathy, tendinosis, or lateral epicondylosis. These terms imply tendon degeneration, which research indicates is a cause of this condition.

Tennis elbow is caused by overuse and overload of the tendon beyond what it is capable of doing. Overuse and overload can mean different things to different people. It depends on how strong you are and what your body is capable of tolerating. For some people, tennis elbow can be provoked by doing more household chores in one day than normal. Others may provoke symptoms by participating in more sporting activities than normal (such as not swinging a golf club all winter and then taking a trip that includes playing 18 holes of golf 4 days in a row).

Overuse and overload leads to small tears in the tendon. Under these conditions, the tendon may not be able to repair itself properly, leading to more small tears. As part of the inadequate healing, the collagen fibers of the tendon, which give the tendon strength and support, become disorganized and weak and more “fibrotic” scar tissue is formed. The tendon becomes thicker, inflexible, and is not very strong or resilient. The improper healing of the tendon can lead to more pain and larger tears in the tendon and muscle.

Many of my patients ask about whether a cortisone injection would help. Research shows that medication and cortisone injections can provide adequate short-term pain relief, but no lasting effects, and one study even noted that tennis elbow treated with cortisone injections had poorer outcomes after 6 weeks of treatment and increased recurrence compared to those who had physical therapy or even for those who took a “wait and see” approach. Inadequate and or delayed treatment can lead to the problem becoming chronic. For more info and my opinion about cortisone injections, click here.

Treatments for this condition will vary based on the stage of healing. Physical therapists are trained to identify the stage of healing of tennis elbow and the appropriate course of treatment. Physical therapists use specific manual therapy techniques and exercises to help reorganize the collagen within the tendon, promoting better healing and improving its strength. If you think you may have tennis elbow, see a physical therapist. You can find one through the APTA.

References

Clinical Evidence Handbook: Tennis Elbow – March 1, 2007 – American Family Physician. (n.d.). . Retrieved March 1, 2011, from http://www.aafp.org/afp/2007/0301/p701.html

Andres, B., & Murrell, G. (2008). Treatment of Tendinopathy: What Works, What Does Not, and What is on the Horizon. Clinical Orthopaedics and Related Research, 466(7), 1539.

Todd E Davenport, Kornelia Kulig, Yogi Matharu, & Cesar E Blanco. (2005). The EdUReP Model for Nonsurgical Management of Tendinopathy. Physical Therapy, 85(10), 1093.

Mobilisation with movement and exercise, corticosteroid injection, or wait and see for tennis elbow: randomised trial — Bisset et al. 333 (7575): 939 — bmj.com. (n.d.). . Retrieved February 28, 2011, from http://www.bmj.com/content/333/7575/939.full

Coombes, B., Bisset, L., & Vicenzino, B. (2010). Efficacy and safety of corticosteroid injections and other injections for management of tendinopathy: a systematic review of randomised controlled trials. The Lancet, 376(9754), 1751.

Physical Therapy Helps Manage Back Pain

MoniquePT — Fri, 15 Oct 2010 02:30:33 +0000

A colleague of mine sent me this article from MSNBC about back surgery. There were a few statistics in it that were staggering including that 26% of those who have back surgery return to work compared to 67% of those who elect not to have surgery. One thing that most people don’t realize about back pain is that most of the time this pain stems from degeneration of the joints within the back. Degeneration is normal and happens to everyone–all of our joints eventually wear out and break down. However, the stress and strain we place on these joints or the way in which we are moving or not moving can accelerate the degenerative process. As the article eludes to, nothing can take away back pain 100%. Though, there are effective non-pharmacological and non-invasive treatments that do help many people with back pain including physical therapy. Many people are not aware that physical therapy will help to relieve symptoms and develop a strategy plan to reduce strain and stress on the affected area of the spine. I’ve found through treating individuals with back pain that degeneration of the joint can be accelerated by the way someone moves, posture, weakness, or inflexibility. These are all addressed in physical therapy. So, although the joint is degenerated, and there is no cure for that…. we can address contributing factors to the continued stress and strain to that area, so degeneration to the joint in the spine can be slowed and the joint can be better protected. There is no silver bullet for back pain, but there is a silver lining. If you have back pain, especially chronic back pain and have never seen a physical therapist you now have a very good treatment option in physical therapy.

