Brain Vandalism

   

By Nick Hannah, PT

I need to begin this blog by emphasizing a very important fact about your body: YOUR JOINTS ARE INHERENTLY STRONG AND STABLE! In the absence of rare circumstances like severe traumas (i.e. joint dislocations) and certain genetic disorders that can physically make your joints ‘loosey-goosey,’ the joints making up your body simply won’t go out of place from day-to-day activities.

However, there are times you could swear they really WERE out of place. Joints and body parts can feel shifted, “off,” “out-of-sorts,” wonky—sometimes as if they were no longer a part of you. These kinds of perceptions are NORMAL and many feel this way. Weird right? So how can it be that your joints FEEL out of place when in reality they’re rock solid? Let’s find out. 

Within your brain different cell groups build a DETAILED map of your body—a helpful analogy is to think of this body map in the brain like a detailed painting (every nook, cranny and unique aspect of your body is represented and accounted for). This means that certain brain areas control the movements and feelings of certain body parts. It’s more complicated than this but that’s the gist of it.

When we have pain in a certain body area (i.e. a hip), our body painting changes—that once crisp, clear image of the hip in the brain gets smudged. The actual brain tissue changes: we call this neuroplasticity. If the pain persists long enough, the brain’s representation of the hip gets even more distorted—the smudging grows and spreads to surrounding body parts of your painting (your once beautiful work of art is under ruin).

With time, this brain ‘vandalism’ alters how you perceive and control movement of the hip & surrounding body parts. THIS is why you feel weird, out of place, and ‘off.’ It also accounts for why pain spreads, and it can happen to any body part.

Side note: these changes aren’t unique to pain. Ask any seasonal golfer what their VERY first swing feels like after many ‘golf-less’ months in the winter—it feels weird! More smudging at work here.

So how do you improve your ‘brain vandalism’?

• First, find yourself a good physiotherapist (or another health professional—I’m biased of course). Education is paramount here: you must understand that the strategies adopted early on and meant to protect you—like fear avoidance, limiting painful movement, rest etc.—are now creating maladaptive changes in the brain and actually making things worse.
• Second, slowly but surely re-expose the painful body part to the normal movements and activities it once performed. This is called graded exposure—and the starting point for everyone will be different. In this way you start to re-trace what was smudged, and begin the process of re-painting the body part as represented in the brain.

Stop thinking you’re out of place. You might FEEL like it, but now you know why.

As always. Don’t sit still. Make moves.

Blog post written by Nick Hannah, PT.  Nick is the winner of the Blog Post Competition I challenged my Instagram followers with this July.  You can find Nick on Instagram @hannahmoves.

What is Kinesiophobia?

 

   

By Ashley Pena, DPT Student

Patients with re-occurring injuries that become chronic conditions such as chronic low back pain or chronic ankle sprains can be a challenge for medical professionals for many reasons. Risk factors for the array of chronic conditions have been studied and identified. However, one problem in this population that is less frequently discussed is that of Kinesiophobia. Kinesiophobia (KPB), or Fear Avoidance Beliefs, are defined as “excessive, irrational, and debilitating fear of physical movement and activity resulting from a feeling of vulnerability to painful injury or re-injury.”8 While this may sound like an extraordinary occurrence, these beliefs to some degree are often a factor in chronic conditions.

To summarize, KPB can be broken down into “Harmful factors” (HF) which reflect the patient’s belief that something is seriously wrong with the body; and “Activity avoidance factors” (AAF) which represent the belief that avoiding exercise/activity will prevent an increase in pain. These beliefs generally lead to a vicious cycle involving an avoidance of movement or any activities that might cause pain or reinjury (see Figure above). Over time, the inactivity that stems from this fear leads to physical consequences such as muscle atrophy, loss of spinal range of motion, and psychological consequences. Psychological consequences include reduced calibration to painful stimuli and behavioral changes. This in turn can affect patient prognosis and healing times.10

Figure 2

The physiological and psychological changes that occur in chronic pain conditions are well- studied and is described in David Butler’s “Explain Pain.”1 Essentially, your body adapts to what is being sent it’s way, so if pain or “danger” messages keep being sent to the brain, the sensory neurons become more sensitive to incoming excitatory chemicals, the sensors stay open longer, eventually more sensors are produced and neuronal sprouting can occur. Another change which occurs in the brain is homunculus “smudging”. With this occurrence, the area of the cerebral cortex which is devoted to sensation and representation of the involved body part becomes larger, with less distinct outlines and overlaps with surrounding areas of the cortex. All of these things can contribute to perpetuating pain.

