The Proactive Patient
7 Tips for Your Physical Therapist Visit
by Eric Cressey
When I moved to Boston in the summer of 2006, one of the first things I did was pull together a network of professionals to whom I could refer clients.
Manual therapists were a piece of cake. Boston has some of the best soft tissue guys in the world. Doctors weren't a problem, either. There are some excellent orthopedic specialists in this neck of the woods.
Physical therapists, on the other hand, made things pretty interesting. I'm located in close proximity to some of the wealthiest towns in Massachusetts, so you see a lot of physical therapists flock to the area. With more disposable income available, PT's don't have to deal with insurance companies as often. Ask any PT what his biggest headache is, and chances are he'll say dealing with insurance companies (well, aside from ultrasounding the thighs of overweight geriatrics).
After two years of searching, I've established a good network. But you as a Testosteronereader don't have that luxury when your shoulder is throbbing. With that in mind, here are seven tips to help you be an advocate for your cause as you visit a physical therapist.
Tip #1: Immobilization Demands Physical and Manual Therapy.
Over the winter, my girlfriend's sister slipped on some ice fracturing both her distal tibia and fibula. She had surgery to insert some pins and screws, and then her lower leg was immobilized for about ten weeks. After that, she wore a softer boot for two or three weeks.
Fast forward to April, she came to visit and found herself doing a lot of walking as we watched a friend run the Boston Marathon. She limped the entire way and described some pain in her forefoot. When I asked what her physical therapist had done, she told me, "My doctor said I didn't need physical therapy."
She learned an important lesson about the medical model: Some doctors are great surgeons who know very little about physical therapy. Just because you can "get by" without physical therapy doesn't mean you should try to.
Later that afternoon, I checked out her ankle and she had no dorsiflexion range of motion. Her ankle was basically locked at 90 degrees. It's no wonder she was having hypermobility-type pain in the forefoot; she needed to get movement somewhere! If it hadn't been the forefoot that hurt, it would've been the knee (to the basketball players in the audience, think about how this applies to high-top sneakers, ankle taping, and the chronic patellofemoral pain you're experiencing).
Our bodies are great at compensating. Take a look at spastic diplegia, the most common kind of cerebral palsy. It causes spasticity to varying degress in the lower extremities. But what's interesting is that those with spastic diplegia typically have normal or near-normal muscle function above the hips. So, these individuals can substitute quadratus lumborum muscle action to hike the pelvis and allow for more lateral deviation during gait to "get by."
I gave her some ankle mobilizations, had her work on her calves, Achilles, and peroneals (tightened up from walking with so much external rotation at her foot) with a baseball, and then gave her the contact info for a good manual therapist in her area.
Some soft tissue work for the peroneals with, in this case, a tennis ball.
If you're immobilized for any reason, you should not only be getting physical therapy to restore neuromuscular function, but also soft tissue work to free things up in the first place.
Tip #2: Your Shoulder Pain isn't Just About the Rotator Cuff.
Hopefully people have come to realize that while the rotator cuff is where it frequently hurts, it's not always the cause of the pain. Case in point, in a 2006 study, Kibler et al. reported that 49% of athletes with arthroscopically diagnosed posterior superior labral tears (SLAP lesions) also have a hip range of motion deficit or abduction weakness.(2) How often do you see therapists do hip mobility drills with shoulder rehab patients?
With that in mind, if your shoulder hurts, ask them how their rehab program addresses each of the following:
1. Scapular stability.
2. Thoracic spine range of motion.
3. Cervical spine function.
4. Breathing patterns.
5. Mobility of the opposite hip.
6. Mobility of the opposite ankle.
7. Overall soft tissue quality.
8. Glenohumeral (ball-and-socket joint) range of motion.
9. Rotator cuff strength and endurance.
Most therapists will be quite good with #1, #8, and #9. If more PT's simply added #2 and #7 to the mix, things would come around much quicker for most patients. The other four are just a bonus.