Find a PT.

Precious PRICE

MoniquePT — Sat, 09 Oct 2010 13:24:26 +0000

Someone stopped into the clinic yesterday with a hamstring strain asking what type of stretches she should be doing. She also mentioned that someone recommended she put heat on it. First question is always “When did this occur?” “Yesterday.” “Well, in that case, use PRICE.” For 24-48 hours following an injury I recommend PRICE.

Protection: When an area is injured, you want to make sure you protect it from reinjury.

Rest: Do NOT skip this step. Allow your body to heal. If you don’t wait an adequate time and rest the affected area, you run the risk of reinjury or improper healing, and then it could potentially turn into a chronic problem.

Ice: Ice is the only modality you want to use immediately following injury and for two days after, NOT heat. Ice is an anti-inflammatory and at this stage you don’t want to do anything that would increase swelling, such as heat. Use ice 15 minutes every hour in most cases. If you need an ice pack recipe, click here.

Compression: A little bit of compression wrapping will help to limit swelling, but be sure not to wrap the area too tightly as you don’t want to restrict blood flow.

Elevation: Keep the affected limb elevated above the level of your heart in order for swelling to be kept at minimum.

Still in pain, not sure of what to do? Find a PT or seek medical attention from your doctor.

Thanks to wwarby on Flicker.com for this picture!

Are Glucosamine and Chondroitin Beneficial?

MoniquePT — Thu, 07 Oct 2010 15:45:10 +0000

Patients ask me what my opinion is on taking the supplements glucosamine and chondroitin for arthritis. So, for our monthly journal club I decided to read an article published in the September British Medical Journal (BMJ) on this topic.^[i] Researchers analyzed randomized controlled trials that studied the effect of supplements glucosamine and chondroitin on pain levels and measured joint space on radiographs (x-rays) in those with hip and knee osteoarthritis. Osteoarthritis is a degenerative condition in which a joint’s cartilage wears away and joint space narrows leading eventually to “bone on bone” arthritis.

Glucosamine and chondroitin are substances that occur naturally within our joints. The supplements claim to reduce pain and improve joint flexibility and have had mixed evidence as to their effectiveness. There have been studies that show glucosamine sulfate to be just as effective at reducing pain as NSAIDs such as ibuprofen.^[ii] This could be a better option due to the supplements having fewer side effects. There are other studies, like the one published in BMJ, which urged that practitioners not recommend the supplements to patients, stating that the evidence was not statistically significant to support the use of the supplements to reduce pain and slow or improve progression of the disease. That being said, even though the supplements’ effect on pain was not shown to be substantial, it was positive in every case. I haven’t found any good longer-term studies to demonstrate its effect on pain and function in osteoarthritis. It’s unfortunate that this particular study did not look at joint ROM and flexibility as I would have liked to have seen the effect of these supplements on more functional measures, rather than on “radiological joint space.”

My answer to the question, “Are glucosamine and chondroitin beneficial?” is … I’m not completely sure. On one hand there are studies (like the referenced BMJ review) that show little benefit to taking these supplements and on the other there is some research and anecdotal evidence to support their use. Many of my patients claim it has great benefits on pain and function. So I say, go ahead and give it a try, but be sure to try it for a few months before making a decision.

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References

Wandel S, J?ni P, Tendal B, Nuesch E, Villiger PM, Welton NJ, et al. Effects of glucosamine, chondroitin, or placebo in patients with osteoarthritis of hip or knee: network meta-analysis. BMJ 2010;341:c4675.
Muller-Fasbender, H, et al.(1994). Glucosamine sulfate compared to ibuprofen in osteoarthritis of the knee. Osteoarthritis Cartilage. 2:61-69.

