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The Combined Sections Meeting of the American Physical Therapy Association (APTA) kicked off yesterday with a presentation on Healthy People 2020 and how physical therapy can help America achieve its goals in health and wellness.  Healthy People 2020 was developed by the US Department of Health and Human Services as a ten-year plan to improve the nation’s health.  The APTA is part of the Healthy People Consortium, a group of organizations and partners that have agreed to be active participants in helping to achieve the goals of Healthy People 2020.  As we move towards these goals, physical therapists will advocate for healthier, more active lifestyles, and provide rehabilitation and recommendations to ensure all Americans can start or return to being physically active for health.

The second course I attended was on the biomechanical factors impacting running injuries.^[i] As America strives towards its Healthy People goals, more people will be taking up new activities for exercise.  A popular and relatively cheap endeavor for someone looking to stay active for health is running.  As the presenters discussed each running injury and the contributing biomechanical factors, some information popped up which I thought you(either the beginner runner or experienced) might find useful.

• 79% of runners will be injured and 46% will have recurrence of the problem
• If the alignment of your trunk, pelvis, and legs are off, you’re at increased risk of sustaining an injury.  Not only that, the presenters did not mention this would impact your performance.  Bad alignment = inefficiency
• It is possible to have good alignment and still be at increased risk of injury due to inability of the muscles to absorb shock.  When the body’s active shock absorbers (muscles) are inadequate, it starts to rely on passive shock absorbers (bone and cartilage).

Many of the factors that contribute to running injuries can be corrected with instruction in better form, safe training guidelines, and strength training.  Number one on my list is strength training the hips.  More info on my recommendations can be found here.

Physical therapists can help turn an unhealthy and injured runner into a healthy and happy one.  A comprehensive physical therapy running evaluation consists of gait analysis, strength training, movement analysis, flexibilty, and ROM.  It will not only feel good to have the pain gone, but the runner will likely improve performance as a result.

©2012 Geaux to Physical Therapy. All Rights Reserved.

1. Powers, C & Davis, I (2011). “Biomechanical Factors Underlying Running Injuries: Proximal and Distal Factors” presented February 10, 2011 at the Combined Sections Meeting of the American Physical Therapy Association, New Orleans, LA.

Can anything be done for tired, sore feet after a long day of standing?  The key is prevention.  Research has shown that having a softer surface to stand on, such as anti-fatigue mats and cushioned shoe insoles can reduce fatigue and discomfort associated with standing prolonged periods.   Researchers from Milwaukee, WI tested three different flooring conditions for assembly line workers.  After an 8 hour shift, workers filled out a questionnaire rating comfort and fatigue.  The general response was less fatigue and improved comfort with softer flooring such as a anti-fatigue mat and cushioned shoe insole. ^[ii]

When I know I’m going to be on my feet for a long time, say at a football game,  observing art at MAM, meandering the festival grounds, or while on vacation walking 24,910 steps in Rome, I try to be prepared.  Here are a few more suggestions to combat foot pain and fatigue:

1. I wear GOOD shoes.  This is on the top of my list of things to invest your hard-earned money in (as well as mattresses and pillows).  Don’t go cheap, because your body will be able to tell the difference sooner or later.  Though most good shoes are expensive, not all expensive shoes are good ones.  Good shoes for prolonged standing have good cushioning and arch support and are slightly bigger to accommodate for foot swelling.  You may even need 1/2 size bigger than your regular shoe.
2. When I go on vacation I buy a cushioned gel insert for my boots.
3. I wear knee high socks with light compression.  This helps to combat swelling.  You could wear stockings to combat swelling as well.
4. Alternate standing with walking and periods of sitting.  Whenever possible, take a load off and elevate your feet up, even before fatigue has set in.  If you’re in the workplace and are in the same place for a prolonged period, try to use a stool to relieve the pressure periodically.
5. Do a few calf raises.  To get the blood pumping out of my feet and legs and circulating back to my heart I do a few calf raises periodically in the day.
6. As soon as I get home, I elevate my feet, pump my ankles back and forth,  and then give them a good rest.
7. As mentioned previously, anti-fatigue mats are a good solution if you stand in one place for a long time.  I’ve seen people buy them for their kitchens and I have to say they are very comfortable.
8. Of course, you could also ask for a good foot rub from your spouse…

©2012 Geaux to Physical Therapy. All Rights Reserved.