Figure 3

The good news: many of these changes are reversible. As depicted below, after injury the body has a new tissue tolerance level (Figure 2). The key to combating this over-sensitivity is pacing and graded exposure (Figure 3). Finding a Baseline tolerance to a task which you can perform without a flare up is essential, since your body will alert you of the need to stop at the “New Protect By Pain” line (Figure 2). By exercising just below the “Flare Up” line one can begin to slowly make changes in their tolerance and eventually resume to their original Tissue Tolerance.1

Blog Post written by Ashley Pena, DPT Student from Cal State Northridge. Ashley is currently in her final clinical rotation with me at Catz PTI.

References:

1. Butler DS, Moseley GL. Explain pain. Adelaide: Noigroup Publications; 2015
2. Crombez G, Vlaeyen JWS, Goubert L. Muscle Pain, Fear-Avoidance Model. Encyclopedia of Pain 2013:1963–1966. doi:10.1007/978-3-642-28753-4_2531.
3. Crombez G, Vlaeyen JW, Heuts PH, Lysens R. Pain-related fear is more disabling than pain itself: evidence on the role of pain-related fear in chronic back pain disability. Pain 1999;80(1):329–339. doi:10.1016/s0304-3959(98)00229-2.
4. Feitosa AS, Lopes JB, Bonfa E, Halpern AS. A prospective study predicting the outcome of chronic low back pain and physical therapy: the role of fear-avoidance beliefs and extraspinal pain. Revista Brasileira de Reumatologia (English Edition) 2016. doi:10.1016/j.rbre.2016.03.002.
5. Guclu DG, Guclu O, Ozaner A, Senormanci O, Konkan R. The relationship between disability, quality of life and fear- avoidance beliefs in patients with chronic low back pain. Turkish Neurosurgery . 2012. doi:10.5137/1019-5149.jtn.6156-12.1.
6. Heymans MW, Ford JJ, McMeeken JM, Chan A, de Vet HC, van Mechelen W. Exploring the contribution of patient-reported and clinician based variables for the prediction of low back work status. Journal of Occupational Rehabilitation 2007; 17(): 383-397. doi:10.1007/s10926-007-9084-1.
7. Lethem J, Slade P, Troup J, Bentley G. Outline of a fear-avoidance model of exaggerated pain perception—I. Behaviour Research and Therapy 1983;21(4):401–408. doi:10.1016/0005-7967(83)90009-8.
8. Neblett R, Hartzell M, Mayer T, Bradford E, Gatchel R. Establishing clinically meaningful severity levels for the Tampa Scale for Kinesiophobia (TSK-13). Eur J Pain European Journal of Pain 2015;20(5):1–10. doi:10.1002/ejp.795.
9. Peña A, Plotkin L, Eagle M, Riehl J, Mathiyakom W. American Physical Therapy Association: Combined Sections Meeting. In: San Antonio; 2017.
10. Vlaeyen JW, Kole-Snijders AM, Boeren RG, Eek HV. Fear of movement/(re)injury in chronic low back pain and its relation to behavioral performance. Pain 1995;62(3):363–372.

BFR & Post-op ACL

   

One of the biggest challenges in ACL rehab is regaining adequate strength in the surgical leg. Even at 1 year post-op, many patients still demonstrate significant strength deficits compared to the non-surgical leg. Traditional early post-op ACL rehab consists of ROM, swelling control, gait training, muscle activation and proprioceptive exercises. Unfortunately the leg continues to atrophy and remain in a state of anabolic resistance caused by the trauma of the surgery and subsequent relative or literal immobilization. Early post-op treatments and exercises, while necessary, do very little to help the muscles hypertrophy. The ACSM recommends that in order for hypertrophy to occur, resistance training needs to be loaded at 70% of 1RM. While in the early stages of rehab, loads in that range are unrealistic and potentially dangerous.

