Injuries & Conditions
The neck (cervical spine) is composed of 7 vertebrae that begin in the upper torso and end at the base of the skull. The bony vertebrae along with the ligaments (which are comparable to thick rubber bands) and muscles provide stability to the spine. The neck has a significant amount of motion and supports the weight of the head. However, because it is less protected than the rest of the spine, the neck can be vulnerable to injury and disorders that produce pain and restrict motion. Between the vertebrae are intervertebral discs which provide spacing and shock absorption between the vertebrae. The cervical intervertebral discs are much smaller than those found in the lumbar spine. Nerve roots exit the neck between each vertebrae. These can become pinched, causing pain in the arms, shoulders.
Neck pain usually results from abnormalities in the soft tissues such as the muscles, ligaments, and nerves, as well as in bones and disks of the spine. The most common causes of neck pain are soft-tissue abnormalities due to injury, prolonged wear and tear, and poor posture which can place the structures of the neck in a compromised position. In rare instances, infection or tumors may cause neck pain. For many patients, neck problems are the source of pain in the upper back, shoulders, or arms. The neck is susceptible to injury in athletic collisions and motor vehicle accidents.
Physical therapy plays a key role in patients suffering from neck pain and addressing contributing factors to neck dysfunction. Interventions include:
- Management of neck pain and stiffness through hands-on manual techniques.
- Education in poor posture and faulty movement patterns resulting in excessive strain on muscles, ligaments, and discs in the cervical spine.
- Addressing the neck, shoulder, and scapula (shoulder blade) through a specific, individualized exercise program.
Common Neck Conditions
The majority of neck pain is mechanical in nature, meaning that there is a defined disruption in the way the components of the neck are fitting together and moving. In some cases, neck pain is associated with spondylosis, normal wear and tear of the cervical spine that occurs with aging.
Sprains and Strains: Sprains and strains of the structures in the neck are common. Sprains are caused by overstretching of ligaments and strains are micro-tears in the muscles. Typically, a sprain/strain of the neck will occur with a fall, an accident, or contact sports. Because the neck must support the weight of the head and there is little bony stability, muscles and ligaments provide most of the stability.
A whiplash injury from a motor vehicle accident is an example of a significant cervical sprain or strain. Following any motor vehicle accident, especially those involving high speeds, x-rays should be taken to ensure that there is no underlying fracture.
Physical therapy for a cervical strain is targeted towards symptom reduction through manual, hands-on techniques, postural education, and proper movement patterns. Sometimes in severe cases, immobilization through a neck brace is needed to allow the damaged tissues time to heal.
Intervertebral Disc Degeneration: This is a common process that occurs over time with aging. With aging, the intervertebral discs lose their flexibility and become more rigid. Usually rubbery and flexible, the discs become less pliable and decrease in height. With this occurring, the articulation between vertebrae can be affected, resulting in neck pain with movement, a “stiff neck”, and restrictions in motion. In some cases, this can also result in nerve impingement as the nerve leaves the cervical spine, causing pain down the arm. The pain may worsen with specific movements.
Physical therapy is geared towards addressing faulty positioning, postures and movement patterns that can increase symptoms. Since the progression of degeneration cannot be reversed, physical therapy will focus on patient education to avoid positions, postures and movements that will exacerbate the condition. Additionally, hands-on, manual techniques will be used to reduce muscle spasms and address any restrictions in movement.
Herniated or Ruptured Disc: A herniation occurs when the outer ring of the disc (the annulus) becomes compromised and the jelly-like nucleus of the disc protrudes outward, placing pressure of the nerves exiting the cervical spine. This compression results in radiculopathy, a painful condition when patients experience shooting pain down the arm. This compression can also result in weakness in muscles in the arm. The pain and weakness typically follow a specific pattern which corresponds to the cervical level where the herniation has occurred. Patients often have difficulty sleeping and finding positions of comfort.
Physical therapy is sometimes effective in reducing symptoms from a disc herniation. Treatment may include traction (manual or mechanical) in an effort to reduce compression on the nerve root. Additionally, manual techniques and modalities may be applied in an effort to reduce symptoms. If numbness, pain, and weakness persist, an evaluation by a surgeon is warranted and surgery can be indicated.
- Cervical Fusion: In cases of severe disc herniation, surgery may be the only option. In this instance, the surgeon will remove the herniation or disc and will fuse the 2 vertebrae together using a plate or cage. In some cases, the surgeon may replace the disc with an artificial disc.
Cervical Radiculopathy: A condition caused by compression, impingement, inflammation, or injury to a cervical spine nerve root. Pressure on the nerve results in pain, numbness, and/or weakness that travels or radiates to the shoulder or arm in a specific pattern. Radiculopathy can be the result of a herniated disc, cervical spondylosis, or intervertebral disc degeneration.
Physical therapy for a cervical radiculopathy is geared towards the source of the compression and the physical therapist will perform specific tests and movements to identify the source of the pain. Based upon their findings, treatment can include manual or mechanical traction, hands-on manual therapy, patient education, postural correction/restoration, and strengthening exercises.
Headaches: A common source of headaches is the cervical spine, most commonly the upper cervical spine. Poor posture and a forward head position can lead to muscle imbalances in the upper cervical area that can affect nerves and blood vessels. Chronic headaches can be the result.
Physical therapy treatment will consist of hands-on manual techniques to address the muscular restrictions, patient education on posture, positioning, and faulty movement patterns.
Postural Dysfunction: Many cervical conditions are caused by long-standing postural and movement dysfunction that places strain on the structures in the neck. A forward head posture can result in excessive muscular strain and can affect the normal kinematics of the spine. Additionally, poor posture and a rounded back position affects the position of the shoulder blades. Muscles that control movement and positioning of the shoulder blades during arm movements attach to the cervical spine. Faulty movement patterns can lead to additional strain on the cervical spine because of the pull of these muscles.
The foundation for physical therapy for the cervical spine is to address posture and faulty movement patterns that are contributing to excessive strain on the cervical region.
Temporomandibular Joint Dysfunction: The temporomandibular joint (TMJ) is the articulation of the mandible (jaw) with the skull. This joint can be affected in patients with cervical conditions and it’s not uncommon to see these conditions related. Poor posture is the main contributing factor. Thus, any treatment for the TMJ must address the cervical spine as well.
Thoracic Outlet Syndrome: The thoracic outlet is the space between your collarbone (clavicle) and your first rib. This narrow passageway is crowded with blood vessels, muscles, and nerves. Thoracic outlet syndrome refers to a sequelae of symptoms that occur as a result of compression of the blood vessels and nerves as they pass through this area. There are multiple factors that can predispose an individual to develop thoracic outlet syndrome. These include heredity, obesity, gender, activity-work/sports, poor posture, muscle imbalances, and movement dysfunction.
Symptoms can include numbness and tingling in the arms, pain in the neck, shoulder and arm, fatigue and weakness. Because this condition affects nerves and blood vessels, upper extremity circulation can also be affected. Symptoms worsen with overhead activities.
Physical therapy treatment is focused on addressing poor posture and faulty movement patterns that are contributing to the condition. This will include specific stretching and strengthening activities of muscles in the shoulder and neck. Additionally, focus will be on patient education and lifestyle changes, including workstation evaluation, positioning, and modifying activities that aggravate the condition.
The shoulder joint is a complex ball (humeral head) and socket (glenoid) joint with many associated soft tissue structures that can be injured. The structure of the shoulder joint allows for a great deal of upper extremity mobility, but because of its anatomy, gains in shoulder mobility are off-set by a reduction in stability. Thus, stability is provided statically and dynamically by the many soft tissue structures within and surrounding the joint.
Many people think of the shoulder as just a ball and socket joint. However, the shoulder joint complex includes the SC (sternoclavicular) joint where the collarbone attaches to the breast bone, the AC (acromioclavicular) joint where the distal end of the collarbone attaches to the shoulder blade (scapula), and the scapulothoracic (ST) joint, where the scapula articulates with the rib cage.
Because of the complexity of the shoulder joint complex, there are many factors that lead to shoulder injury. Your medical provider should take into account the entire shoulder complex to identify areas of dysfunction and the cause of your pain/injury.
Common Shoulder Injuries
Impingement Syndrome: Impingement Syndrome occurs when the supraspinatus tendon is impinged (“pinched”) between the humeral head and the underside of the acromion when lifting the arm. It is typically caused by weakness or dysfunction of the rotator cuff and poor scapular mechanics, but it can also be influenced by the shape of the acromion (bony structure). Symptoms include a painful arc of motion during arm elevation, lateral shoulder pain while at rest, and night pain. This condition typically responds well to conservative therapy, but surgical options include:
- Subacromial Decompression (SAD): A common surgical procedure done alone or in combination with other procedures, the surgeon will use a bur to shave the underside of the acromion. If the rotator cuff tendon isn’t repaired surgically, the rehabilitation following a SAD is straightforward. However, contributing factors, including scapular mechanics, need to be addressed.
Rotator Cuff Tear: The rotator cuff refers to 4 muscles – the supraspinatus, infraspinatus, teres minor, and subscapularis – that originate on the scapula and have tendons that insert on the humeral head. The rotator cuff complex provides dynamic stability to the glenohumeral joint and depresses the head of the humerus during arm elevation.
Rotator cuff injuries can be chronic or the acute result of a fall or other trauma. Different types of rotator cuff injuries include impingement syndrome, tendonitis, rotator cuff strains, partial thickness tears, and full thickness tears. Symptoms can include shoulder pain or lateral arm pain with or without motion, sharp shoulder pain with movement, night pain, and in severe cases the inability to elevate the arm.
Non-operative treatment includes attempts to improve scapular mechanics, strengthen the rotator cuff through specific cuff exercises, and reduce symptoms to improve function.
- Rotator Cuff Repair (RCR): a surgical procedure most commonly done arthroscopically in which the surgeon will repair the rotator cuff tendon using anchors and suture. Depending on the location and size of the tear and the repair procedure, the post-operative recovery may vary. Because of the soft tissue involved, RCR rehabilitation must follow specific pathways and allow for appropriate healing. Surgeon technique and preferences will affect post-operative rehabilitation. Recovery is slow following a rotator cuff repair and many factors will affect recovery time, including appropriate rehabilitation.
Labrum Tear: The labrum is cartilage that serves to deepen the socket (glenoid) and provide additional stability to the glenohumeral joint. The wedge-shaped labrum sits along the entire rim of the glenoid, and combined with the joint capsule and rotator cuff, it is a passive stabilizer of the glenohumeral joint. Injuries to the labrum can be acute or chronic. Acute injuries can occur from a sudden jerk of the arm. Chronic labral injuries are often seen in overhead athletes (throwers, weightlifters), gymnasts, or football players. Injuries can include fraying of the labral tissue or complete separation of the labrum from the glenoid. A SLAP lesion refers to a common labral tear. SLAP stands for superior labrum anterior posterior and it affects the portion of the labrum where the long head of the biceps tendon attaches within the shoulder joint.