1. (Meijsen, P & Hanneke, J. (2007).  Work Related Musculoskeletal Disorders of Perioperative Personnel in the Netherlands. AORN J 86: 193-208.
2. Orlando, AR & King, PM. (2004). Relationship of Demographic Variables on Perception of Fatigue and Discomfort Following Prolonged Standing Under Various Flooring Conditions. Journal of Occupational Rehabilitation, Vol. 14, No. 1, 63-76).

Researchers have investigated back pain in golf and potential risk factors.  An article published in the July 2010 Journal of Orthopaedic and Sports Physical Therapy indicates weakness in trunk extensors and hip muscles may be the differing factor between golfers with and without back pain.^[iii]  Trunk extensors are the muscles that run up and down the back and hold a person erect and provide stability and control.  The golf posture challenges these muscles to stabilize the spine in the address position and throughout the swing.  Without these muscles working optimally, you’re at risk for developing pain.  Differences in hip rotation range of motion between hips and improper coordination of movement between the hips and low back are also seen in golfers with back pain.^[iv]  Of course, other factors can contribute to the development of low back pain in golfers, including technique, level of conditioning, skill level, and equipment to name a few.

Physical therapists help golfers overcome back pain.

The first way I tackle back pain in my golfing clients is to ask a few questions about their style of play and practice:

• How much time do you spend practicing, and how do you structure your practice?
  • Research has indicated that prolonged putting practice can fatigue the trunk extensors and affect the kinematics of the swing.^[v] When these muscles are fatigued, they do not stabilize the spine as well and can contribute to a back strain or disc disease.   I’m not saying to stop practice putting…. but you may not want to practice this for 30 minutes and then practice anything using your full golf swing… i.e. going long with the driver since your muscles will not be able to support your back as well.  This also goes for your pre-round routine.  Don’t get there an hour early and stay hunched over your putter and then try and smash-drive your golf ball into smithereens.  Practice a little putting to get a feel for the greens and leave the longer practice sessions for another time.
• How many times a week do you play?
  • Playing more than 3 times per week?  Your back pain could be simply due to overuse.  Playing 3 times per week and then practicing a few more days is a lot of twisting around your spine.  Too much twisting in a short period of time can lead to an injury.  Allow yourself to rest from golf and stay active with another activity.  Do cross training, strength training, or participate in another non-rotational sport.
• How do you warm up?
  • If the answer to this question is a drive-thru for your grande low-fat 2-pump latte ten minutes before that 7AM tee time, then Houston, we have a problem.  Not warming up before an early morning tee time is especially problematic.  While we sleep, the discs in our back swell.  Once we are upright for at least 1 hour, the discs return to normal height and become less swollen.  Placing load and stress on the discs, as the golf swing does, when they are swollen increases the risk of tearing or herniating them.  Wake up early and stay standing for at least 1 hour prior to playing golf. If you don’t wait this amount of time you are really setting yourself up for a disc injury.  Just think about it as actually enjoying your breakfast and getting mentally prepared for the best game of your life.
  • Don’t hold your stretches when warming up.  If you hold your stretches you can induce muscular weakness and research has shown that this type of stretching as a warm-up impairs the golf swing kinematics, resulting in a less supported spine and reduced performance.  Do your stretches, but do them “dynamically” which means continuously moving, never holding.

The other component of my treatment approach to back pain in golfers is a comprehensive physical therapy evaluation.  In particular, I look at hip mobility, flexibility, strength in the trunk and core, movement patterns, and posture.  As a TPI-certified medical professional, I also assess golf setup posture or address position and screen the swing.  If technique is an issue, I send my clients to a PGA Golf Professional.  Don’t let back pain keep you from playing golf.  If you have any pain, consult with a physical therapist that specializes in sports and orthopaedics.  Take care of your back and enjoy golf for years to come.