Tip #3: MRI's and X-Rays Don't Tell You Everything.
Courtesy of Dr. Jason Hodges, here's an X-ray of a chronic rotator cuff tear in a 90-year-old woman. You can't typically see acute tears on X-rays, but chronic ones show up easily.
According to Dr. Hodges, "The relevant findings are that the humeral head is higher than normal (a.k.a. high riding). There's bone-on-bone contact between the head and the acromion. The acromion is remodeled with undersurface curvature. The acromion looks extra white from bony proliferation in response to the chronic pressure of the head. If you did an MRI, you'd find the supraspinatus and infraspinatus to be essentially gone from chronic shredding, thus allowing the head to migrate upwards."
You want to know the kicker? He concluded his email with, "I don't know of any shoulder symptoms in this patient. Usually, these are asymptomatic.î(3)
Yes, folks, that's one-half of the rotator cuff shredded and no symptoms. I guess Great Grandma isn't a good bet to come out of the bullpen and save tonight's ballgame.
Speaking of pitchers, you'll find labral fraying in every MRI you do on pitchers' throwing shoulders. But they aren't all symptomatic.
Likewise, in the past three months, I've had two high school baseball players come to me with completely "clean" elbows on MRI's and X-rays, but significant pain when they throw at over 50% effort. In the first case, three diagnostic tests (one X-ray, two MRI's) simply missed out on a bone chip floating around in the joint from a little league fracture four years prior. It was only "viewable" when the X-ray was performed while the elbow was actively repositioned by the doctor.
In the second case, the MRI's and X-rays didn't pick up on a case of gross functional instability. Rather, it took a good physical therapist to test the supporting ligaments to get to the root of the problem. Just because an ulnar collateral ligament is intact doesn't mean that it isn't lax.
Here's a good analogy I've used with my young athletes and their parents.
Imagine a joint being like a baseball team on a field. You take a photo (MRI or X-ray) of that team from the stands and it might look fine. Or, it might look terrible — there's no left fielder, the pitcher isn't facing the plate, or the third baseman forgot his glove. Diagnostic imaging picks up the obvious stuff.
That photo, however, doesn't show how that team thinks, moves, fields, hits, or throws. That's the stuff you don't see on a MRI or X-ray: scar tissue, posterior capsule (shoulder) stiffness, poor force transfer, or varying degrees of instability.
And, perhaps even scarier, Belgian researchers found that MRI accuracy was 88% and 85% for medial and lateral meniscal tears, respectively. Of the 100 patients involved, there were 23 patients with 27 incorrect diagnoses. According to the researchers, "12 (44%) were unavoidable, 10 (37%) equivocal, and 5 (19%) interpretation errors."
When examined under arthroscopy and compared against the MRI results, 12 of the 67 (18%) meniscal tears had been missed on the imaging. The researchers concluded, "Subtle or equivocal findings still make MRI diagnosis difficult, even for experienced radiologists.î(4) You're always going to see some false positives and negatives.
So, with all that said, your best bet is to simply ask doctors and physical therapists, "Did the diagnostic imaging confirm or refute your physical examination of my problems?" If you have pain, and your MRI and X-ray are both negative, that doesn'tmean that you don't have a problem. Likewise, if your MRI or X-ray is positive, see how it relates to that physical examination.
Tip #4: Find Out What You Can Do.
As I noted in The 10 Rules of Corrective Lifting, I'm a firm believer in telling people what they can do, not just what they can't do.
It's the doctor's job to contraindicate certain activities. These recommendations are based on what I call the "stupid factor." Doctors assume that all patients, physical therapists, trainers, and strength and conditioning coaches are inherently stupid until proven otherwise.
So, let's say you break a bone in your hand and the doctor tells you that you can't do any upper body lifting with that arm while you're in a cast. This recommendation is black and white — and necessary to accommodate the stupid factor.