Labrum tears present with dull, aching shoulder pain, a “dead arm” feeling, and feelings of weakness. Oftentimes, patients aren’t able to perform their work-related or athletic activity without pain or discomfort. Labrum tears are also associated with increased glenohumeral instability in severe cases.
- Labrum Repair: a surgical procedure done arthroscopically to reattach the labrum to the glenoid through the placement of anchors and suture. Depending on the size, location and chronicity of the tear, the surgical approach and procedure may vary and will affect post-operative rehabilitation. Because of the need to protect the repaired soft tissue, post-operative guidelines and restrictions must be carefully followed by the physical therapist. Rehabilitation will focus on protecting the repair, restoring range of motion (ROM) within surgeon guidelines, and improving rotator cuff strength and scapular mechanics. Return to full activity will require good surgeon/therapist communication and patient compliance during rehabilitation.
Biceps Tendonitis: The long head of the biceps tendon can be a common source of anterior shoulder pain for many patients. Occurring with or without associated rotator cuff or labral pathology, the long head of the biceps tendon can become inflamed or irritated and can be a source of chronic shoulder pain. Many factors affect predisposition to developing biceps tendon-related issues, including activity level, types of activity (sports, work), posture, and scapular mechanics. Biceps tendon issues are commonly seen along with labral pathology, especially SLAP tears.
Conservative care for biceps tendonitis is geared towards removing the aggravating factors through activity modification, postural exercises, soft tissue mobilization, scapulohumeral exercises, and use of anti-inflammatory modalities.
- Biceps Tenodesis: a surgical procedure often associated with a labral repair, the surgeon will release the long head of the biceps and anchor the tendon on the humerus using anchors and suture.
- Biceps Tenotomy: a surgical procedure where the surgeon will cut the long head of the biceps tendon and will allow it to retract into the upper arm. The tendon will not be re-attached in this case.
AC Joint Separation: The AC joint (or acromioclavicular joint) is the junction of the distal end of the clavicle and the acromion process of the scapula. The clavicle and scapula can become separated, usually as the result of an acute, traumatic incident such as a fall or a tackle. The resulting separation is graded in degrees – first, second or third. Pain is the primary symptom although a deformity on the top of the shoulder may also be present, depending on the severity of the injury. Conservative treatment includes pain relief, rest, and activity modification. Following the acute injury, therapy may focus on the return of normal scapular mechanics and maximizing the strength of the rotator cuff and surrounding musculature. Often, AC separations can become chronic and result in arthritic changes in the AC joint, which are painful and limit overhead activities.
- AC Joint Reconstruction: a surgical technique to stabilize the AC joint and reduce pain. The surgeon may resect a portion of the distal clavicle and stabilize the joint with allograft (cadaver) tissue. Rehabilitation requires protection of the repair and slow restoration of movement, strength, and scapular mechanics.
SC Joint Separation: The SC joint (or sternoclavicular joint) is where the proximal end of the clavicle meets the sternum (breast bone). This is the only bony attachment of the entire shoulder/upper extremity complex (clavicle, scapula, upper arm, elbow, forearm, and hand) to the axial skeleton. Injured infrequently, an SC joint separation can be a severe medical emergency. Because of the proximity of important cardiovascular structures to the SC joint, injuries to this area should not be taken lightly. Injuries will likely be traumatic occurring from a fall or direct blow to the SC joint. Seek medical attention for any suspected SC joint separation.
- SC Joint Reconstruction: a surgical technique complicated by the cardiovascular structures in the immediate area of the SC joint. Similar to an AC joint reconstruction, the surgeon will attempt to restore normal structure and biomechanics to the injured joint.
Shoulder Dislocation: A term often confused with a “shoulder separation”, a shoulder dislocation is specific to the glenohumeral joint. A dislocation occurs when the head of the humerus is forced off the edge of the glenoid. Dislocations can occur in any direction (anterior, inferior, or posterior), although dislocations are most commonly anterior, meaning the head has been forced in front of the joint. Most primary dislocations are traumatic. Dislocations can spontaneously reduce themselves or may require reduction by a physician. Due to the strong force needed to dislocate the shoulder, there is usually associated soft tissue trauma, including labrum tears and capsular tears. In severe cases, there can also be tendon rupture.
Depending on severity, dislocations can be treated conservatively. Treatment includes bracing, positioning, pain reduction, strengthening, and activity modification. The goal of conservative treatment is to allow the soft tissue to heal and scar down, while minimizing the recurrence of dislocation through aggressive strengthening and stabilization.
Recurrent dislocation can become problematic and may require surgical intervention. Rehabilitation post-surgery requires protection of the repair through strict management of range of motion (ROM) restrictions progressing to ROM, and strengthening and dynamically stabilizing the glenohumeral joint.
Multidirectional instability: Refers to a glenohumeral joint that is unstable in more than one direction. Often seen in athletes with or without traumatic injury, these patients will complain of pain with activity, pain at rest, a “dead arm”, and inability to perform daily or sport-specific activities. These patients can pop their shoulder in and out of the socket at will, and will do so often without discomfort.
Rehabilitation focuses on total body dynamic strengthening, dynamic shoulder/scapular stabilization, rotator cuff strengthening, and patient education. Surgical intervention can be warranted if conservative treatment fails, although these patients may also suffer from associated soft tissue/connective tissue disorders that make them hyper-mobile.
Frozen Shoulder: A controversial term that refers to a stiff (frozen) shoulder with a predictable loss of motion and the inability to perform simple functional tasks. This condition is associated with significant pain, especially with motion, and night pain and the inability to sleep. Rehabilitation is geared towards restoring motion through joint mobilization and ROM. Unfortunately, this condition is painful and recovery can take time.
- Shoulder manipulation: Restoration of full range of motion while the patient is under general anesthesia. Includes tearing and breaking of adhesions in the joint capsule. Daily PT follows for 2 weeks.
Muscle Strain: The arm is attached to the body through the shoulder joint, allowing for a great deal of motion. Therefore, there are multiple large and small muscles associated with the shoulder that work together and can be strained during physical activity. Whether through an acute injury or overuse, muscle strains in the shoulder are common and need evaluation by a medical professional to keep from becoming chronic conditions. Early ROM is critical following a shoulder strain.
Osteoarthritis: OA is a degenerative disease process otherwise known as “wear and tear”. Chronic shoulder injuries, a history of frequent dislocations, or rotator cuff pathology can lead to excess wear and tear in the ball and socket of the shoulder.
- Total Shoulder Arthroplasty/Reverse Total Shoulder: Surgical procedure in which the surgeon removes the humeral head and the glenoid and replaces them with a prosthesis. Typically, patients can expect a reduction in pain and improved function following a shoulder replacement. PTs play a role after surgery in restoring ROM and strength and improving ability to perform daily activities.
Muscle Imbalances: As experts in movement dysfunction, PTs are able to identify underlying muscle imbalances that lead to shoulder dysfunction. Because of the shoulder’s mobility and intrinsic lack of stability, muscular function is critical. A physical therapist is best suited to identify muscle imbalances and faulty movement patterns that can lead to more serious injury if not addressed.
Low and Mid Back: The spinal column and associated structures are complex and intertwined. From the pelvic junction to its articulation with the base of the skull, the spine provides the main support for your body allowing you to remain upright, bend and twist. Additionally, the spinal column plays a critical role in the protection of the nervous system. With 33 individual bones (vertebrae) stacked on top of each other, the spine is remarkably stable due to the hundreds of ligaments, muscles, tendons and connective tissue that provide additional stability and support. Intervertebral discs provide spacing and shock absorption between the vertebrae. Collectively, the spinal column provides a conduit and protection for the nervous system. Pairs of nerve roots exit the spinal column at each level and provide and receive motor and sensory information to and from the brain to the extremities.
If you suffer from low back pain, you’re not alone. Estimates show up to 80% of adults experience low back pain at some point in their lives. The direct medical cost and indirect costs (lost productivity, missed work) associated with low back pain make it the 3rd most burdensome condition in the U.S. in terms of mortality and poor health, behind ischemic heart disease and chronic obstructive pulmonary disease (COPD).
The lower back (lumbar) area is most commonly affected in the general population, although the mid-back (thoracic) region can be affected as well. The lumbar region of the spine supports the majority of body weight and can be compromised by many factors including age, activity level, body mechanics, posture, genetics, occupational hazards, weight gain, pregnancy, and mental health issues. Some of these contributing factors can be addressed, while others cannot. Physical therapy plays a key role in:
- Preventing acute low back pain through patient education, workplace education, body mechanics education, and postural education.
- Early treatment of acute low back pain through appropriate interventions such as monitored exercise/activity, joint mobilization/manipulation, and patient education. Additionally, patients benefit from alternative hands-on techniques, including instrument-assisted soft tissue mobilization, trigger point dry needling, and massage.
- Educating and correcting poor movement patterns or body mechanics resulting in excessive strain on the spine and associated structures.
- Encouraging an active and healthy lifestyle.
Common Spinal Conditions
The vast majority of low back pain is mechanical in nature, meaning there is a defined disruption in the way that the components in the back move and fit together. In some cases, low back pain is associated with spondylosis, which refers to the normal wear and tear of the spine and general degradation of the spinal components with age.
Sprains and strains: These account for most acute episodes of back pain. Sprains are caused by overstretching or tearing ligaments, and strains are tears in tendon or muscle. Both can occur from twisting or lifting something improperly, lifting something too heavy, or overstretching. Such movements may also trigger spasms in back muscles, which can be painful. Physical therapy treatment is focused on proper movement, encouraging activity in a safe and controlled environment, use of hands on techniques such as joint mobilization/manipulation and trigger point dry needling, and patient education. Restoration of function and prevention of recurrence is the primary goal of physical therapy treatment.
Intervertebral disc degeneration: This is a common mechanical cause of low back pain, and it occurs when the usually rubbery discs lose integrity during the normal process of aging. In a healthy back, intervertebral discs provide height and allow bending, flexion, and torsion of the lower back. As the discs deteriorate, they lose their cushioning ability and flexibility. This can lead to dysfunction in the articulation between vertebrae in the spine, resulting in pain, loss of function, and spasms.
Physical therapy treatment is targeted at reducing acute symptoms through activity, patient-specific exercises, and hands-on techniques, as well as a focus on ongoing patient education in exercise, wellness, and body mechanics to avoid further injury.
Herniated or ruptured discs: occur when the intervertebral discs become compressed and bulge outward (herniation) or rupture, causing low back pain. A herniated disc can result in compression of a spinal nerve root, resulting in radiculopathy, and a central disc herniation can result in compression of the spinal cord itself. Bowel and bladder incontinence associated with a low back injury is a medical emergency and immediate medical attention should be sought.
Physical therapy for a ruptured disc is geared towards reducing symptoms and restoring safe and appropriate movement patterns and exercise. Treatment may sometimes include mechanical traction in an effort to create relief and reduce pressure on the impinged nerve root. Additionally, the therapist may have patients move repeatedly in specific patterns to reduce symptoms, a treatment known as the McKenzie Method.