References

1. Foster,Larry. (2004). Dr. Divot’s Guide to Golf Injuries. North Salem, NY: Doctor Divot Publishing.

2. Parziale JR, Mallon WJ. Golf Injuries and Rehabilitation. Phys Med Rehabil Clin N Am 17 (2006) 589–607.

3. Tsai YS, Sell TS, Smoliga JM, et al. (2010). A Comparison of Physical Characteristics and Swing Mechanics Between Golfers With and Without Back Pain. Journal of Orthopaedic and Sports Physical Therapy. 40(7): 430-438.

4. Harris-Hayes M, Sahrmann SA, & Van Dillen LR. (2009). Relationship Between the Hip and Low Back Pain in Athletes Who Participate in Rotation-Related Sports. J Sports Rehabil. 18(1):60-75.

5. Evans K, Refshauge KM, Barrett R, & Adams RD. Swing Kinematics in Skilled Male Golfers Following Putting Practice.  J Orthop Sports Phys Ther. 2008;38(7):425-433.

©2012 Geaux to Physical Therapy. All Rights Reserved.

1. Foster,Larry. (2004). Dr. Divot’s Guide to Golf Injuries. North Salem, NY: Doctor Divot Publishing.
2. Parziale JR, Mallon WJ. Golf Injuries and Rehabilitation. Phys Med Rehabil Clin N Am 17 (2006) 589–607.
3. Tsai YS, Sell TS, Smoliga JM, et al. (2010). A Comparison of Physical Characteristics and Swing Mechanics Between Golfers With and Without Back Pain. Journal of Orthopaedic and Sports Physical Therapy. 40(7): 430-438.
4. Harris-Hayes M, Sahrmann SA, & Van Dillen LR. (2009). Relationship Between the Hip and Low Back Pain in Athletes Who Participate in Rotation-Related Sports. J Sports Rehabil. 18(1):60-75.
5. Evans K, Refshauge KM, Barrett R, & Adams RD. Swing Kinematics in Skilled Male Golfers Following Putting Practice.  J Orthop Sports Phys Ther. 2008;38(7):425-433.

http://www.youtube.com/watch?v=k1hlY0EMYJw

To make your runs more efficient and prevent an injury, participate in other activities and exercises to strengthen, stretch, and stabilize key areas of the body.  It’s important to remain flexible in the hips and lower legs to prevent a host of running conditions from plantar fasciitis to iliotibial band syndrome.  To maintain good linear motion and prevent fatigue, strength train, particularly at the hip and core, but also postural muscles to maintain a neutral and straight spinal position.

Diversifying Activities:

1. Pilates: It builds hip and core strength,which is important to maintain good running form, in addition to working on your posture

2. Yoga: Don’t like to stretch? Try yoga. You’re stretching multiple muscle groups in a session and it’s more fun that holding a quad stretch for 30 seconds. Additionally yoga can benefit your body by reducing stress and improving balance.

3. Strength Training: Hard to run up that hill? You need to work on your strength. Use weights and get stronger.  Also work on the muscles in your back to maintain a good posture while running.

4. Bike: Looking to work on your endurance in other ways?  Try another endurance sport that requires good leg strength- cycling.  Try some interval training for variety.

So, yes, you may have to take days out of the week to do exercise that does not involve running.  If you’re unsure of what to do, a physical therapist can evaluate your running mechanics and look at your strength and flexibility to make a customized exercise program to fit your needs.  In the long term, running less will make you a better runner.  Diversifying your activities will improve your form, making you more efficient and faster, and keep your body more balanced and free of musculoskeletal injuries.

If you want a yoga and pilates breakdown, visit PTJess’ blog here for yoga and here for pilates

More on the chicken guy whoa.  Would like to know the end of the story and how he finished that marathon…

©2012 Geaux to Physical Therapy. All Rights Reserved.

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

©2012 Geaux to Physical Therapy. All Rights Reserved.

Our meeting was inspired by questions from patients regarding our opinions on stretching regimens.  Static stretching, holding a muscle in a lengthened position for at least 20 seconds for a low number of repetitions, has been widely touted in the past for improving flexibility and preventing injuries.  Dynamic stretching, bringing muscles into lengthened positions without holding and performing several repetitions, which resembles more of a warm-up, has fallen into favor as the pre-sport regimen of choice to improve performance and prevent injuries.  O Research, O Research, wherefore art thou Research?