Blood Flow Restriction Therapy can be introduced as early as a few days post-op and can also help stop anabolic resistance by initiating protein synthesis, which leads to muscle hypertrophy even at loads of 30% of 1RM and lower. This is possible because the tourniquet creates a hypoxic environment which forces the recruitment of type 2 muscle fibers, even though the load is more appropriate for type 1. Type 1 muscle fibers require oxygen and are important for endurance and low load exercises. While exercising under BFR the stored oxygen becomes depleted and the remaining reps are carried out by type 2 muscle fibers. Type 2 muscle fibers are responsible for speed and power and their byproduct is lactate. The cuff not only restricts the venous return flow, it also holds the lactate in the limb which initiates a systemic response that causes the pituitary gland to release Growth Hormone.  Growth hormone is responsible for collagen synthesis which is how muscle, tendon, ligament, cartilage and bone heal.

Equipment

Tourniquets are considered medical devices and their use needs to be monitored, there are inherent dangers to improper use of tourniquets. Currently a few types of BFR tourniquet systems and wraps are available and present on social media, but only one is FDA approved as a medical device. The Delfi Personal Tourniquet System contains a Doppler that can accurately measure the amount of blood flow restriction and can adjust for pressure changes during exercise. The Delfi System comes with 3 cuff sizes, each one is wide and tapered for comfort and safety. When deciding to incorporate BFR into your rehab, look for a certified provider on the Owens Recovery Science website.

Treatment Session

A typical treatment session will usually consist of 3-5 different exercises.  Each exercise will be performed for 75 reps broken down into 4 sets.  1 set of 30 reps and 3 sets of 15 reps.  There is a 30 second rest period between sets with the cuff inflated.  The cuff will be deflated for at least 1 minute between exercises.  You can expect to see swelling, color change and muscle fatigue after each treatment.  Because loads are very low there is no muscle breakdown and little to no subsequent DOMS.

For more information visit  OwensRecoveryScience.com

Forward Head Posture

   

By Ashley Pena, DPT Student

Although “forward head posture” (FHP) has long been regarded as a problem leading to pain and disability, with increased time spent on smartphones in recent years, it is becoming a very common source of pain. In a study performed by Kim et. al. which studied the effect of duration of smartphone use on muscle fatigue and pain caused by forward head posture in adults using EMG analysis, it was found that prolonged smartphone use resulted in increased upper trapezius and cervical erector spinae fatigue.

As a result of FHP, compensatory motions occur such as severe extension of the upper cervical spine. Often seen in conjunction with FHP, rounded shoulder posture (RSP) occurs when the acromion protrudes anterior to the shoulder joint. Scapular elevation, protraction, and downward rotation are also seen. Several studies have found that this combination of FHP and RSP promote an imbalance in muscle strength and length leading to Janda’s Upper Crossed Syndrome:

• Weakness of the deep neck flexors, middle and lower trapezius, and serratus anterior
• Stiffness of the pecs, upper trapezius, levator scapulae, SCM and suboccipitals.

Together, these impairments can lead to dysfunctions at the OA joint, C4/C5 segment,  CT junction, or GH joint resulting in neck and/or shoulder pain and increased disability.

Below is a 3 part video series to help you gain mobility and build postural strength to combat our love affair with cell phones and laptops.

Blog Post written by Ashley Pena, DPT Student from Cal State Northridge. Ashley is currently in her final clinical rotation with me at Catz PTI.