Radiculopathy: A condition caused by compression, inflammation and/or injury to a spinal nerve root. Pressure on the nerve root results in pain, numbness, or a tingling sensation that travels or radiates to other areas of the body served by that nerve. Radiculopathy may occur when spinal stenosis or a herniated/ruptured disc compresses the nerve root. Physical therapy treatment will focus on the likely source of the radiculopathy and the therapist will work with the patient using exercise, patient education, and hands-on techniques to improve function and reduce symptoms.
Sciatica: A form of radiculopathy caused by compression of the sciatic nerve, the large nerve that travels through the buttocks and extends down the back of the leg. This compression causes shock-like or burning low back pain combined with pain through the buttocks and down one leg, occasionally reaching the foot. In the most extreme cases, when the nerve is pinched between the disc and the adjacent bone, the symptoms may involve not only pain, but numbness and muscle weakness in the leg because of interrupted nerve signaling. The condition may also be caused by a tumor or cyst that presses on the sciatic nerve or its roots.
Physical therapy treatment for sciatica aims for symptom resolution and centralization of symptoms (reducing pain, numbness, or tingling in the extremity). Treatment may include specific exercises prescribed by your therapist, hands-on techniques, activity modification, and patient education.
Spondylolisthesis: A condition in which a vertebra of the lower spine slips out of place, pinching the nerves exiting the spinal column. There are various grades of spondylolisthesis based upon radiographic findings.
Physical therapy treatment is dependent upon the degree of slippage and the symptoms that are occurring. Emphasis will be placed upon patient education, positioning, posture, activity modification, and core stabilization.
Traumatic injury: such as from playing sports, car accidents, or a fall can injure tendons, ligaments or muscle and result in low back pain. Traumatic injury may also cause the spine to become overly compressed, which in turn can cause an intervertebral disc to rupture or herniate, exerting pressure on any of the nerves rooted to the spinal cord. When spinal nerves become compressed and irritated, back pain and sciatica may result.
Your physical therapy treatment will be geared towards restoration of function, correct movement patterns, and patient education in positioning, and protection while your injury heals.
Spinal stenosis: is a narrowing of the spinal column that puts pressure on the spinal cord and nerves that can cause pain or numbness with walking and over time leads to leg weakness and sensory loss.
Physical therapy will involve patient education in proper positioning and activities and strategies to reduce symptoms. Proper exercise tailored to your specific condition is paramount.
Skeletal irregularities: include scoliosis, a curvature of the spine that does not usually cause pain until middle age, lordosis, an abnormally accentuated arch in the lower back, and other congenital anomalies of the spine.
Your physical therapist will work with you to address muscular imbalances to promote activation of specific muscles and to address faulty movement patterns that may or may not be contributing to your condition.
Postural Dysfunction: Poor posture is a contributing factor in developing sub-acute or chronic musculoskeletal pain. Often, poor posture puts unnecessary strain on tissues surrounding the spinal column and, over the long term, can contribute to compensatory changes in the musculoskeletal system. Often, children demonstrate poor posture and corrective exercises and treatment plans can be beneficial as early intervention to prevent long term dysfunction.
Physical therapy will focus on patient education, postural restoration, and patient-specific exercises to address muscle imbalances and posture.
Muscle Imbalances: A sedentary lifestyle has been associated with an increased incidence of back pain. Often, long standing muscle imbalances in the system (core) between trunk extensors and trunk flexors develop resulting in subsequent low back/mid back pain. Additionally, the associated lower extremity and hip musculature can play a role in low back dysfunction.
Physical therapy should be geared towards restoring correct movement patterns and muscle activation and balance. Patient specific exercises and an active, healthy lifestyle are encouraged.
Non-mechanical low back pain: It’s possible that there can be non-mechanical sources of low back pain. All are serious medical conditions that should be evaluated further by a physician. A physical therapist will ask questions and perform an examination that will help rule out any non-mechanical conditions and will refer to a specialist when in doubt.
- Infection: Infections can cause pain when they involve the vertebrae, a condition called osteomyelitis; the intervertebral discs, called discitis; or the sacroiliac joints connecting the lower spine to the pelvis, called sacroiliitis.
- Tumor: Occasionally, tumors begin in the back, but more often they appear in the back as a result of cancer that has spread from elsewhere in the body.
- Kidney Stones: Can cause sharp pain in the lower back, usually on one side.
- Cauda Equina Syndrome: As discussed previously, a serious but rare complication of a ruptured disc. It occurs when disc material is pushed into the spinal canal and compresses the bundle of lumbar and sacral nerve roots, causing loss of bladder and bowel control. Permanent neurological damage may result if this syndrome is left untreated.
- Abdominal aortic aneurysm: Occurs when the large blood vessel that supplies blood to the abdomen, pelvis, and legs becomes abnormally enlarged. Back pain can be a sign that the aneurysm is becoming larger and that the risk of rupture should be assessed.
- Osteoporosis: A metabolic bone disease marked by a progressive decrease in bone density and strength, which can lead to painful fractures of the vertebrae
- Fracture: Whether back pain is related to osteoporosis, a fall, trauma, or otherwise, a fracture within the spinal column should be suspected and assessed. A good medical history should identify potential sources of a fracture and symptoms regarding non-mechanical back pain.
The elbow is a joint that is comprised of 3 bones – the upper arm (humerus) and two bones in your forearm (radius and ulna). Tendons from muscles in the upper arm (biceps and triceps) cross the elbow joint and result in elbow flexion (bending) and extension (straightening). Additionally, muscles in the forearm that control hand and wrist movements also cross the elbow joint and provide stability. The elbow is further stabilized by ligaments that connect bone to bone. Generally speaking, the elbow is a stable joint that allows the placement of the hand in space through elbow flexion and extension as well as forearm supination (hand up) and pronation (hand down). Nerves from the cervical spine traveling to the forearm, wrist and hand also cross the elbow and can become compressed or entrapped causing pain, numbness/tingling, or weakness in the hand.
The most common injuries in the elbow are soft tissue in nature, meaning most injuries are related to the muscles, tendons, ligaments and nerves that cross the elbow joint and that provide stability to the elbow and control wrist/hand motion. A thorough examination by your medical provider should include evaluation of structures above and below the elbow joint, especially in instances of suspected nerve involvement.
Common Elbow Injuries
Distal Biceps Strain/Tear: The bicep muscle is the powerful muscle on the front of your upper arm. Its primary function is to bend the elbow, although it also has a role in forearm supination (hand up) and shoulder movement. A strain/tear of the distal biceps tendon can occur with forceful elbow extension against a load. Most distal biceps injuries are sudden injuries that occur resulting in tearing of the tendon of varying degrees.
A partial tear of the distal biceps tendon may be treated conservatively with physical therapy. Your therapist will work to strengthen other muscles to help compensate for a loss of strength associated with the disruption in tendon integrity. They will also use soft tissue mobilization techniques to ensure proper healing of the tissue (instrument assisted soft tissue mobilization).
A complete tear of the distal biceps tendon requires surgery.
- Distal Biceps Repair: A surgical procedure to repair a complete rupture of the distal biceps tendon. Various techniques for repair exist and should be discussed with your surgeon. The sooner surgery can occur following the injury the better.Following surgery, you will be immobilized for a period of time before physical therapy will begin. It’s a slow process because of the soft tissue injury and repair, therefore initial therapy will focus on protection of the repair and regaining ROM. As your recovery progresses, active motion and strengthening will be incorporated into your treatment plan. Eventually, functional activities will resume and therapy will focus on your goals and return to activity. As with any surgical procedure, good communication and teamwork between surgeon and therapist is key to a good outcome.
Triceps Strain/Tear: The triceps is the powerful muscular complex on the back of your upper arm. Its primary function is to extend (straighten) the elbow. With various attachments on the humerus, the triceps’ 3 heads come together to form the triceps tendon which attaches on the olecranon (the pointy part of your elbow).
A strain or tear of the triceps is rare although injury can be related to overuse or a sudden change in activity such as a new weight lifting program. Additionally, triceps tears can occur in sporting environments such as football when the elbow is forcefully bent against resistance.
A minor strain of the triceps tendon will generally resolve with rest. Should therapy be needed, treatment will include soft tissue mobilization, strengthening exercises, and activity modification.
- Distal Triceps Repair: A surgical procedure to repair/reattach the triceps tendon to the olecranon using anchors.
Post-operative rehabilitation is a slow process and will typically follow a period of immobilization. Initial therapy will focus on protection and the restoration of motion. As the tissue heals, gentle strengthening and resistive exercises will begin. During the final phases of recovery, a more aggressive exercise and return to activity progression will occur.
Lateral Epicondylitis: Also known as “tennis elbow,” this condition is caused by inflammation of the wrist and finger tendons (tendonitis) that attach on the outside of the elbow. Caused by overuse or repetitive stress, symptoms of this condition include pain with gripping, especially with the elbow in an extended position. If chronic, the condition can lead to degradation of the tissue, or tendonosis.
Symptoms include pain or burning on the outer part of the elbow at rest or during activity. Activity may worsen the symptoms. Patients may also notice a weakening of grip and the inability to perform normal daily activities like holding a jug of milk.
Treatment is mostly conservative, including physical therapy interventions. Treatment will include rest, splinting, activity modification, and evaluation of activities resulting in symptoms. Instrument-assisted soft tissue mobilization and other hands-on techniques like trigger point dry needling can also be effective. Specific strengthening and exercises focused on the entire upper extremity kinetic chain should be incorporated into the treatment program as well.
If conservative treatment fails after 6-12 months, surgery might become an option.
Medial Epicondylitis: Also known as “golfer’s elbow,” this condition causes inflammation of the tendons of the forearm and fingers at the inside of the elbow. Causes are related to gripping and forceful wrist flexion or forearm rotation overuse. Symptoms include pain and tenderness at the medial elbow where the forearm and finger flexors attach. Care should be taken to evaluate other structures at the medial elbow to look for ligament injury and/or nerve compression.
Treatment is mostly conservative with rest, activity modification, stretching and strengthening exercises of the upper kinetic chain, soft tissue mobilization techniques, and pain reducing modalities like ice massage.
Ligament Sprain/Tear: On the inner and outer sides of the elbow, thicker ligaments (collateral ligaments) hold the elbow joint together and prevent dislocation. The ligament on the inside of the elbow is the ulnar collateral ligament (UCL). It runs from the inner side of the humerus to the inner side of the ulna, and must withstand extreme stresses as it stabilizes the elbow during overhand throwing.
The most commonly affected ligament in the elbow is the UCL. Injuries of the UCL can range from minor sprains and inflammation to a complete tear of the ligament. Athletes will have pain on the inside of the elbow, and frequently notice decreased throwing velocity. This is an injury seen most commonly in overhand throwers, such as baseball players and pitchers.