Static stretching has been shown to improve flexibility and range of motion and this form of stretching is used widely in physical therapy.  Several studies we discussed and researched showed that immediately following static stretching, including up to an hour afterwards, a muscle can be weakened.  In terms of injury, when a muscle is weakened it may not give the best joint protection, thus there may be more injuries and certainly impaired performance.  Looking through some of this research, the ways in which muscles are weakened is uncertain.  One study found that stretch-induced muscle weakness may only be present at certain positions when a muscle contracts.  I wasn’t able to find research on effects of static stretching on injury prevention in sports.  A question I had following reading through some of the research on the topic was, “How long does this stretch-induced weakness last?”  Can we stretch a few hours ahead of a sport-activity and return to pre-stretch strength?

Because of these findings many trainers and physical therapists advocate against static stretching immediately before sports events.  Not only can static stretching immediately before sports activities put you at potential risk for injury, but it can also negatively impact sports performance.  In regard to golf, static stretching pre-round has been shown to reduce clubhead speed, accuracy, drive distance, and ball contact. Thus, I recommend a specific dynamic warm-up that targets key muscle groups for golf.

What about those who participate in a regular static stretching program.  Is regular stretching beneficial?  A study published in Medicine and Science in Sports and Exercise by researchers from Brigham Young University-Hawaii and Louisiana State University shows a regular stretching program alone can improve physical performance.  After 10 weeks of a regular stretching program 3 days per week,  muscle strength, power, and strength endurance was improved.

In terms of static stretching’s ability to prevent injuries, a review of literature from 2002 in the British Medical Journal concluded that the reviewed articles deemed reductions in muscle soreness following exercise were not significantly impacted by stretching.  Injury risk reduction in military recruits was insignificant based on review and there was insufficient evidence to make a conclusion for athletes.   I reviewed an article from 2003 in Military Medicine, that examined the effects of stretching in 901 Japanese military recruits during their 3-month basic training.  The authors stated that most of the military recruits were not used to the regular, strenuous activity that basic military training entails.  The stretching group of this study engaged in 20 minutes of a stretching program prior to and immediately following daily physical training.  It was found that recruits that were assigned to the stretching group had lower injury rates for muscle and spinal injuries, though overall rates were not significantly different.  The muscle and spinal injuries include strains, tendinitis, and back pain.  As a physical therapist who sees many people with these types of injuries, it does not surprise me that those who stretched regularly endured less of these types of injuries.  To stretch, perchance to reduce injuries, seems plausible if done regularly for certain types of conditions.

It’s hard to research the effects of regular static stretching on injury prevention in the general population, those who are coming to physical therapy.  I have a few words that come from my experience and training.  Regular static stretching is particularly important to prevent painful conditions and injuries in those who are not flexible.  Inflexibility in certain muscles can cause altered postures and bad joint positions, which can in turn lead to most significantly- back pain and rotator cuff disorders to name a few.  If a muscle is tight, it must be stretched.  As we age, our muscles lose elasticity, thus it becomes more important to stretch the older we get to prevent joint stiffness and maintain good mobility.  If you are as bendable as Gumby, you shouldn’t be focusing on stretching.  When muscles and ligaments are stretched too much, it can render a joint unstable.  If a joint is unstable it can move slightly in and out of position or it’s joint socket.  Over time this can create painful conditions including arthritis.  In this condition, it is important to do strengthening, resistive training.

Prior to doing strenuous work, say shoveling snow, gardening, or moving furniture, I recommend warming up dynamically and avoiding static stretches as discussed previously.  Because static stretches can weaken muscles and these types of physical activities can demand full muscle strength, you may be setting yourself up for an injury.  A warm-up would include any aerobic activities that get the body moving, say, repeated squats, biking, jumping jacks, or walking in place for 5 – 10 minutes.

If you are unfortunate enough to have sustained an injury or are dealing with a painful musculoskeletal condition, a physical therapist is best trained to determine A: Whether you need to do certain stretches  and B: What stretches you should be doing.