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❗️4th Student of the year❗️ Welcome Ashley, from my alma mater Cal State Northridge. Continuing with the BFR hazing. Stay tuned for some 💻blog posts from her soon. #CSUN @ashpena3r

A post shared by Chris Butler, MPT, CSCS (@cbutlersportspt) on Jun 13, 2017 at 12:18pm PDT

References:

1. Kim E-K, Kim JS. Correlation between rounded shoulder posture, neck disability indices, and degree of forward head posture. Journal of Physical Therapy Science. 2016;28(10):2929-2932. doi:10.1589/jpts.28.2929.
2. Kim S-Y, Koo S-J. Effect of duration of smartphone use on muscle fatigue and pain caused by forward head posture in adults. Journal of Physical Therapy Science. 2016;28(6):1669-1672. doi:10.1589/jpts.28.1669.
3. Kwon JW, Son SM, Lee NK. Changes in upper-extremity muscle activities due to head position in subjects with a forward head posture and rounded shoulders. Journal of Physical Therapy Science. 2015;27(6):1739-1742. doi:10.1589/jpts.27.1739.
4. Upper Crossed Syndrome. Muscle Imbalance Syndromes RSS. http://www.muscleimbalancesyndromes.com/janda-syndromes/upper-crossed-syndrome/. Accessed June 13, 2017.

Lateral Ankle Sprains

    

By Michael Joseph, DPT Student

Ankle sprains are a common injury; in the United States there is an incidence rate of 2.15 ankle sprains per 1000 people every year. Nearly half of all ankle sprains (49.3%) occurred during athletic activity, with basketball (41.1%), football (9.3%), and soccer (7.9%) being associated with the highest percentage of ankle sprains during athletics.

This article will focus on lateral ankle sprains, which occur as a result of excessive ankle inversion, when the foot rolls inwards under the leg. The three lateral ligaments that may be affected are the anterior talofibular ligament, calcaneofibular ligament, and posterior talofibular ligament. Ankle sprains are divided into three categories: Grade I, where the ligament is stretched and may have slight tears. Grade II where the ligament is partially torn. And Grade III where the ligament is completely torn.

Management:

The PRICE (Protection, Rest, Ice, Compression, Elevation) protocol is an important part of treatment during the acute phase, as it is an effective method for reducing pain and inflammation. However, combining PRICE with exercise may be more beneficial. A randomized controlled trial from Bleakley, et al. evaluated the effectiveness of accelerated rehab after an ankle sprain. One group of subjects followed the PRICE protocol for the first week after injury and then began exercise rehab during the following four weeks. The experimental group began the PRICE protocol and exercise rehab immediately, during the first week post injury, and then followed the same 4 week exercise rehab. The authors stated the early exercises were from a “general protocol” that included ankle range of motion and strengthening exercises. The study found short term outcomes (4 weeks) were significantly better in the group that began exercising immediately, but there was no significant difference in long term outcomes (16 weeks).

 Rehabilitation and Prevention:

There is some evidence to support that taping and/or bracing is effective at reducing the risk of recurrent ankle sprains in sports. However, the decision between tape or bracing depends on the individual and the requirements of the sport. There is no evidence that one is significantly more effective than the other.

Kerkhoffs et al, identified four intrinsic risk factors that predispose individuals to lateral ankle sprains: strength, proprioception, range of motion, and balance. A rehab exercise protocol should address all four of these risk factors in order to prepare the athlete to return to sport and to prevent recurring sprains. Proprioception exercises should be sport specific and should focus on the demands of the sport. For example, a basketball player’s program needs to include takeoff and landing ankle mechanics in an square stance (jump shot) and off of one leg (lay up).

Blog Post written by Michael Joseph, DPT Student at Mount Saint Mary’s University. Michael is currently in his final Clinical Rotation with me at Catz Physical Therapy Institute.

Sources:

1. Bleakley CM, O’connor SR, Tully MA, et al. Effect of accelerated rehabilitation on function after ankle sprain: randomised controlled trial. BMJ. 2010;340:c1964.
2. Kerkhoffs GM, Van den bekerom M, Elders LA, et al. Diagnosis, treatment and prevention of ankle sprains: an evidence-based clinical guideline. Br J Sports Med. 2012;46(12):854-60.
3. Waterman BR, Owens BD, Davey S, Zacchilli MA, Belmont PJ. The epidemiology of ankle sprains in the United States. J Bone Joint Surg Am. 2010;92(13):2279-84.