Conservative treatment includes rest and physical therapy. Therapy will consist of specific exercises to address strength, flexibility, and upper extremity biomechanics. Additionally, a physical therapy program will include a gradual return to throwing as well as a biomechanical evaluation of throwing mechanics. Teamwork between the surgeon, physical therapist, athlete, and coaches is paramount in avoiding further injury.
Thrower’s Elbow: Overhand throwing places high stresses on the elbow. In baseball pitchers and other throwing athletes, these high stresses are repeated many times and can lead to serious overuse injury.
Unlike an acute injury that results from a fall or collision with another player, an overuse injury occurs gradually over time. In many cases, overuse injuries develop when an athletic movement is repeated often during single periods of play, and when these periods of play are so frequent that the body does not have enough time to rest and heal.
Although throwing injuries in the elbow most commonly occur in pitchers, they can be seen in any athlete who participates in repetitive overhand throwing.
Throwing injuries can affect multiple structures in the elbow; therefore, careful examination is important. Muscles, ligaments and nerves can all be affected in the throwers elbow. As such, it’s important to assess all potential sources of injury.
- Flexor Tendonitis: Overuse and repetitive throwing can cause inflammation of the flexor/pronator tendons as they attach to the humerus. Athletes will have pain on the inside of their elbow/arm during activity and, in severe cases, at rest.
- Ulnar Collateral Ligament Sprain/Tear: This is the most commonly injured ligament in the elbow. Injuries can range from minor sprains to a complete rupture of the UCL. Athletes will notice and complain of medial elbow pain and decreased throwing velocity.
- Ulnar Neuritis: The ulnar nerve is stretched as the elbow is bent. Located at the inside of the elbow, the ulnar nerve is also referred to as the “funny bone.” In a thrower with repeated elbow flexion and forceful extension, the ulnar nerve can become irritated and painful. Usually, athletes will complain of “shocks” occurring in their forearm or numbness and tingling in their pinky or 4th finger while throwing or at rest.
- Ulnar Extension Overload: The throwing motion is hard on the elbow and the forces result in a torsion/torque on the medial elbow. This additional torque can result in a wearing of the articular cartilage and compensatory build-up of bone spurs (osteophytes) between the humerus and ulna as a response to the added stresses on the area. Athletes with UEO complain of medial elbow pain, swelling, and tenderness in the affected area.
- Stress Fracture: A stress fracture can occur when forces normally absorbed by muscular contraction are transferred to the bone instead. This often is a result of fatigue, muscle imbalance, or improper training/deconditioning. In throwers, the most common area for a stress fracture is the olecranon. Athletes will complain of diffuse, aching pain during activity and at rest.
Physical therapy and activity modification will play a large part in the recovery of these various injuries as part of conservative care. Therapy will focus on symptom management, strengthening of the upper extremity kinetic chain (including the shoulder and scapular muscles), throwing mechanics, and a gradual return to throwing.
If conservative treatment fails, there are surgical options.
- Arthroscopy. Bone spurs on the olecranon and any loose fragments of bone or cartilage within the elbow joint can be removed arthroscopically.
Because the arthroscope and surgical instruments are thin, the surgeon can use very small incisions (cuts), rather than the larger incision needed for standard, open surgery.
- UCL reconstruction (Tommy John). Athletes who have an unstable or torn UCL, and who do not respond to nonsurgical treatment, are candidates for surgical ligament reconstruction.
Most ligament tears cannot be sutured (stitched) back together. To surgically repair the UCL and restore elbow strength and stability, the ligament must be reconstructed. During the procedure, the doctor replaces the torn ligament with a tissue graft. This graft acts as a scaffolding for a new ligament to grow on. In most cases of UCL injury, the ligament can be reconstructed using one of the patient’s own tendons.
- Ulnar nerve anterior transposition. In severe cases of ulnar neuritis, the nerve can be moved to the front of the elbow to prevent stretching or snapping. This is called an anterior transposition of the ulnar nerve because the nerve is moved (transposed) to a new area of the elbow (anterior).Following any of these procedures, patients will enter physical therapy. Depending on the procedure performed, rehabilitation guidelines will vary. Therefore good teamwork and communication between therapist and surgeon is paramount, especially as the patient begins returning to throwing activities. If surgery is performed, it can take up to 6-9 months to return to sports.
- Cubital Tunnel: Compression of the ulnar nerve at the inside part of the elbow. This nerve is very superficial (also known as the “funny bone”) and can be compressed when the elbow is held in a bent position for too long. Symptoms include pain, tingling, and numbness in the ring and little finger and decreased grip strength.
- Radial Tunnel: Compression of the radial nerve at the elbow resulting in a set of symptoms that include fatigue or a dull, aching pain at the top of the forearm with use. Although less common, symptoms can also occur at the back of the hand or wrist.
- Radial Head Fractures: The radial head is the proximal (closest to the elbow) end of the radius. Radial head fractures often occur as a result of a fall on an outstretched arm or a direct blow. Radial head fractures are common and are graded I – III based on radiographic findings. More severe fractures involve displacement of the fracture and often require surgical fixation or replacement.Following immobilization, physical therapy will be initiated, focusing on restoring ROM and strength when appropriate. In some cases, a certified hand therapist may make a splint to aid in protection.
- Olecranon Fractures: The olecranon is the pointy end of your elbow. It’s the end of the ulna that “cups” the distal humerus, creating a hinge joint. Because it’s not protected by soft tissue, the olecranon can be fractured due to a fall or direct blow. Extremely painful, an olecranon fracture will need emergency treatment.Some fractures can be treated with casting and splinting and careful monitoring by the physician. In other cases, surgery is required using a plate and screws or wires/pins to piece the olecranon back together.Surgery is followed by a period of immobilization in a cast or splint, although early passive range of motion is helpful following surgery to prevent elbow stiffness, which is the most common complication following surgery. Lifting or forceful contraction of the triceps is avoided initially in order to allow the fracture to heal.As therapy progresses, ROM activities will continue as will a gradual return to functional activities. Often there is a loss of elbow extension following an olecranon fracture; therefore, physical therapists will work aggressively with the patient on maximizing ROM.
- Distal Humerus Fractures: The humerus (upper arm) can be fractured close to the elbow joint due to either a direct blow or a fall on an outstretched arm. Distal humerus fractures are uncommon. However, when they occur, they require evaluation by a physician.Depending on the severity of the fracture and the displacement of the pieces of bone, treatment may proceed conservatively with the patient being placed in a splint or cast and monitored closely while the fracture is allowed to heal. In other cases, a distal humerus fractures require surgery with the placement of plates/screws or pins/wires to reconstruct the humerus. There are careful considerations that your surgeon will take into account in order to provide the best outcome.Physical therapy will be a part of your post-operative recovery with exercises and hands-on therapy focused on restoration of motion following surgery or immobilization. Your therapist will be keenly aware of restrictions in activity in order to protect the repair while maximizing motion and improving function. Typically, it takes 4-6 months to begin returning to normal activities, but it can take even longer to regain full strength and mobility.
Osteoarthritis (OA): A degenerative process, otherwise known as “wear and tear” arthritis, can lead to a breakdown in the articular cartilage within the elbow joint. Arthritis in the elbow is uncommon and is usually associated with previous fracture or trauma to the joint. Additionally, those with occupations that place repetitive stress on the stabilizing ligaments of the elbow can have a higher incidence of articular cartilage breakdown due to the additional stress placed upon the elbow, causing chronic instability.
Conservative treatment can include physical therapy focusing on maximizing ROM and strength through exercise and manual therapy, while educating patients on joint protection techniques.
Rheumatoid Arthritis (RA): An inflammatory disease process in the body that results in chronic inflammation in joints and causes a breakdown of the cartilage and eventual cartilage loss in the joint. RA can be painful and severely debilitating for patients.
Conservative care for a patient suffering from RA in the elbow will focus primarily on joint protection and patient education.
- Total Elbow Replacement: A total elbow replacement isn’t nearly as common as a total hip or total knee replacement. The surgeon will remove the damaged parts of the humerus and ulna and replaced them with a hinged prosthesis. There are different types of surgical techniques and prostheses.Physical therapy following a total elbow replacement will focus on the restoration of movement and strength while focusing on function and returning to normal activities of daily living.
The human hand is comprised of 27 bones, including the carpal bones, the metacarpals, and the phalanges. At the distal end of the upper extremity kinetic chain, the hand gives us the ability to perform fine motor skills. The wrist is the articulation of the forearm (radius and ulna) with the hand (carpal bones). There are 8 carpal bones, including a proximal row (articulates with the distal radius and ulna) and a distal row (articulates with the metacarpals).
The hand has some of the densest areas of nerve endings in the body, which allows for a tremendous sense of touch as well as the greatest positioning capability. There are extrinsic muscles that move the hand and wrist. Finger flexors and extensors originate in the forearm. Their tendons cross the wrist and insert at various points on the phalanges to allow for finger flexion (bending, grasping) or finger extension (straightening). There are also intrinsic muscles in the hand that control finger or thumb movements. They originate either on bony landmarks in the hand or have muscular origin (lumbricals).
Because of the complexity of the hand and its unique necessity in performing activities of daily living, injuries to the hand and wrist can be debilitating for the individual. Injuries can affect the bones, the tendons, the nerves, and the ligaments. Additionally, the integrity of the skin and underlying tissue can be affected by burns. Skilled medical care following a hand injury, including physical and/or occupational therapy, is critical in regaining functional capabilities.
Common Hand/Wrist Injuries
Fractures: Fractures of the hand can occur in either the small bones of the fingers (phalanges) or the long bones (metacarpals). They can result from a twisting injury, a fall, a crush injury, or direct contact in sports. Fractures in the wrist can include the carpal bones or the distal forearm. These injuries can result from a fall or a direct blow. Here are examples of common fractures involving the hand and wrist.
- Distal Radius Fracture (Colles Fracture)
- Hand/Finger Fractures (Boxer’s Fracture)
- Carpal Fracture (Scaphoid Fracture)
Suspected fractures in the fingers or wrist should be evaluated by a physician. Depending on radiographic and exam findings, a period of immobilization will occur. Some fractures require surgery with screws/plates, or pins and wires. The goal of immobilization is to allow the bone to heal. Displaced fractures will generally heal in 4-6 weeks. Following immobilization, stiffness is common. Following surgery, stiffness, hypersensitivity, and weakness may occur.
Physical and occupational therapy will focus on regaining motion, strength, and improving the ability to perform functional activities and fine motor skills.
Tendon Injuries: The tendons of the hand and thumb can be injured through a variety of mechanisms. Laceration from a sharp object can result in severing of one or multiple tendons. Overuse and repetitive motion can cause tendons and tendon sheaths to become inflamed and thickened, resulting in pain, weakness, and loss of function. Additionally, other medical conditions like rheumatoid arthritis can cause tendon disruption due to the weakening of the soft tissue. Below are several examples of tendon injuries that can occur.