My final thoughts on stretching:

• Generally, if you are not flexible you need to engage in a regular static stretching program
• Perform dynamic warm-ups and stretches prior to athletic events to prevent injury, this is not the time to do static stretches
• Stretching helps many people overcome pain and injury and should be prescribed by a trained, educated professional for such cases
• Don’t overstretch- if you are VERY flexible, you should be focusing on getting stronger, so you can add stability to your joints

References

Arnold G Nelson, Jason D Allen, Andrew Cornwell, & Joke Kokkonen. (2001). Inhibition of maximal voluntary isometric torque production by acute stretching is joint-angle specific. Research Quarterly for Exercise and Sport, 72(1), 68-70.

I Shrier. (2004). Does Stretching Improve Performance? A Systematic and Critical Review of the Literature. Clinical Journal of Sports Medicine, 14(5), 267-273.

Gergley, J.. (2009). ACUTE EFFECTS OF PASSIVE STATIC STRETCHING DURING WARM-UP ON DRIVER CLUBHEAD SPEED, DISTANCE, ACCURACY, AND CONSISTENT BALL CONTACT IN YOUNG MALE COMPETITIVE GOLFERS. Journal of Strength and Conditioning Research, 23(3), 863-867.

Rob D Herbert, & Michael Gabriel. (2002). Effects of stretching before and after exercising on muscle soreness and risk of injury: Systematic review. British Medical Journal, 325(7362), 468.

Masatoshi Amako, Takaaki Oda, Kazunori Masuoka, Hiromichi Yokoi, & Paolo Campisi. (2003). Effect of static stretching on prevention of injuries for military recruits. Military Medicine, 168(6), 442-6.

©2012 Geaux to Physical Therapy. All Rights Reserved.

Risk Factors:

• Gender– women are at increased risk, though men get osteoporosis too!
• Increased Age
• Body Size– a thin frame
• Ethnicity– especially European and Asian
• Genetics—family history of fractures
• Low Calcium and Vitamin D intake
• Smoking
• Alcohol intake (>2 per day)
• Physical Inactivity
• Low estrogen or testosterone levels
• Certain long term medication use, including corticosteroids
• High Caffeine intake

Statistics from the NOF reports, “about 85-90% of adult bone mass is acquired by age 18 in girls and 20 in boys.”  The key to maintaining good bone health is being active and getting adequate nutrition, starting at an early age.  Regular weight-bearing exercise makes our bones strong, while immobility leads to diminished bone mass and weakness.  Some examples of weight-bearing exercise include: walking, running, aerobics, weight training, dance, hiking, and tennis.  It is important in all stages of life to maintain an active lifestyle that includes weight-bearing activities and exercise. You can stimulate bone growth by staying physically active because of Wolff’s Law.

Exercise can reduce your risk of fracture by:

• Building and maintaining bone density
• Improving balance
• Increasing flexibility
• Strengthening key muscle groups
• Correcting faulty posture that can lead to spinal fractures

If you have osteoporosis, it is important to reduce your fracture risk by not only performing weight-bearing exercise (for the lower body, upper body, and the spine), but also by working on your balance and posture in order to reduce falls.  Certain postures or positions should be avoided to prevent spinal fractures, including a flexed posture.  When you are “flexed” or bent over or slouched, you put more load and stress through the vertebrae.  Osteoporotic bone is less likely to handle the load and stress and can fracture.

If you have been diagnosed with osteoporosis, you should avoid the following to reduce fracture risk:

• Bending forward, such as sit ups and toe touches (Make sure you logroll out of bed, never sit up!)
• Twisting at the spine
• Golf and Bowling (mainly because you are twisting in a bent over position)
• Lifting
• Poor Posture

Nutrition and Osteoporosis
Research has shown that a combination of supplemental calcium and vitamin D can reduce the risk of fracture.  You should consume 1200-1500mg per day of calcium and 800-1000 International Units (IU) of vitamin D per day.  Calcium and vitamin D rich foods include: milk, yogurt, cheese, fortified foods or juices, almonds, green leafy vegetables such as broccoli and kale, salt-water fish, and liver.  15-20 minutes a day of sunlight exposure can also increase vitamin D production.  Sodium, caffeine, and carbonated beverages increase calcium excretion, so limit the amount of these items in your diet.  Excess protein increases calcium excretion, however protein is needed for fracture healing, so the key is moderation!  The recommended daily intake for  protein is 56 grams for men and 46 grams for women.