Speed to Perform

    Chris Butler Sports PT

By Darelle Noel

Most people believe speed is something you’re born with and that you’re genetically inclined to be fast. But it has little to do with that – it’s a science. You can train your body to produce more force and the way you deliver force to the ground. And once that happens, it will completely change your perception of how fast or explosive you ever thought you could be.

Speed is an integral part of every sport and can be expressed as one of or a combination of Power(Elastic Strength) for acceleration, absolute speed and speed endurance. Speed is the quickness of movement of a limb generated by the athletes ability to apply force and generate it with great frequency.

(Force X Frequency=Speed)

Maximizing stride length and stride frequency is mainly influenced by the athletes stability, mobility, strength and technique. Having good hamstring flexibility and hip mobility improves stride frequency (the ability to strike and recover) and stride length is improved by developing muscular strength and explosive power i.e. olympic Lifts and Plyometrics.

Developing speed is a rather complex process that is controlled by the nervous system, learning the movements needed to develop speed and learning how to perform them are equally important. In order to move faster the muscles have to adapt and contract faster, The brain and the nervous system have to learn the motor skills to control these fast movements efficiently. Practicing the basic fundamentals of running will not only improve your running ability but also improve your brains ability to adapt and perform the movements quickly. Complex coordination and timing of the motor units and muscle groups must be performed beginning with slow speeds transitioning to high speeds to improve patterns. Maintaining some form of speed training on a consistent basis will ensure that your movement patterns and nervous system will stay in sync.

General Principles for speed development are:
•Work on your mobility to develop ROM, range of motion in your hips will drastically effect your speed and assist in preventing injuries.
•Improve flexibility to improve your turnover ability.
•Perform explosive and plyometrics movements such as jumping, hopping and bounding to develop explosive power that translate to running.
•Implement skill development for sports specific speed. IT HAS TO TRANSLATE TO THE SPORT!!
•Train Energy System specifically to maintain and maximize endurance and speed over time.

 Blog Post written by Darelle Noel, Athletic Gaines Performance Specialist.  I have had the good fortune to work with him at Catz Physical Therapy/Athletic Gaines Pasadena. You can find him on Instagram @dmn_1of1

Is Your Lack of Ankle Mobility Increasing Your Risk for Knee Injury?

 Follow Chris Butler Sports PT

By Ashley Pena, DPT Student

 According to the NCAA Injury Surveillance system, knee internal derangements accounted for the highest percentage of more severe injuries sustained by college athletes (44.1% in games and 25.5% in practices) and approximately 70% of all game and practice injuries affected the lower extremities. As a result of these studies, much thought has gone into what factors contribute to this in an attempt to prevent, or rehabilitate these injuries while decreasing pain and improving performance. Although there are many factors which have been found to contribute such as muscle weakness, body type, training factors and others, little thought is given to the ankle joint unless it is giving the athlete pain.

When a person lacks dorsiflexion range of motion, often times compensations begin to manifest such as excessive pronation or “fallen arch”,  hip external rotation or “out-toeing” during walking, or lack of knee flexion with landing, all of which can increase the valgus forces on the knee and decrease shock absorption which can place a person more at risk for ACL injury, meniscus injury, or collateral ligament strains. In a systematic literature review done by Mason-McKay et. al, strong evidence was found that a restriction in DF ROM alters landing mechanics with specific studies reporting that altered frontal plane ankle motion (inversion and eversion), reduced sagittal knee excursion, and greater peak knee valgus.

 Blog Post written by Ashley Pena, DPT Student from Cal State Northridge.  Ashley is currently in her final clinical rotation with me at Catz PTI.