- Tendon Rupture:
- Tendon laceration: A medical emergency. Lacerations typically occur from a traumatic insult from a sharp object. Tendons must be repaired microscopically by a hand surgeon, usually an orthopedic or plastic surgeon. Rehabilitation requires extensive splinting to protect the damaged tendons while maintaining mobility of other structures. As the tendons heal, focus will shift towards regaining strength and function in the affected hand. Tendon lacerations can occur in multiple zones including the wrist, hand, and fingers.
- Mallet Finger: This condition is usually the result of a direct blow to the tip of the fingertip. It results in damage to the extensor tendon insertion at the distal phalanx. The resulting deformity is a fingertip that cannot be fully straightened actively. Treatment involves splinting using a splint that keeps the tip of the finger extended while allowing other movements at other joints in the finger. This allows the damaged tendon to heal which can take 6-8 weeks. Stiffness is often present, thus a therapist will work to restore motion and the ability to perform activities of daily living.
- Boutonniere Deformity: Boutonnière deformity is the result of an injury to the tendons that straightens the middle joint of your finger (extensor). This results in a middle finger joint that will not straighten. This injury can be caused by a direct blow, a laceration or arthritis. Treatment will include specific splinting, stretching exercises and patient education in protection.
- Tendonitis (tendinosis): Tendons that cross the wrist into the hand or thumb can become inflamed through overuse or repetitive motion. This causes pain and discomfort with specific motions, depending on the area of injury. Tendinosis refers to the non-inflammatory condition of tendons where thickening of the tendon occurs along with breakdown of the tendon tissue over time.
- DeQuervain’s Tendinosis: De Quervain’s tendinosis occurs when the tendons around the base of the thumb are irritated or constricted. The word “tendinosis” refers to a swelling of the tendons. As the tendons swell, they become irritated by repetitive motion, resulting in pain and tenderness. The goal of treatment is to reduce the pain through splinting and protection, instrument-assisted soft tissue mobilization, and activity modification. NSAIDs or corticosteroid injections may also be prescribed by a physician in certain cases.
Nerve Injuries: There are 3 nerves that cross the wrist that supply the motor and sensory ability to the hand. The hand has the densest concentration of nerve endings in the body, therefore it’s not uncommon for the nerves to be affected in an injury. With significant lacerations and associated surgery and trauma, nerves can be affected resulting in loss of sensation. In other cases, nerves that cross the wrist can become compressed or compromised over time. This can be because of multiple factors including age, sex, heredity, activity, pregnancy, and medical conditions like diabetes. Here are 2 examples of the most common non-traumatic nerve conditions affecting the hand/wrist.
- Carpal Tunnel Syndrome: Carpal tunnel syndrome is a common source of hand numbness and pain, occurring more often in women than men. The carpal tunnel refers to the “tunnel” created by the carpal arch and the transverse carpal ligament. The finger flexors and median nerve pass through this tunnel. “Carpal tunnel syndrome” occurs when the tissues surrounding the flexor tendons in the wrist swell and put pressure on the median nerve, resulting in numbness and weakness in the hand.Rarely is there one identified cause of carpal tunnel syndrome. Typically, the cause of the condition is multi-factorial and it develops over time. Additionally, because the median nerve in the wrist/hand is a continuation of the neural plexus leaving the cervical spine crossing the shoulder and elbow, there are often other areas where the nerve can be compromised. This “double crush” theory makes the diagnosis and treatment more complex. As such, evaluation and treatment by a physical or occupational therapist should focus on the entire upper extremity kinetic chain, not just the wrist. Conservative treatment includes splinting, patient education, activity modification and joint protection. Neural gliding can assist.
- Carpal Tunnel Release: Performed either arthroscopically or “open”, the transverse carpal ligament is released thus reducing the pressure on the median nerve in the carpal tunnel.Physical or occupational therapy following a carpal tunnel release will follow the specific physician’s protocol. Generally speaking, emphasis will be on nerve gliding, splinting, and gentle ROM of the fingers progressing to functional activities when appropriate.
- Ulnar Tunnel Syndrome: Ulnar tunnel syndrome occurs when the ulnar nerve is compressed at the wrist. The ulnar nerve is one of the three main nerves that provide feeling and function to the hand. It travels from your neck down into your hand, and can be constricted in several places along the way. Symptoms usually develop gradually and include weakness and numbness on the little finger side of the hand. Causes can because of a cyst or positioning during work or sport.
Conservative treatment is geared towards changing or eliminating aggravating factors through splinting, patient education, and positioning.
Ligament Injuries: There are a multitude of ligaments that support the joints in the hand and thumb. A sprain is a ligament injury when the ligament is stretched beyond its normal range of motion. There are ligaments in the thumb called the collateral ligaments that are most commonly sprained, typically in sports. The thumb is important for grasping activities, therefore injuries can greatly limit function.
- Skier’s Thumb: This is an injury to the ulnar collateral ligament of the thumb. This injury usually occurs from a fall on an outstretched hand. In the case of a skier, this injury occurs when they land with their hand on their ski pole, resulting in ligament damage.Conservative treatment includes splinting so that the ligament has time to heal, followed by strengthening exercises and return to functional activities.
Arthritis: The hand and wrist have multiple small joints that work together to provide motion, including the fine motion needed to button a shirt or thread a needle. When the joints in the hand are affected by arthritic changes, activities of daily living become more difficult and painful. There are multiple causes of arthritis in the hand but the most common are osteoarthritis and rheumatoid arthritis.
- Osteoarthritis is much more common and generally affects people as they age. Also known as “wear and tear” arthritis, osteoarthritis causes articular cartilage to wear away. It appears in a predictable pattern in certain joints of the hand. Often the thumb (CMC) joint is most affected.
- Rheumatoid arthritis is a chronic disease that can affect many parts of your body. It causes the joint lining (synovium) to swell, which causes pain and stiffness in the joint. Rheumatoid arthritis most often starts in the small joints of the hands and feet. It usually affects the same joints on both sides of the body. In severe cases, rheumatoid arthritis can result in severe degenerative changes in the joints of the hand leading to deformity. This affects the ability to lift, grasp, hold and manipulate objects.
Physical or occupational therapy is often prescribed as conservative care for arthritic conditions. While the disease process cannot be affected or reversed, a physical or occupational therapist will work with patients to splint painful joints, strengthen supporting muscles, and improve flexibility. Most importantly, patients will be educated in joint preservation and protection. This includes education on compensatory mechanisms to avoid positions or activities that can result in increased pain and decreased function.
The hip is a ball (femoral head) and socket (acetabulum) joint. Unlike the shoulder, the hip joint has more bone to bone congruency that leads to stability and better weight-bearing ability. With the additional stability, however, the hip loses mobility and there is much less freedom of movement as compared to the shoulder joint.
The hip complex is more complicated than the bony anatomy would suggest. During weight bearing activities (walking, running, etc), forces are transmitted up through the kinetic chain, starting when the foot hits the ground, through the knee, hip, pelvis and lumbar spine. As such, movement dysfunction and muscle imbalances throughout the entire lower extremity can play a significant role in hip disorders. Often, hip disorders occur in combination with other issues – knee patellofemoral pain, lumbar pain, and more. The hip joint complex needs to be evaluated and treated by experts on its optimal function and familiar with its anatomy.
Because of the complexity of hip disorders and the multiple factors that can play a role in hip dysfunction, your medical providers should perform a comprehensive evaluation of the entire kinetic chain. Many common hip disorders can be treated conservatively through the application of a specific physical therapy plan.
Common Hip Injuries
Muscle Imbalance/Muscle Strain: There are a multitude of large and small muscles that are classified as “hip joint” muscles that are susceptible to imbalance due to weakness or faulty movement patterns over time. Oftentimes, this muscle imbalance leads to pain. Examples of this include:
- Piriformis Syndrome
- Hip Flexor Strains
- IT Band Syndrome (greater trochanteric bursitis)
- Anterior Hip Pain
- Posterior Hip Pain
- Lateral Hip Pain
- Hamstring Strains
- Quadriceps Strains
- Gluteal Strains
Physical therapy should look at the entire kinetic chain from the foot to the hip and should also include evaluation of core strength. Appropriate activity modification, patient education, and patient specific exercises will be a part of your rehab program, the goal of which is to restore proper movement patterns during functional activities. Additionally, your therapist will be evaluating you for inorganic sources of your hip pain, because other structures can refer pain to the hip region.
Hip Impingement/Labral Tears: The labrum in the hip is a ring of fibrocartilage that surrounds the rim of the acetabulum, effectively deepening the hip socket and, in combination with the fibrous joint capsule, creating negative pressure (suction) in the hip joint. For a variety of anatomic and/or movement reasons, the labrum can become repetitively pinched (impinged) and subsequently damaged. This impingement and subsequent damage of the hip labrum can often become a source of anterior hip pain, posterior hip pain, and groin pain and it can severely limit function. A goal of physical therapy is the restoration of normal movement patterns and the reduction in muscle imbalances. Your therapist will also look at biomechanics to identify any contributing factors to the condition.
- Hip Arthroscopy: An area of orthopedics that has exploded within the last 8-10 years with the advancements in arthroscopic technology. The surgeon will enter the hip joint arthroscopically in order to remove bone on the femoral neck, debride damaged tissue and repair the hip labrum using bio-absorbable anchors. Physical therapy following hip arthroscopy follows specific pathways geared towards protecting the repair, restoring normal movement and a gradual increase in function. Good teamwork and communication between therapist and physician is important in the post-op recovery.
Osteoarthritis: Osteoarthritis (OA) of the hip is a medical condition referring to “wear and tear” arthritis. In the hip, OA can become extremely painful, limiting the ability to walk and perform weight-bearing activities. Often, OA of the hip is characterized by significant stiffness of the ball and socket. Therefore, conservative management of hip osteoarthritis can include physical therapy, including joint mobilization and manual therapy to maximize joint accessory motion. The PT will also work with the patient to restore movement and address faulty movement patterns and muscle imbalances.
- Total Hip Arthroplasty (THA): A surgical procedure in which the ball and socket, or the ball only, are removed and replaced with a prosthesis. There are various surgical approaches to the hip and advancements in technology have led to muscle sparing techniques, minimizing hip precautions and post-operative morbidity. Post-operative physical therapy in the hospital will focus on mobility (in and out of bed, chair, and walking) as well as patient education on precautions. Generally speaking, patients that have undergone a hip replacement feel an immediate reduction in the pain they suffered from prior to surgery. Outpatient PT will continue with strengthening and improving functional mobility.
- Lower Body
Lower Extremity Muscle Strains: There are several injuries that can occur in the lower extremity that may or may not be associated with a particular joint. These typically present as muscle strains (or pulls) that can limit one’s abilities and can become nagging and chronic in nature.
Quadriceps Strain: The term ‘quadriceps’ refers to a powerful set of muscles on the front of the thigh that serve primarily to extend (or straighten) the knee joint. There are 4 primary muscles that make up the quadriceps complex – the rectus femoris, vastus lateralis, vastus intermedius, and vastus medialis. These 4 muscles originate on the femur (with the exception of the rectus femoris) and come together to form the patellar tendon. The rectus femoris originates on the pelvis and serves as a hip flexor as well as an extensor of the knee.