However, go to a good therapist, trainer, or coach, and he's going to have you doing manual resistance lateral raises, prone trap raises, one-arm presses, horizontal abductions — basically anything where manual resistance above the elbow can be provided. In fact, I'm training two athletes right now who had nerve transpositions done in their elbow and wrist. They've got two good legs, one good arm, and plenty of core musculature in the middle that still need a training effect.
We just had a top 100 soccer prospect get started with us and he's got probably the worst adductor (groin) strain I've ever seen. In spite of that, he's been able to jump rope and do reverse sled drags.
The take-home point here is to be an advocate for yourself and ask what you can do to train the injured limb without interfering with your recovery. It's the job of the therapist to set guidelines for you.
Tip #5: Ask if You Can Make Modifications to Your Daily Life to Ease Pain.
Have you ever met a roofer, floorer, cyclist, or plumber who has a healthy back?
The reason for their back issues is that lumbar spines really don't like being stuck in flexion (especially if you add compression and rotation). Oddly enough, though, these flexion intolerant people will actually sit in flexion when they aren't hammering shingles, laying carpet, pedaling, or fighting with the porcelain gods. It's kind of like a guy leaving work with a headache to go home to bang his head against a wall.
Not surprisingly, if you put these people in some extension, they get some relief of their symptoms. A good example is a towel folded in half and used as a lumbar support in their chair or car. (Yes, folks, I'm a rocket scientist on the side.)
Tip #6: Ask Why Hamstrings Need to be Static-Stretched.
I was doing sprint work with some of my baseball guys a month or so ago, and one of our newer athletes (left-handed batter) said that he was having some right-sided lower back pain. I checked him out, and he had very little hip internal rotation on that front leg (it's very important to have lead-leg internal rotation for both throwing and hitting in baseball). I gave him a mobilization to do, and didn't hear anything more of it for a few weeks. Until he walked in claiming that he had "pulled his hamstring" down by the knee.
I'm not a diagnosis guy, but I said to Tony Gentilcore that my hunch was that it wasn't a hamstring strain at all. The way he presented made it seem more and more like a case of neural tension. Basically, a little nerve impingement at the spine radiates some pain down into the leg. Strains that far down the hamstring aren't as common as the ones closer to the glutes.
And, here's the interesting part: He was pain free on any exercise that didn't involve much compressive loading (i.e. dumbbell lunges vs. squat variations). The added compression would push on that nerve a bit, and he thought the hamstring was going to go. Conversely, he had no problem doing any single-leg movement, which would put some stress on that hamstring.
We worked around it that Thursday, and on Friday, while playing first base, he jumped to catch a throw and took the baserunner's shoulder right in his ribs. That night, he was in the emergency room with a broken rib and punctured lung.
Believe it or not, it only amounted to four days of downtime for him, as apparently, lungs can re-inflate fast, and the rib wasn't symptomatic at all (they never confirmed it on an X-ray, anyway). So, he got the go-ahead to return to play. Interestingly, his hamstring issue was nowhere to be found. As those of you who've ever had a hamstring strain can attest, they don't just magically disappear.
So what happened? He got some downtime from the rib and lung issues, and got antsy because he couldn't do any exercise. He then decided to actually start doing the stretches I gave him. Loosen up the hips, remove the offending stimulus for a few days, and then get back to hitting and throwing when the inefficiency is resolved. Funny how that works.
How does this all relate to stretching the hamstrings? Well, a lot of back pain is because people are stuck in anterior pelvic tilt and a lordotic posture. Typically, this entails weakness in the glutes, rectus abdominus, and external obliques. All of which can keep someone in posterior pelvic tilt.
However, what many people don't realize is that the hamstrings are also posterior tilters of the pelvis, even if they aren't the most mechanically efficient of the bunch. They might be the only muscles exerting any posterior tilting action on the pelvis. Do you think that having tight hamstrings might be the only thing that prevents people with nagging back pain from going to debilitating back pain?