Running Gait Analysis

MoniquePT — Tue, 05 Oct 2010 02:05:15 +0000

Today I helped a high school athlete return to competing in a cross country meet and not only that, meet a personal best and without knee pain. In just 2 short sessions. Ok, so I know I’m bragging, but I was really proud of this accomplishment, which was 75% the effort of my patient and 25% me shoving them in the right direction. A key 25% achieved through a running gait analysis and customized exercise program with instruction in proper form and alignment with functional movements. I perform a running gait analysis on all of my clients that are runners. Running gait analysis is a skilled observation of running technique and form that is then compared to the main complaint to come to a biomechanical hypothesis as to why they are in pain and how they can improve their performance. Physical therapists are also trained to analyze walking gait. Running analysis is then used to guide instruction in appropriate running form to address the main complaints. Comprehensive testing of strength, movement patterns, balance, and neuromuscular control is also done to identify contributing factors to the inefficient pattern to achieve a well-rounded plan of attack. Though whether it be to relieve a sore knee or just improve performance, a running gait analysis should be the first step in helping a runner to achieve his or her goals. When instruction is given to reduce an inefficient technique and this is combined with a personalized exercise program you get happier, less stressed joints and possibly….. a personal best.

Want a free analysis? Attend our runners clinic this Wednesday, October 6th. Click on the events tab for more information.

Rotator Cuff Tears

MoniquePT — Fri, 11 Jun 2010 14:05:22 +0000

I recently coordinated continuing education on treatment of the shoulder for physical and occupational therapists at HealthReach Rehab. My final contribution to the courses was evidence-based treatment of rotator cuff tears. The rotator cuff is a group of four muscles at the shoulder, named supraspinatus, infraspinatus, teres minor, and subscapularis. The most commonly torn muscle is the supraspinatus. The main function of the rotator cuff is to add stability to one of the most unstable joints at the shoulder. Without the rotator cuff working properly, reaching overhead becomes more difficult and painful. Many times another condition called shoulder impingement and rotator cuff tendinitis can lead to a rotator cuff tear. As I was looking at the research in regard to rotator cuff tears I found some statistics that I thought some of you might find interesting.

The United States spent $7 Billion in 2000 in healthcare costs to treat shoulder pain
Rotator cuff tears increase in incidence after the age of 40 and up to 40% of the population over 60 years old has a full-thickness rotator cuff tear
78% of patients with rotator cuff tendinitis were treated successfully with non-operative treatments including a combination of medication and physical therapy
75% of those with a large rotator cuff tear retear the muscle after surgical repair
70% of full-thickness rotator cuff tears are expereinced in those that do light work and are relatively sedentary

The risk factors for rotator cuff tears and tendinitis:

age-related degeneration
muscle atrophy
poor posture
smoking
repetitive overuse
shoulder impingement and rotator cuff tendinitis
impaired shoulder mechanics
anatomical variation of the shoulder

The research indicates those that do best after a rotator cuff surgery are patients that are relatively young and have an acute injury. In other words, don’t wait months and months to get treatment for this condition, because it may be too late to do surgery if you need it. If you think you may have done something to your shoulder and you are over 40, definitely schedule an appointment with your physical therapist or physician. If a rotator cuff tear is suspected, your physician may order a test to confirm the diagnosis. Research indicates that diagnostic ultrasound and MRI are the most effective and are equally effective at diagnosing rotator cuff tears. Diagnostic ultrasound is cheaper than MRI, but most physicians order an MRI because diagnostic ultrasound requires the technician to be highly trained and skilled. If you have to pay for this out-of-pocket and are concerned about the cost, ask your physician if they know where to send you for a diagnostic ultrasound.

One article mentioned a study of outcomes following surgical repair of rotator cuff tears. They found that satisfaction and function (improved flexibility, range of motion, and ability to reach overhead) improved even in the presence of a failed surgery! They attributed this in part to the fact that after a patient undergoes surgery they are much more committed and compliant with exercises to strenghten the rotator cuff and shoulder. The exercises are soooooo important! As a physical therapist, I see many people with shoulder pain including those with rotator cuff tendinitis, rotator cuff tears, and after surgery to repair a rotator cuff tear. This condition is extremely painful, but can be managed successfully in physical therapy with a combination of manual therapy and exercises. Physical therapy can help you overcome developing rotator cuff tears in almost all of the risk factors listed above. Wake up and smell the muscles! Be sure to pump up your shoulders with resistive exercise to keep them strong and prevent a painful condition, the rotator cuff tear.