Muscle strains usually occur when a muscle is stretched beyond its limit, tearing the muscle fibers. They frequently occur near the point where the muscle joins the tough, fibrous connective tissue of the tendon. A similar injury occurs if there is a direct blow to the muscle. Muscle strains in the thigh can be quite painful.
Once a muscle strain occurs, the muscle is vulnerable to reinjury, so it is important to let the muscle heal properly and to follow preventive guidelines from your doctor and physical therapist.
Physical therapy treatment will initially focus on rest, ice, and compression (RICE). As recovery progresses, treatments will expand to include strengthening and flexibility exercises, instrument-assisted soft tissue mobilization, and a functional progression back to sports and activity. Physical therapy will also focus on contributing factors that may have made the individual more susceptible to injury, including patient education on dynamic warm-ups, appropriate stretching, and deconditioning/fatigue.
Hamstring Strain: Hamstring muscle injuries (“pulled hamstrings”) occur frequently in athletes. They are especially common in athletes who participate in sports that require sprinting, such as football, soccer, baseball, and basketball. The term hamstring refers to the muscles in the back of the thigh. There are 3 muscles that make up the hamstring muscle complex – the semitendinosis, semimembranosis, and biceps femoris. All three muscles originate on the pelvis at the ischial tuberosity aand insert below the knee on the medial and lateral tibia. The hamstrings serve to flex (bend) the knee and extend (straighten) the hip.
A hamstring injury can be a slight pull, a partial tear, or a complete tear. Injuries are graded on a 1-3 scale. Most hamstring injuries occur in the thick, central part of the muscle or where the muscle fibers join tendon fibers. An avulsion injury, where the muscle is torn completely from the bone, can occur at the ischial tuberosity. This injury requires surgery. A hamstring strain is the result of muscle overload that occurs when the muscle is contracting as it lengthens. This occurs in sprinting activities when the muscle is contracting during push-off. Risk factors for suffering a hamstring strain include deconditioning, inflexibility, muscle imbalance, muscle fatigue, and activity level.
Physical therapy treatment will initially focus on rest, ice and, compression (RICE). As recovery progresses, treatments will expand to include strengthening and flexibility exercises, instrument-assisted soft tissue mobilization, and a functional progression back to sports and activity. Also, physical therapy will focus on contributing factors that may have made the individual more susceptible to injury, including muscle imbalances, patient education on dynamic warm-ups, appropriate stretching, and deconditioning/fatigue. Early treatment with a plan that includes the RICE protocol and physical therapy has been shown to result in better function and quicker return to sports.
The knee is a hinge joint. It is the meeting point of the femur (thigh bone) with the tibia (shin bone). With minimal bony approximation, the knee joint is heavily reliant on soft tissue structures for stability. These include ligaments, the meniscus, and tendons. Soft tissues include ligaments, meniscus, and tendons. An additional joint in the knee is the articulation of the patella (kneecap) with the femur. The patellofemoral joint is a common area for injury and pain.
There are numerous injuries that can occur, some acute and some chronic, and there are many surgical procedures used to address knee injuries and pain.
Common Knee Injuries
Ligament Tears: There are 4 ligaments in the knee – 2 cruciate ligaments (ACL, PCL) and 2 collateral ligaments (MCL, LCL). Ligaments connect bone to bone, and these 4 ligaments serve to provide stability to the knee joint. The knee ligaments can be injured in a multitude of ways. Since they check movement of the knee in certain directions, injury usually occurs when the knee is twisted or torqued abnormally.
Anterior Cruciate Ligament (ACL): Probably the most ‘famous’ of the 4 knee ligaments, the ACL is most commonly injured by high torque within the knee causing a shift, tearing the ACL. Injury may be associated with an audible “pop” and immediate joint effusion (swelling within the joint). Injuries can be related to a direct blow to the knee, however, ACL injuries often occur with no contact at all. They can be isolated or associated with related injuries to other structures, including the meniscus, articular cartilage, or the other knee ligaments (MCL).
- ACL reconstruction: An arthroscopic surgical procedure performed to restore the normal function of the ACL using a tissue graft. The surgeon will remove the original ACL tissue, drill new tunnels into the femur and tibia, and use a tissue graft to reconstruct the ACL. Surgeon preferences on graft type and surgical technique vary.
Post-op rehabilitation is important in protecting the repair, restoring normal range of motion (ROM), reducing post-op swelling, and recovering normal muscle function. As rehabilitation progresses, your therapist will begin to include additional exercises to maximize strength, endurance, power, and coordination to prepare for a return to normal activities.
Typically, rehabilitation following an ACL reconstruction can take up to and beyond 4-6 months, depending on associated injuries and goals following surgery. Your surgeon and therapist will work together to determine your readiness to return to sport.
Posterior Cruciate Ligament (PCL): Less commonly injured than the ACL, the PCL also serves to provide stability to the knee. The PCL checks excessive motion of the tibia posterior on the femur as well as rotatory torque in the knee. Isolated PCL injuries aren’t common but do occur, often due to a direct blow to the tibia while the knee is bent (such as during a car accident, or when landing on the knee). More commonly, the PCL is injured in combination with other ligaments and structures in the knee due to a high velocity, high torque injury. Suspected PCL injuries should also include evaluation of neurovascular structures.
- PCL Reconstruction: Similar to an ACL reconstruction, the PCL is also repaired using a tissue graft to restore normal position and function. Repair is complicated due to the anatomy of the knee and vessels and nerves in close proximity to the PCL. Post-operative rehabilitation is similar to post-op ACL reconstruction with some differences. Most importantly, protecting the repair while restoring ROM, increasing strength, and reducing swelling are the primary goals of your therapist. As rehabilitation progresses, your therapist will work with you on restoring function and preparing you for a full return to activity. Good therapist/surgeon communication and teamwork is critical.
Medial Collateral Ligament (MCL): Another commonly injured ligament, complete tears of the MCL are uncommon. Typically graded in degrees, a MCL sprain can be extremely painful (more so than ACL/PCL injuries). Often the MCL is injured because of a direct blow to the outside of the knee, causing excessive medial gapping. It can also be injured due to high velocity, high torque activities such as pivoting or twisting.
- MCL Reconstruction: Surgical reconstruction of the MCL is uncommon. Depending on other injured structures in the knee, an MCL sprain/tear will usually be treated conservatively with physical therapy. Because of the anatomy of the MCL and its proximity to the knee joint capsule, treatment is geared towards scarring down and allowing it to heal gradually. Your physical therapy will be focused on reducing pain, gradual restoration of ROM, strengthening, and progressing to return to activity/sports.
Lateral Collateral Ligament (LCL): The LCL is also not commonly injured. Its primary function is to prevent “gapping” of the lateral (outside) of the knee joint. Typically, the LCL is injured in combination with other knee structures (PCL, ACL, posterior joint capsule) to due high velocity, high torque injuries resulting in dislocation of the tibia on the femur.
- LCL Reconstruction: Surgical repair involves using graft tissue to reconstruct the LCL. Other structures damaged will also be repaired depending on the injury and surgeon preference. Rehabilitation will focus on protecting the repair, restoration of ROM/Strength and gradual return to normal activities. Physical therapy is typically complicated by other concomitant injuries to adjacent structures. Physical therapist/surgeon communication is important.
Meniscal Tears: The medial and lateral meniscus are circular, cartilaginous, wedged-shaped structures that sit on the tibia and serve to 1) provide shock absorption and 2) deepen the socket for the femoral condyles. The medial meniscus is more commonly torn than the lateral meniscus due to its relative immobility. Tears in the meniscus can occur in multiple areas (or zones) and can be of various shapes and sizes (radial, bucket-handle, etc).
- Menisectomy: An arthroscopic surgical procedure where the damaged area of the meniscus is trimmed and removed. Advances in arthroscopic technology have made this procedure relatively simple as compared to the past. Physical therapy following a menisectomy is focused on restoring ROM, strength, balance, and returning to normal activities. Typically, therapy can start immediately following surgery and full recovery can be attained within 6-8 weeks, depending on the scope of the procedure.
- Meniscus Repair: An arthroscopic surgical procedure in which the torn meniscus is repaired. Multiple factors determine whether or not the meniscus will be repaired, including age, type of tear, location of tear, and size of tear. The surgeon will use suture to repair the torn meniscus, being careful to retain its original structure/shape. Physical therapy following a meniscal repair is more complicated than following a menisectomy because of the healing time required for the repair. In rehab, your therapist will follow guidelines for ROM and activity and work with your physician to make sure that the repair isn’t stressed. The meniscus will take up to 6-8 weeks to heal at which point rehab can progress more quickly.
- Meniscus Replacement: The least common procedure for meniscal injuries, a replacement is usually reserved for young, active patients with severe meniscal injury. A meniscal graft will be surgically introduced into the joint and sutured into place. Post-operative rehabilitation will be slower and will follow specific pathways to allow for healing. Good surgeon/physical therapist communication and teamwork is critical.
Patellofemoral Pain/Dysfunction: The patella (knee cap) is a sesamoid bone that articulates with the distal femur and serves to increase the leverage of the quadriceps during knee extension. It also serves to provide some protection to the anterior knee joint. Because of the dynamic nature of the patellofemoral joint, there are many causes of dysfunction resulting in anterior knee pain. While some causes are related to anatomical variances, many causes of patellofemoral pain are dynamic in nature and can be addressed through a comprehensive, individual physical therapy treatment plan. Your physical therapist should assess the entire kinetic chain (from foot to hip/core) when evaluating you, and they should be considering a multitude of factors including walking/running biomechanics, standing posture, muscle length and strength throughout the lower extremity, and hip/core strength. Typically patellofemoral pain/dysfunction is treated non-operatively. However, in certain instances, surgery may occur. Procedures may include:
- Arthroscopic Debridement – debridement of the underside of the patella
- MPFL Reconstruction – reconstruction of the medial patellofemoral ligament (MPFL)
- Lateral Release – surgical release of the lateral retinaculum
- Fulkerson Procedure – surgical shift of the tibial tubercle
- HTO (High Tibial Osteotomy) – surgical realignment of the lower extremity
Patellar Tendonosis vs Patellar Tendonitis: Tendons connect muscle to bone, therefore tendons serve to transfer energy from a contracting muscle to move the bone and body part. The quadriceps (thigh) muscle is a large, powerful muscle on the front of the leg. When it contracts, energy is transferred through the quadriceps tendon, patella, and patellar tendon to extend the knee. If there is excessive force, overuse, and/or muscle imbalance, micro-trauma in the tendon can occur. Tendonitis refers to active inflammation in the tendon tissue. Tendonosis refers to degenerative changes in the tendon. Both conditions are related, although tendonosis is more common due to ongoing micro-trauma, with or without inflammation. Over time, this condition results in pain and loss of function.