The best way to confront osteoporosis is through education and prevention.  If you are a postmenopausal woman especially, you should ask your doctor about whether you need a bone mineral density (BMD) test.  I continually educate women about osteoporosis and have identified a few people with osteopenia (pre-osteoporosis).  These women were able to be counseled about exercise, diet, and the appropriate supplements to support bone health and help prevent progression to osteoporosis.  The NOF states, “…in 2005, osteoporosis-related fractures were responsible for an estimated $19 billion in costs.”  We can stand to save so much by preventing this disease and its consequences.

References:
Foundation for Osteoporosis Research and Education
http://www.fore.org/

“Osteoporosis and Bone Health” The Burden of Musculoskeletal Disorders in the United States. (2008).
http://www.boneandjointburden.org/

National Osteoporosis Foundation
http://www.nof.org/

NIH Osteoporosis Resource Center
http://www.niams.nih.gov/Health_Info/bone/default.asp

©2012 Geaux to Physical Therapy. All Rights Reserved.

First, here’s a few basic tips…

1. If you are serious about running, go to a store that specializes in running shoes and has knowledgeable staff.  The staff should ask you about how you train and your mileage.
2. Old shoes are a high risk factor for the development of running injuries.  Change them out at around 300 miles.
3. When you pick up the shoe, try to bend and twist it.  If it looks like you can squeeze it like a towel, it doesn’t have much support and could lead to overuse injuries.  Get new ones or buy different ones.
4. Get the right size.  Your foot swells by 1/2 to 1 whole size when you run, so get measured.  Don’t end up like these guys.
5. Before you buy the shoe, run in them.  It’s not enough to stand or walk, because that’s not what you’ll be doing in them.

I value my skills in analyzing foot arches, resting joint positions, and torsions (rotations) of the bones in the lower legs when assessing posture of a runner.  I would like to think the findings of such a postural assessment is the most important consideration in the decision-making process when shopping for shoes.  I recently attended a good running biomechanics course presented by Bryan Heiderscheit, PT, PhD, Director of the University of Wisconsin Runners’ Clinic.   In the course, research was presented that shows that static leg and foot alignments are not the most significant factor for injury prevention.^[i]  Research indicates that perceived comfort may be the most important aspect of picking the correct, injury preventive shoe.

The way your body responds to different shoe designs is not necessarily dependent on your arch type – flat (pronated) versus high (supinated).^[ii] The research findings were conflicting, showing different responses to the same shoe between people of similar foot types.  These findings emphasize the importance of evaluating running mechanics and style for each individual.  When a PT evaluates running mechanics, they are looking at stride characteristics and alignment of the knee, hip and ankle, and trunk positioning at different times in the running cycle.  The way each of us moves and the muscles our body chooses to utilize are unique and are not necessarily dependent on our foot type or static alignment.  If you’ve ever watched people run, you can appreciate the MANY different styles and preferences of running.  Also, use of inserts that are perceived to be more comfortable have been shown to reduce stress fractures and pain compared to no inserts in research by Mundermann et al. in a study of the military population.^[iii]

If you’re a runner and are looking for the perfect pair of kicks, you shouldn’t base your decision on your arch type alone.  Having a knowledgeable professional, such as a physical therapist, evaluate your legs’ resting and dynamic biomechanics is definitely the place to start.  Make sure the person making shoe recommendations not only checks stationary foot posture, but also watches you RUN in the recommended shoes.  Some shoe stores, like Performance Running Outfitters, watch you run before buying.  Ultimately, though, if your body isn’t comfortable in the recommended shoe, keep running around until you find the perfect fit.

©2012 Geaux to Physical Therapy. All Rights Reserved.

1. Heiderscheit, B. (2009).  ”Running Biomechanics: Evaluation and Treatment Strategies.” presented October 8, 2009 at the Wisconsin Physical Therapy Association Fall Conference, Middleton, WI.
2. Butler et al. (2006). Interaction of Arch Type and Footwear on Running Mechanics. J Sports Med. December 2006 vol. 34 no. 12 1998-2005.
3. Mundermann et al. (2001). Relationship between footwear comfort of shoe inserts and anthropometric and sensory factors. Medicine and Science in Sports and Exercise: November 2001 – Volume 33 – Issue 11 – pp 1939-1945.