View this post on Instagram

❗️4th Student of the year❗️ Welcome Ashley, from my alma mater Cal State Northridge. Continuing with the BFR hazing. Stay tuned for some 💻blog posts from her soon. #CSUN @ashpena3r

A post shared by Chris Butler, MPT, CSCS (@cbutlersportspt) on Jun 13, 2017 at 12:18pm PDT

Sources:

1. Arendt E, Dick R. Knee Injury Patterns Among Men and Women in Collegiate Basketball and Soccer. The American Journal of Sports Medicine. 1995;23(6):694-701.
2. Dick RM, Putukian M. Descriptive Epidemiology of Collegiate Women’s Soccer Injuries: National Collegiate Athletic Association Injury Surveillance System, 1988–1989 Through 2002–2003. Journal of Athletic Training. 2007;42(2):278-285.
3. Kerr ZY, Marshall SW. College Sports–Related Injuries — United States, 2009–10 Through 2013–14 Academic Years. Centers for Disease Control and Prevention. https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6448a2.htm. Published December 11, 2015. Accessed June 5, 2017.
4. Mason-Mackay A, Whatman C, Reid D. The effect of reduced ankle dorsiflexion on lower extremity mechanics during landing: A systematic review. Journal of Science and Medicine in Sport. 2017;20(5):451-458. doi:10.1016/j.jsams.2015.06.006.
5. Taunton JE, Ryan MB, Clement DB, McKenzie DC, Llyod-Smith DF, Zumbo BD.  A retrospective case-control analysis of 2002 running injuries.  Br J Sports Med 2002; 36: 95-101.

What is Turf Toe?

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By Meggie Morley, DPT

During Game 3 of the Clipper’s series against the Utah Jazz, Blake Griffin suffered an injury to his toe that would rule him out for the remainder of the playoffs. He recently underwent surgery to treat his injury, which was reported as an injury to the plantar plate of his big toe. This injury is also known as turf toe, and even though it may seem like a small injury it can greatly affect the ability to participate in sports, recreational activities and even walking.

Toe Anatomy

Turf toe typically refers to an injury to the big toe. The big toe is comprised of two bones, known as the distal and proximal phalange. The proximal phalange attaches to the metatarsal bone in the foot, forming the metatarsal phalangeal joint (MTP). Underneath the MTP is the plantar plate, a small sesamoid bone, and various ligaments and muscle attachments.   

Mechanics of Injury

Turf toe typically occurs when the first toe is hyperextended. In other words, when the toes are planted on the ground and the rest of the foot is lifting off the ground. This position places strain on the bottom of the MTP joint, causing damage to the plantar plate and surrounding structures. This injury occurs commonly on turf due to the harder surface, which can cause the toes to be stuck in place. The symptoms of turf toe include pain, tenderness, bruising, stiffness and swelling at the joint.  Parents should watch for avoidance behaviors and painful gait patterns in their children.

Ligament Sprain Grade

Grade I: The ligament is stretched and there may be small tears

Grade II: Large tear, but the tear doesn’t completely go through the ligament

Grade III: Complete rupture of the ligament

Recovery time depends on the grade of the sprain, and in the case of complete tears surgery may be necessary. For any turf toe injury, rest is required in order to allow for healing.  Bracing, splinting and taping are often used for weight bearing tolerance so it is important to prevent adhesions in the injured structures. Passive ROM can be initiated within a few days of Grade I and II injuries along with non-impact activities. Grade III injuries require immobilization but even if surgery is needed, ROM can be performed at 5-7 days post op.  Make sure to see a PT and find out what you can be doing throughout all phases of recovery.

Blog Post written by Meggie Morley, DPT.  At the time of posting Meggie was in her final clinical rotation with me at Catz Physical Therapy Institute.

References

1. Stanley, Laura. Physical Therapist’s Guide to Turf Toe. Retrieved from http://www.moveforwardpt.com/symptomsconditionsdetail.aspx?cid=6db543a6-7a53-4dcd-8141-3137c4391f07

2. McCormick JJ, Anderson RB. Turf toe: anatomy, diagnosis, and treatment. Sports Health. 2010; 2(6):487–494.

3. Garguilo, C. (2015). Foot and Ankle Orthopedics (Power Point slides). Retrieved from https://courseworks.columbia.edu/access/content/group/PHYTM8610_081_2015_2/Lectures/Ankle/Camtasia%20Foot%20and%20Ankle%20Lectures/Camtasia%20Lecture%20Foot%20Ankle%20Disorders%20Handout%202015%20Section%203.pdf

Bike Fitting Basics: Keep Riding, Reduce Your Injury Risk

 Chris Butler Sports PT is Social

By Michael Joseph, DPT Student

In my three years working as a professional bicycle fitter I have done fits for every level of cyclist, from individuals who were purchasing their first road bike to professional level cyclists and national team members. A properly fit road bike is imperative to ensure the frame and components are the right size for the rider.  The purpose of professional fitting is to reduce pain, increase comfort and maximize speed and efficiency. The following article will cover basics of fit measurements, positioning, and reasons why riders may be experiencing pain or discomfort on the bike. The bulk of this content is based on my professional experience as a bicycle fitter and the training I received from GURU Cycling.