Physical therapy treatment will focus on unloading the affected tendon through activity modification, exercises focused on strengthening the entire kinetic chain, and improving technique and biomechanics during activity. Additionally, instrument-assisted soft tissue mobilization can be used to kick-start the healing process in the degenerative tissue. This technique can assist in tissue remodeling in combination with ongoing activity prescribed by your therapist.
Cartilage Defects: At its articulation with the tibia, the distal end of the femur is covered by protective hyaline cartilage. Injuries and lesions to the hyaline cartilage are common in traumatic knee injuries. An osteochondral defect (OCD) can occur, leaving a “hole” or “crater” in the hyaline cartilage which may or may not leave that section of bone exposed. There are several categorizations and grades of cartilage lesions within the knee, so prognosis is dependent upon multiple medical factors. Surgical treatment is usually the only option, although physical therapy can be used to assist with activity modification, patient education, and strengthening.
- Surgical Intervention: From arthroscopic fixation (“nailing”) of the lesion to more advanced techniques such as OATS, ACI, Carticel, or an osteochondral bone graft, there are multiple medical options to discuss with your surgeon. Physical therapy following any of these procedures is complicated by the need to protect the repair and the time associated with healing. Many patients will be restricted in weight-bearing and ROM for some period of time. Your therapist should be working with your surgeon to develop the best pathway for your recovery.
Osteoarthritis: Chronic trauma and breakdown of the hyaline cartilage in the knee is also referred to as Osteoarthritis (OA) or “wear and tear” arthritis. Osteoarthritis occurs when the cushioning and protective hyaline cartilage breaks down, resulting in decreased joint space and degenerative changes in the cartilage. This can become quite painful, especially during weight-bearing activities.
Conservative treatment for OA includes physical therapy. Your therapist will educate you on weight-management and activity modification, as well as prescribing exercises to strengthen and stretch the muscles surrounding the affected joint. Remaining active is an important part of the treatment of OA and your physical therapist can help you find activities that reduce the load on your joints
- Total Joint Replacement: Usually a last resort option for patients with severe OA and pain resulting in loss of function, a total knee arthroplasty (TKA) is a major surgical procedure that generally results in a brief hospital stay. The surgeon will use cutting blocks and a saw to remove the ends of the femur and tibia, replacing them with artificial prostheses that will serve as your new knee joint. Physical therapy following TKA is geared towards promoting safe mobility initially. As you gain in confidence and the ability to bear weight, your physical therapist will work on regaining ROM, strength and, most importantly, function.
The foot and ankle complex is a dynamic structure that allows humans to walk and run while upright. At the bottom of the lower extremity kinetic chain, the foot and ankle allow for accommodation through shock absorption at heel strike and gait propulsion as the foot becomes a rigid lever at toe-off. Biomechanically fascinating, the foot and ankle complex is a complicated matrix of bones and joints held together by ligaments and connective tissue. It consists of 3 sections – rearfoot, midfoot and forefoot. Chronic or acute injuries in the foot and ankle complex can cause loss of the ability to walk, run, hike, or do many of the things we do to stay active.
The traditional ankle joint is comprised of 3 bones – the tibia (shin bone), the fibula and the talus. The tibia and fibula come together distally to form a mortise in which the talus fits. This structure allows for the up and down motion of our foot (dorsiflexion and plantarflexion). This joint is supported by multiple ligaments as well as tendons of muscles that originate on the lower leg. There are large powerful muscles on the back of the lower leg – gastrocnemius and soleus – that come together to form the Achilles tendon. The anterior tibialis and posterior tibialis also originate on the tibia and turn into tendons that cross the ankle joint to provide support and motion.
The subtalar joint refers to the articulation of the talus and the calcaneus (heel bone). The subtalar joint allows for side to side motion of the rearfoot. These motions are called inversion and eversion and they are especially important during walking and running, especially on uneven surfaces.
The midfoot is comprised of tarsal bones that fit together, articulating proximately with the talus and calcaneus and articulating distally with the metatarsals (forefoot). The tarsal bones, along with supporting ligaments, form the arch of the foot, making the foot biomechanically advantageous.
The forefoot refers to the metatarsals and phalanges that end as toes 1-5. Many of the tendons that cause your toes to extend or curl insert distally on the phalanges.
With all of the moving parts and the ground-reaction forces that the foot and ankle absorb every time the foot hits the ground, it’s remarkably efficient and stable. However, there are injuries that can occur and physical therapists play a big role in recovery from these injuries.
Common Foot and Ankle Injuries
Ankle Sprain: An ankle sprain is one of the most common orthopedic injuries – occurring 25,000 times per day. It occurs when the ankle moves beyond its normal range of motion, stretching or tearing the ligaments that are in place to prevent excessive motion. When those ligaments are stretched beyond normal limits, the result is acute pain and swelling. Ankle sprains are classified by grade (I-III) and grades are related to the amount of ligament damage. A grade III sprain refers to a complete tear of the ligament. Acute management of an ankle sprain is fairly straightforward. R.I.C.E is an acronym that stands for Rest, Ice, Compression, and Elevation. With low grade sprains, physical therapy treatment will focus initially on reducing swelling and pain. You may wear an air cast or other brace to help with stabilization while the ligament heals. As symptoms resolve, your therapist will work on range of motion and strengthening exercises as well as balance (proprioception) activities that will advance you towards a return to activity. Chronic ankle sprains can become problematic and are often seen in patients with significant ligament laxity due to repeated microtrauma or an untreated grade 2 or 3 sprain. These patients will participate in aggressive strengthening and balance activities in therapy, along with sport-specific or functional activities.
- Ligament reconstruction: There are instances when the damage to the ligament is too severe and it is unable to support the ankle and prevent excessive movement despite conservative care such as physical therapy. In these cases, a surgeon will reconstruct the affected ligament using a tissue graft and anchors.
Following a reconstruction and a period of immobilization (surgeon dependent), physical therapists will work to protect the repair while regaining motion/strength through controlled ROM and strengthening exercises. Since soft tissues like ligaments need time to heal, more aggressive therapy will begin approximately 6-8 weeks following surgery. This will include balance activities, strengthening, and a progression to sports specific/functional activities.
High Ankle Sprain: The term “high ankle sprain” has become more commonplace recently. A high ankle sprain refers to injury to the syndesmotic tissue between the tibia and fibula above the ankle joint. Located in the lower leg, these ligaments serve to hold the tibia and fibula together creating a mortise in which the talus articulates. High ankle sprains are rotational in nature and occur when the lower leg and foot are forcefully rotated externally.
High ankle sprains do not heal as easily as a traditional ankle sprain and often need further evaluation by a physician. For a less severe high ankle sprain, treatment will usually include a 6-week period of immobilization to allow the ligament time to heal, followed by a period of physical therapy. For severe high ankle sprains with significant damage to the syndesmosis, surgery is often needed. The surgeon will stabilize the tibia and fibula using screws, allowing the ligament time to heal.
Physical therapy following a high ankle sprain will focus primarily on symptom management, protection, range of motion, strengthening, and balance (proprioceptive) activities. Functional transition to sport-specific or activity specific exercises take some time and are dependent on how well the injury is healing.
Plantar Fasciitis: This is one of the most common causes of heel pain. It involves inflammation of the plantar fascia, a tough band of connective tissue that runs along the bottom of the foot and that helps to support the normal arch of the foot. Typically, patients complain of severe, stabbing pain on the bottom of their foot, usually worse in the morning upon waking from bed. Patients may also complain of increased symptoms with prolonged standing or with activity, such as walking or running.
The plantar fascia acts as a bowstring that assists in supporting the normal arch of the foot. There are many potential biomechanical breakdowns that can occur, increasing the risk of repeated micro-trauma in the plantar fascia. Often, there is localized micro-trauma and subsequent inflammation where the plantar fascia attaches to the calcaneus (heel bone). Most patients can point to this spot as a localized pain source.
Conservative treatment including physical therapy is most common. Many times patients will attempt to self-treat using over the counter NSAIDs (such as Ibuprofen), arch supports, and night splints. Physical therapy treatment should include an evaluation of the entire patient and lower extremity kinetic chain along with symptom management. Treatment may include instrument-assisted soft tissue mobilization, arch taping, ice, stretching and strengthening of lower extremity muscles, gait analysis to identify biomechanical breakdown, footwear recommendations, and patient education in activity modification. Treatment and recommendations may also include a discussion on shoe inserts or more permanent orthotic recommendations/fabrication.
Tendonitis: Tendonitis, simply put, is inflammation of a tendon. Tendons connect muscle to bone. In the foot and ankle, there are several lower extremity muscles that serve to support and move the foot in different directions. These muscles become tendons that attach on certain bones in the foot. For a variety of reasons, these tendons can become acutely inflamed and painful. Long term, chronic inflammation can lead to microscopic breakdown and degradation of the tendon tissue, a term referred to as tendinosis.
Below are descriptions of the 3 most common sites for tendonitis in the foot and ankle.
- Achilles Tendonitis: The Achilles tendon is the largest tendon in the body. It is formed by the distal ends of the calf muscles (gastrocnemius and soleus) coming together and inserting on the heel (calcaneus). When the calf muscle contracts, it causes ankle plantarflexion (foot pointing down, up onto toes). This muscle is important for walking, running, and jumping.Achilles Tendonitis typically develops over time due to overuse and repetitive stress. This can be caused by a sudden increase in activity, tight calf muscles, or a bone spur at the heel that irritates the insertion of the Achilles on the calcaneus.
Patients can suffer from “non-insertional tendonitis”, meaning that the inflammation is localized in the mid-substance of the tendon, or “insertional tendonitis”, meaning that the inflammation is occurring at the point of insertion on the heel bone. Both conditions are characterized by pain, point tenderness, swelling, pain with activity, and reduced ability to perform functional activities or sports.
Conservative care is the most common intervention. Depending on the length of time the symptoms have been occurring, recovery time can vary. With chronic, long-standing symptoms, recovery can take longer. Physical therapy can be highly effective in reducing symptoms and preventing recurrence.
Treatments will include: ice massage, instrument-assisted soft tissue mobilization, stretching, eccentric strengthening program, and evaluation of lower extremity biomechanics including gait analysis, footwear evaluation recommendations and orthotic consideration. Focus will also be placed on activity modification and rest as needed to resolve symptoms.
- Posterior Tibialis Tendonitis: The posterior tibialis muscle originates on the mid-lower tibia in the posterior compartment. Its tendon runs medially behind the medial malleolus (inside ankle bone) and under the foot, inserting on the navicular and cuneiform (midfoot tarsals), as well as the metatarsals and calcaneus. It plays a key role in passive stabilization of the arch. Contraction of the posterior tibialis results in ankle plantarflexion (toes pointing down) and ankle inversion (foot turning inward).
Posterior Tibialis Tendonitis indicates acute inflammation of the posterior tibialis tendon. This can occur as a result of a sudden increase in activity level and will typically resolve with rest, anti-inflammatory medication, or modalities. It’s important to address contributing factors in order to avoid Posterior Tibialis Dysfunction.