This is why stretching the hamstrings can sometimes do more harm than good. If it's just muscular tension, the risks can outweigh the benefits (assuming they're using enough glutes, external obliques, rectus abdominus, and there's adequate length of the hip flexors). However, if it's neural tension, you can be putting a pissed off nerve on a stretch. Isn't it interesting how closely a slump test — a provocative test for neural problems — closely resembles a hamstrings stretch?
The slump test (my apologies for the dude in his undies).
Plus, if a guy has weakness in the aforementioned muscles, and you stretch (temporarily weaken) the hamstrings, you've basically lost the only stabilizer that can actually posteriorly tilt the pelvis (very important for avoiding stress fractures, groin strains, spondylolisthesis, etc.).
For a lot of you, this anatomy stuff probably doesn't make a lot of sense, but at the very least, it shows that having strong (and possibly tight) hamstrings might be the only thing protecting guys who are tight in their hips. It's one reason why I favor conservative mobilizations over static stretching if I'm going to do anything at all for hamstrings length.
So, just ask your therapist what the rationale for stretching the hamstrings out is. It might be justified, but the only way you'll know is if you ask.
Tip #7: Make Sure They Check the Ankles and Discuss Footwear.
The ankles and feet are the root of a lot of the problems further up the kinetic chain — lower back pain, in particular. John Pallof, a physical therapist in my neck of the woods, once described the subtalar joint as a "torque-converter." Basically, it takes tri-planar movement (pronation and supination) at the ankle and below and converts it to tibial and femoral internal rotation. It's the reason that the function of your foot can change the positioning of the head of your femur in your hip "socket."
For simplicity's sake, let's just assume that pronation (what we do to decelerate) is going to correspond to more internal rotation of the tibia and femur. This means that you're going to need more strength in the external rotators of the hip to decelerate that movement. So, think gluteus maximus, piriformis, biceps femoris, and a bunch of smaller, deep external rotators.
Now, let's take the typical 35-year-old female. She wears high heels (drive more pronation), has weak hamstrings (physiological difference between men and women), hasn't fired her glutes in the ten years since she started sitting at a desk all day, and spends three hours per week on the stairmaster and elliptical (stuck in anterior pelvic tilt).
If she doesn't get ankle, hip, or knee issues first, it's easy to see why piriformis would act up (small muscle doing a big job by itself) or she'd start to get extension-based back pain (no glutes to pull her into posterior tilt to resist the anterior weight-bearing she's imposed).
I don't want to leave you with a bad taste in your mouth about the medical community, so I'll conclude with this: There are someincredible health care professionals out there. As with any profession, there are others who just opt to punch the clock instead of really caring about the work they do.
It's up to you to develop your go-to network and to do so today. It's better to know who you're going to contact when you get injured than it is to scramble to find someone on a moment's notice when you're already in pain. Start asking around and find someone who's good at what they do.
About the Author
Eric Cressey is a highly sought-after strength and conditioning coach and owner of Cressey Performance just west of Boston. Eric has worked with athletes of all levels, from youth sports to the professional and Olympic levels. Feel free to contact him and sign up for his free newsletter at EricCressey.com, and check out his daily updates at his blog.
Eric's new book, Maximum Strength, is now available here.
1. Wong RA, Schumann B, Townsend R, Phelps CA.A survey of therapeutic ultrasound use by physical therapists who are orthopaedic certified specialists. Phys Ther 2007 Aug;87(8):986-94.
2. Kibler WB, Press J, Sciascia A. The Role of Core Stability in Athletic Function. Sports Med. 2006;36(3):189-9.
3. Hodges, J. Personal Communication. April, 2008.
4. Van Dyck P, Gielen J, D'Anvers J, Vanhoenacker F, Dossche L, Van Gestel J, Parizel PM.. MR diagnosis of meniscal tears of the knee: analysis of error patterns. Arch Orthop Trauma Surg. 2007 Nov;127(9):849-54.
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