References

1. Hemang Yadav, Shane Nho, Anthony Romeo, John D MacGillivray. Rotator Cuff Tears: Pathology and Repair. Knee Surgery, Sports Traumatology, Arthroscopy. Heidelberg:Apr 2009. Vol. 17, Iss. 4, p. 409-421

2. J Winslow Alford. Exploring treatment options for rotator cuff disorders. The Journal of Musculoskeletal Medicine. Darien:Mar 2009. Vol. 26, Iss. 3, p. 99-103 (5 pp.)

3. Boissonnault WG, Badke MB, Wooden MJ, Ekedahl S, Fly K. Patient Outcome Following Rehabilitation for Rotator Cuff Repair Surgery: The Impact of Selected Medical Comorbidities. JOSPT 2007; 37(6): 312-319.

4. Long JL, Ruberte Thiele RA, Skendzel JG, Jeon J, Hughes RE, Miller BS, Carpenter JE. Activation of the Shoulder Musculature During Pendulum Exercises and Light Activities. JOSPT 2010; 40(4): 230-237.

Active Joint Supports: Our Muscles

MoniquePT — Mon, 24 May 2010 12:41:24 +0000

Joints allow us freedom of movement; without them we lose our ability to stay active, mobile, and independent. Walking, squatting, biking, reaching, hiking, stooping, lifting, sitting, running… all impossible without the ability for joints to move freely, stay stable, and work together. As important as they are to living an active life, are we really taking as good of care of them as possible? In physical therapy sessions, I get asked about my recommendations for good joint supports and braces. Looking for a good joint support? Why not start with your muscles? A joint’s stability is maintained by its joint capsule, cartilage, ligaments, tendons (end points of muscles), and the muscles. Research hasn’t found a way to replace cartilage yet; ligaments can be repaired, but this requires surgery. There is no way to strengthen or tighten a joint capsule. So what does that leave? Our body’s active joint support: the muscles. The heart of a physical therapist’s treatment is improving the function of these active joint supports. Muscles pull on joints to make them move, but they also hold joints stable when you’re not moving. They provide the dynamic support to a joint, keeping the bones in good alignment and maintaining stability when you are moving. When you are trying to improve the active support of a certain joint, try to strengthen all the muscles surrounding that joint. If you’re unsure of what to strengthen to support a joint for management of pain or for prevention of musculoskeletal conditions, find a physical therapist to help you design an exercise plan. The best bracing options start with your body’s natural active supports.

Link to knee anatomy. Note all of the muscles surrounding the knee to give it stability.

Video showing the knee joint, including the muscles surrounding it, and arthrosis (degenerative arthritic changes).

http://www.youtube.com/watch?v=l9sS4wfD-AU

Sustained Positions And Its Effect on Your Movement

MoniquePT — Mon, 15 Mar 2010 14:33:35 +0000

Did you know that what you do when you aren’t moving will affect how you move later on? Our body responds to the stresses placed on it everyday and adapts. The sustained positions we put ourselves in may contribute to certain inflexibilities and a loss in joint range of motion. Inflexibility and a loss of joint range of motion eventually impairs how we move and our ability to do certain tasks as well as we could. There are several times when we may be in one position for a long time: sitting, standing, sleeping, lounging… and muscles and joints will adaptively shorten and stiffen based on these positions. Think about the times during the day when you are in one position for a long time. For many of us it may be sitting due to increased use of the computer for work and life. If you work in a profession that requires lots of sitting, you probably have tight hamstrings, pecs, biceps, and hip flexors. It is important to stretch these muscles out and move out of this seated position frequently during the day to avoid adaptive shortening and stiffening. If this occurs, it creates an imbalance in the musculoskeletal system and this in turn will negatively affect the way in which the body moves. One colleague uses the example of a tent. When you are driving the spikes to hold a tent in place it is important to keep equal tension on all ropes so the tent is centered. If your sustained positions cause inflexibilities and stiffnesses, your tent will be lop-sided with more tension in one rope than the other and if these inflexibilities are severe enough, you may not even be able to drive the spikes into the ground on one side. To continue with the sitting example… if you have tight hip flexors (hip crease muscles) because you sit a lot and they never get stretched, this imbalance causes the lumbar spine to arch, or develop a “sway back,” which places you at greater risk for arthritis of the spine. This tightness can cause abdominal weakness. Weak abdominals do not support the spine as well as they should, and it could get harder to get in and out of bed. If a muscle is weak, it doesn’t perform its job optimally and your function will suffer over time. For your body to move optimally, it has to remain balanced, with all tent ropes pulling and working equally. Here is a self-check to assess your frequented positions and possible imbalances.