Saddle Height 

Saddle height is measured with the rider seated on the saddle with his or her foot at the 6 o’clock position. The rider’s pelvis should be level on the saddle and there should be 40 degrees of knee flexion (plus/minus 5 degrees). Measure both legs to ensure no there are no imbalances. Common symptoms of a saddle that is too high include IT band syndrome, posterior knee pain, and hip or low back pain. Common symptoms of a saddle that is too low is anterior knee pain from stress on the quadriceps and patellar tendons.

Saddle Setback

Saddle setback refers to the fore and aft position of the saddle. When the foot is in the 3 o’clock position, the front surface of the knee should be directly over the pedal spindle. This can be measured using a plumb bob or laser. The rider should feel like they are pushing the pedal straight down, not in front of them or behind them; the pedal stroke should feel powerful and efficient. If the saddle is set too far back, it can irritate the IT band and hamstrings tendons. If it is too far forward, it may put excessive pressure on the quadriceps and patellar tendons.

Type of saddle  

Saddle selection is highly subjective. Every manufacturer seems to develop their own way of fitting a saddle to a rider. This can include basing it on width of the pelvis, sit bone pressure points, or spinal flexibility. However, the best way to determine the which type of saddle to use is to test ride it. Saddle selection is all about finding the saddle that fits the rider’s body type.

Cleats  

Cleat fitting might warrant an entire article all on its own, but here are some basics.

The fore aft position of the cleat on the shoe should align the ball of the foot with the pedal spindle. The medial/lateral position of the cleat should position the knee directly over the foot. The rotational position of the cleat should position the foot so it is facing directly forward. Knee pain can be caused by improper foot and cleat positioning. If a rider has knee pain and the saddle height and setback are positioned correctly, cleat positioning may be the culprit.

Handlebar Reach

Handlebar reach is defined as the distance from the saddle to the handlebar and is measured from the front tip of the saddle to the center of the tubing of the handlebar. When fitting reach, the rider should place his or her hands on the brake hoods. The reach should be as long as possible, while still feeling comfortable. A longer reach allows for a longer stem, which makes the front of the bike more stable and makes steering more responsive. However, in this position the shoulder should not exceed 90 degrees of flexion. There should also be about 15 degrees of elbow flexion. If the reach is too long, the rider may experience elbow pain, tension in the neck and shoulders, and back pain.

Handlebar Drop

Handlebar drop is defined as the difference in height between the saddle and the handlebar. Increasing the drop makes the rider position more aggressive and aerodynamic. This may be ideal for a rider participating in stage or criterium racing. However, for a leisure rider, a more upright position will likely be more comfortable. If the drop is too low, the rider will experience symptoms in the hands and wrists, such as pain from too much weight on the hands. This can also cause nerve irritation; riders may experience numbness, tingling, and burning sensations in the hands.   

Blog Post written by Michael Joseph, DPT Student at Mount Saint Mary’s University. Michael is currently in his final Clinical Rotation with me at Catz Physical Therapy Institute.

Sources:

1. www.gurucycling.com
2. Asplund, Chad, St. Pierre, Patrick. Knee Pain and Bicycling: Fitting Concepts for Clinicians. The Physician and Sports Medicine. April 2004. 32(3).

What are Shin Splints?