Posterior Tibialis Dysfunction (Tendonosis) is a term that refers to a very common condition in the foot and ankle. It occurs due to long term inflammation, microtrauma, tears, and subsequent degradation of the posterior tibialis tendon resulting in the tendon’s inability to provide support for the arch. Over time, chronic posterior tibialis dysfunction will result in excessive pronation (flat foot). This condition is painful, and typically the pain worsens with activity such as standing and walking.
Depending on the history of the condition, treatment will vary – although conservative care is most common in addressing posterior tibialis dysfunction. Physical therapy plays a big role in the management of symptoms and the prevention of further injury. Immediate treatment includes activity modification and symptom reduction. This may include modalities or instrument-assisted soft tissue mobilization. Additionally, your therapist will work on strengthening the posterior tibialis as well as other lower extremity, hip, and core muscles. It’s important to identify through gait analysis where the breakdown is occurring and to address the breakdowns with a comprehensive exercise program, including the entire kinetic chain. Footwear changes and over the counter or custom arch supports (orthotics) can also reduce the chances of recurrence.
- Peroneal Tendonitis: The peroneal tendons run along the outside of the foot and ankle. They pass behind the lateral malleolus (distal fibula) and insert on the foot. The peroneus brevis tendon inserts on the 5th metatarsal. The peroneus longus tendon passes under the arch of the foot and inserts on the 1st metatarsal. Both muscles contract to cause ankle eversion (turning the foot outward).
Peroneal tendonitis would indicate acute inflammation of the peroneal tendons. This condition is typically caused by a sudden increase in activity and would be associated with pain, tenderness and swelling behind the outside ankle bone (distal fibula). There may also be pain with resisted eversion of the ankle (turning the foot outward) or ankle inversion (turning the foot inward).
Peroneal tendonosis is the result of chronic inflammation and is classified as an overuse injury. Tendonosis refers to the breakdown and degradation of the tendons, leading to thickening of the tendon. Typically, inflammation is no longer present. This condition is the result of increases in training, poor footwear or structural variances in anatomy (varus hindfoot) that affect the biomechanics of the foot when it strikes the ground.
Conservative care is most common in treating peroneal tendonitis. This may include a period of immobilization in a boot. Additionally, physical therapy is often needed and the go-to treatment for this condition. Activity modification, footwear recommendations, and patient education on return to activity will occur throughout your treatment. Additionally, instrument-assisted soft tissue mobilization as well as exercises specific in addressing lower extremity kinetic chain mechanics will be prescribed. Gait and running analysis will assist in identifying areas of breakdown that are occurring and will help in developing a treatment plan.
Tendon Rupture: All of the tendons listed above (Achilles, Posterior Tibialis, Peroneal) are subject to an acute rupture or a partial or complete tear due to chronic overuse. A tendon rupture may occur acutely due to a sudden contraction, like jumping, or a sudden overstretching of the tissue that causes it to fail. An Achilles tendon rupture occurring acutely is most common. This is seen in sports such as football, basketball, baseball, or soccer, often early in the season or after a period of deconditioning.
A complete tendon rupture requires surgical repair. Depending on the injury, the damaged tissue, and the surgeon, techniques for repair may vary. Following surgery, protecting the repair is most important. This will require immobilization of the foot and ankle and weight-bearing restrictions to allow the damaged/repaired tissue to heal for approximately 6-8 weeks.
Physical therapy will begin at varying times in the recovery (surgeon dependent). Depending on timing post-surgery, physical therapy interventions will vary depending on the rate of tissue healing. Early in recovery, protecting the repair while gradually restoring ROM is the main goal. As time progresses, ROM, strength, scar mobility, and a gradual return to function will become the most important objectives. Later in the recovery period, physical therapy will focus on proprioception (balance), more aggressive strengthening throughout the entire kinetic chain, and functional activities such as running, jumping, and cutting. As with any post-operative status, communication between the physical therapist and physician is important to align goals and manage patient expectations.
Calf Strain: The calf muscle on the back of the lower leg is actually comprised of 9 different muscles. The gastrocnemius, the soleus muscle, and plantaris insert distally on the calcaneus (heel bone) and work together to plantarflex the ankle (point the foot downward). The other 6 muscles that comprise the calf are the popliteus, flexor digitorum longus, flexor hallucis longus, tibialis posterior, and the peroneus longus and brevis. Some of these have been discussed in other sections as common sources of lower extremity injury and dysfunction.
A calf strain is caused by overstretching or tearing any of the 9 muscles of the calf, most commonly the gastrocnemius/soleus complex. Calf strains can occur suddenly or slowly over time, and activities, such as walking, climbing stairs, or running can be painful, difficult, or impossible.
A muscle strain is graded according to the amount of muscle damage that has occurred:
- Grade 1. A mild partial stretch or tearing of a few muscle fibers. The muscle is tender and painful, but maintains its normal strength. Use of the leg is not impaired, and walking is normal. These strains can sometimes appear as a minor “pull” that is felt during activity.
- Grade 2. A moderate stretch or tearing of a greater percentage of the muscle fibers. A snapping or pulling sensation may occur at the time of the injury and after the injury. There is more tenderness and pain, noticeable loss of strength, and sometimes bruising. Use of the leg is visibly impaired, and limping when walking is common. This commonly occurs in the mid-calf area where the muscle (gastrocnemius) becomes more tendinous.
- Grade 3. A severe tear of the muscle fibers, sometimes a complete muscle tear. A “popping” sound may be heard or felt when the injury occurs. Bruising is apparent, and sometimes a “dent” in the muscle where it is torn is visible beneath the skin. Use of the leg is extremely difficult, and putting weight on the leg is very painful.
When muscles are strained or torn, muscle fibers and other cells are disrupted and bleeding occurs, which causes bruising. Within a few hours of the injury, swelling can occur, causing the injured area to expand and feel tight and stiff.
Physical therapy initially will focus on symptom management, including rest and/or bracing/crutches, ice, compression and heel lifts in each shoe to reduce strain on the damaged tissue. Additionally, depending on the severity of the injury, your physical therapist may consult with other medical providers such as orthopedic surgeons or sports medicine specialists if needed.
As the injury heals, physical therapists will continue to focus on reducing symptoms by applying modalities (ice, heat, etc.), performing instrument-assisted soft tissue mobilization, and using heel lifts, bracing, or kinesiotape to support the area. Additionally, therapy will begin to focus on motion-incorporating stretching and flexibility exercises. As recovery progresses, calf and lower extremity strengthening exercises will begin, as will gradual return to sport-specific or functional activities. Lastly, patient education and analysis of contributing factors to the injury will be addressed throughout treatment.
Much of the recovery is based on the severity of the injury and response to treatment and can take anywhere from several days to several months.
Fractures: There are many possible mechanisms of injury and many possible bones in the foot and ankle that can be fractured.
- An ankle fracture refers to a break in one or more of the bones that make up the ankle joint – tibia, fibula or talus. Depending on the number of fractures and the structures involved, treatment will range from immobilization in a cast or boot to surgical reconstruction using screws and plates.
Physical therapy following an ankle fracture will focus on restoring ROM, restoring strength and proprioception, and returning the patient to functional weight-bearing activities, including walking, stair climbing, and moving from sit to stand. Some patients may require desensitization techniques following surgery on the ankle joint.
- A calcaneus fracture refers to a break of the calcaneal bone and these injuries are often quite severe and debilitating. Usually calcaneus fractures are the result of a high-energy event, such as an automobile accident or a fall from height. Most of the time, surgery is required to restore the normal anatomy of the calcaneus, although sometimes immobilization in a cast is prescribed.Whether your treatment is surgical or nonsurgical, physical therapy will be very similar. The time it takes to return to daily activities will vary depending on the type and severity of the fracture and whether you have other injuries.
Some patients can begin weight-bearing activities a few weeks after injury or surgery, others may need to wait 3 months or longer before putting weight on the heel. Most patients are able to begin partial weight bearing between 6 and 10 weeks after injury or surgery.
Many doctors encourage motion of the foot and ankle early in the recovery period. For example, you may be instructed to begin moving the affected area as soon as your pain allows. If you have had surgery, you may be instructed to begin moving the affected area as soon as the wound heals to your doctor’s satisfaction.
Physical therapy following a calcaneus fracture/repair will include exercises that help improve the range of motion in your foot and ankle and strengthen supporting muscles. Your physical therapy will focus on regaining motion, strength, and proprioception (when appropriate), as well as a gradual return to functional activities as appropriate. Following weight bearing restrictions is paramount for patients following a calcaneus fracture/repair. The body needs time to heal and allow the bone to repair itself. Non-compliance with weight bearing restrictions can cause the metal implants to fail. Aquatic therapy can be a great resource for these patients as the buoyancy provided by the water assists in reducing weight bearing.
- Other foot and ankle fractures to occur and include: Lisfranc fractures, pilon fractures, stress fractures, and toe fractures.
Osteoarthritis: At the lower end of the kinetic chain, the foot and ankle provide support, shock absorption and accommodation to the stresses of walking, running, jumping, and so on. With over 30 joints and 28 bones in the foot, it is remarkably stable and mobile at the same time.
Osteoarthritis (OA), or “wear and tear” arthritis, occurs when the articular cartilage, the slippery substance that covers the ends of most bones, becomes worn and degenerative. This can occur as a function of the normal aging process, because of excess wear and tear on a particular joint, or as a result of an injury (post-traumatic arthritis) that disrupted normal joint kinematics. OA can be painful and results in the inability to perform functional activities. Although arthritis cannot be reversed, progression of the disease and its symptoms can be addressed with proper treatment.
Physical therapy can be helpful in assisting patients with activity modification and patient education on assistive devices, footwear, inserts, and bracing. Additionally, exercises to improve muscular strength and flexibility can assist in improving function and the ability to perform functional activities safely.
- Total Ankle Arthroplasty: Not as common as a total knee, hip or shoulder replacement, a total ankle replacement can assist patients suffering from advanced arthritis, pain and loss of function.
Physical therapy following a total ankle replacement will focus on ROM, strength, and safe return to functional activities.
- Ankle Arthrodesis: An arthrodesis is a fusion of one or more joints in the foot and ankle, thus eliminating motion and pain at that joint.
Balance Disorders: Whether a function of aging or other medical conditions, balance can be affected in patients and can result in increased risk of falls. The foot and ankle complex plays a key role in balance and foot accommodation during functional activities such as walking. For many patients, a loss of balance becomes a significant issue over time, and the inability to react to a change in walking surface or a change in direction can result in a fall that can have disastrous consequences, such as a hip fracture.
Physical therapy can be helpful for patients suffering from reduced functional mobility due to balance concerns. First and foremost, your physical therapist will address your safety and your ability to move safely. Physical therapy will work on functional activities, balance activities, assistive devices to improve safety, and patient/family education.