Sustained Positions Self-Check

During the course of a day, try to be consciously aware of the positions you put yourself in- start from the bottom up: feet, knees, hips, back, shoulders, neck. Are you forward, backward, bent in any certain position for a prolonged period?
Make a note of your preferred and comfortable postures. Do you tend to slouch? Does your back round? Do you jut your head forward? Is your head turned one way or the other?
When you are seated do you always cross one leg? Do you feel weight on one buttock versus the other? Do you prefer to prop yourself up on one elbow versus the other?
Do you have a preferred sleeping position? Do you always lie on one side? Are your back and legs rotated? If you sleep on your belly (not a good sleeping position and not recommended by me) do you always have your head turned left or right?
When you have to stand for a long time in one spot where do you place your weight? Are you more on one leg versus the other? Do you put more pressure on the balls or heels of your feet? Are your feet rolled inwards or outwards?

If you find certain asymmetries, for instance you always sleep on your right side or when you stand you feel most of your weight on your heels, try to correct them. The goal here is to keep the body balanced. If you always sleep on your right side, try to sleep on your left side sometimes. If you feel more than 50% of your weight on your heels, try to shift your weight on your feet so you feel equal weight between the balls of your feet and the heels. Our bodies have subtle preferences such as these that over time can lead to musculoskeletal problems. If you can catch them now and do something about them, you may be able to prevent a painful condition down the line.

Safety for Snow Shoveling: Prevent a Back Injury

MoniquePT — Fri, 26 Feb 2010 08:18:14 +0000

We are almost through February, and I have to say, this Wisconsin winter hasn’t been that bad. Anything compared to the snowmageddon of the northeast is better, and I know I’ve been thankful that it hasn’t been as bad as the past two years. Though I may be from Louisiana, this transplant knows we aren’t out of the woods yet, at least until June. Each year I see patients with snow shoveling and related injuries, typically of the lower back, neck, and shoulders. Many times these injuries could have been avoided if these patients had read the information I have posted links to from the American Physical Therapy Association (APTA) and the American Academy of Orthopaedic Surgeons (AAOS). It’s important to use common sense, warm up, stretch, take your time, and know your own limitations. Sometimes you may have to ask others for help because you may not be physically able to remove the snow, particularly if it is hard and heavy, and especially if you have a bad back. When shoveling, keep your back straight and brace your abdominals before lifting by drawing your belly button to your spine. As you lift keep your abdominals braced and push up with your legs, keeping your shoulders down. Do NOT lift and twist because this movement, especially when you are lifting something, can cause a low back disc injury. If you are going to rake your roof, use similar principles, try keeping your shoulders down and use your legs to walk the snow back as much as possible. If you have trouble or you feel a real pull or pain when you lift your arms up, you should have someone else do this chore. Beyond orthopaedic strains and pains, snow shoveling puts heavy demands on your heart. If you do not engage in regular aerobic exercise, I don’t recommend you do the shoveling, because your heart may not be ready for this type of vigorous activity. Read the information I have posted below as well as watch the videos in order to help prevent a winter injury.

PHYSICAL THERAPISTS OFFER SNOW SHOVELERS ADVICE TO AVOID INJURIES- APTA

Snow Shoveling Safety Tips from A PT- Video

American Academy of Orthopaedic Surgeons: Prevent Snow Shoveling and Snow Blowing Injuries

Video: A Physical Therapist’s Recommendations for Snow Shoveling

Snow Removal Tips from Popular Mechanics: 16 Cardinal Rules for Snow Shovelling