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By Michael Joseph, DPT Student

Definition and Risk Factors:

Medial Tibial Stress Syndrome (MTSS), better known as shin splints, is a common athletic injury caused by repetitive stress to the tibia. MTSS is more prevalent in activities involving a great deal of running and jumping, like distance running, sprinting, basketball, tennis, gymnastics, and dancing; it is also common in military personnel. MTSS can be caused by many factors stressing the tibia, including: periostitis (inflammation of connective tissue surrounding bone), periosteal remodeling, tendinopathy, and dysfunction of muscles surrounding the tibia, like the tibialis posterior, tibialis anterior, flexor digitorum longus, and soleus muscles. Risk factors for MTSS include flat feet and/or over-pronation, repetitive running and jumping, excessive hip range of motion, smaller calf girth, and a body mass index above 20.2.

Symptoms:

Symptoms include pain of the middle and lower thirds of the medial shin. Individuals may experience pain during and/or after physical activity. During the early onset of MTSS, symptoms may be felt at the beginning of exercise, but may subside as activity continues. As MTSS progresses, pain may be felt throughout exercise and may linger afterwards.

Diagnosis:

A thorough physical therapy subjective and objective exam is usually sufficient to diagnose MTSS. However, patients may require further imaging or work up to rule out pathologies like stress fractures, exertional compartment syndrome, or peripheral vascular disease.

Management of Shin Splints:

Acute Phase:

The goal of physical therapy in the acute phase is to reduce pain and inflammation. This can be done through stretching, manual therapy of the injured tissue, taping, icing, and rest. For many athletes prolonged rest from their sport is not ideal. MTSS management may require “relative” rest, meaning their activity level may need to be adjusted but not stopped completely. This depends on the activity and severity of the pathology.

Subacute Phase:

The goal of physical therapy in the subacute phase is to modify training regimens and correct biomechanical abnormalities. According to Galbraith et al, reducing weekly training frequency and intensity by 50% will likely improve symptoms without completely stopping training. However, this depends on each patient’s case and may need to be adjusted. Training can also be augmented with low impact exercises, like swimming or cycling, to help maintain strength and cardiovascular endurance.

Create a Physical Change in Your Body and Movement

Another treatment of MTSS is to strengthen the arch of the foot and hip, and increase core stability; this will help to improve jumping and landing mechanics, as well as single leg stability. Specifically, strengthening the tibialis posterior and intrinsic foot musculature will help increase arch support and prevent excessive pronation. Improving hip extensor and abductor strength can help improve lower extremity mechanics. Stretching and eccentric strengthening of the calf has also been shown to be beneficial by decreasing muscle fatigue with running and jumping.

Changing running biomechanics may also be beneficial. A study from Leiberman et al, found that heel first strike during initial contact, when running, creates an impact transient equal to nearly three times the individual’s body weight. Not only is this incredibly inefficient, but this creates a large force traveling directly up through the tibia with each step. The impact transient with forefoot first strike during initial contact is seven times lower than with a heel strike. This evidence suggests forefoot running is more efficient and less injurious. 

Blog Post written by Michael Joseph, DPT Student at Mount Saint Mary’s University. Michael is currently in his final Clinical Rotation with me at Catz Physical Therapy Institute.

Sources:

1. Budde, Kari Brown. Physical Therapist’s Guide to Shin Splints (Medial Tibial Stress Syndrome). http://www.moveforwardpt.com. Accessed May 11, 2017.
2. Galbraith, R. Michael, Lavelle, Mark E. Medial tibial stress syndrome: conservative treatment options. Curr Rev Musculoskelet Med. 2009 Sep; 2(3):127-133.
3. Lieberman, Daniel E., Venkadesan, Madhusudhan, Werbel, William A., Daoud, Adam I., D’Andrea, Susan, Davis, Irene S., Mang’Eni, Robert Ojiambo, Pitsiladis, Yannis. Foot strike patterns and collision forces in habitually barefoot versus shod runners. Nature. 2010 Jan; 463:531-535.
4. Moen, Maarten Hendrik, Holtslag, Lenoor, Bakker, Eric, Barten, Carl, Weir, Adam, Tol, Johannes L., Backx, Frank. The treatment of medial tibial stress syndrome in athletes; a randomized clinical trial. Sports Med Arthrosc Rehabil Ther Technol. 2012 Mar; 4(12).