Physical Therapist's Guide to Osteoporosis

Osteoporosis is a common disease that causes a thinning and weakening of the bones. It can affect people of any age. Women have the greatest risk of developing the disease, although it also occurs in men. Osteoporosis affects 55% of Americans aged 50 or older; one-half of women and a quarter of men will fracture a bone as a result of low bone density (osteopenia) or osteoporosis. Thin bones are the cause of 1.5 million fractures per year in the United States; hip fractures alone result in 300,000 hospitalizations. It is important to diagnosis low bone density or osteoporosis early so that steps can be taken to rebuild bone strength and lessen the risk of fracture.

What is Osteoporosis?

Osteoporosis is a bone disease characterized by low bone density (thickness of the bone), decreased bone strength, and a change in the bone structure, which can lead to an increased risk of fracture. The normal bone structure becomes thinned out and porous with poor nutrition, aging, or when osteoporosis develops, lessening the ability of the bone to withstand the typical forces that are applied in everyday living. Fractures from low bone density and osteoporosis can be serious, causing pain and affecting quality of life.

Bone is living tissue. Normally, one type of cell removes bone and another type of cell adds bone in a balanced, ongoing process. In osteoporosis, bones weaken when not enough new bone is formed and/or too much bone is lost. This imbalance commonly begins in women during the first 5 years of menopause. However, it can also occur in men and in children, often due to diseases that affect bone development, such as celiac disease, inflammatory bowel disease, rheumatoid arthritis, spina bifida, cystic fibrosis, or kidney disease. Some medicines, such as steroids, may increase the risk of developing osteoporosis. Athletes who are underweight during the time of peak bone development are also susceptible.

There are many factors that can cause a person to be at risk for developing osteoporosis. It is important to know your risks so that you can be diagnosed and proactive in your treatment.

Risk Factors for Osteoporosis

Noncontrollable risks

  • Female gender

  • Small frame

  • Advanced age

  • Hormone levels

  • Genetics

  • Predisposing medical conditions

Controllable risks

  • Cigarette smoking

  • Excessive alcohol intake

  • Inactive lifestyle

  • Excessive caffeine intake

  • Lack of weight-bearing exercise

  • Drugs (eg, steroids, heparin)

  • Poor health

  • Low weight

  • Calcium-poor diet

  • Low vitamin D levels

 

How Does it Feel?

Osteoporosis is a disease that can be "silent." There may be no outward symptoms until a fracture occurs. If you are middle-aged or older, you may notice a loss of height or the appearance of a humpback. You may also begin to experience pain between your shoulder blades or above the crest of the pelvis.

People with low bone density may experience fractures in everyday situations that would not occur in persons with healthy bones, such as breaking a hip or a wrist with a fall from a standing height, breaking a rib when opening a window or when receiving a hug, or breaking an ankle after stepping off a curb. These are called fragility fractures and are a red flag for bone disease. Spinal compression fractures, particularly those in the upper back or thoracic spine (area between the neck and the lower back), are the most common fractures, followed by hip and wrist fractures.

How Is It Diagnosed?

If you are seeing a physical therapist for back pain or other rehabilitation issues, the therapist will review your medical, family, medication, exercise, dietary, and hormonal history, conduct a complete physical examination, and determine your risk factors for osteoporosis. The assessment may lead the physical therapist to recommend further testing.

Osteoporosis is best diagnosed through a quick and painless specialized X-ray called the DXA, which measures bone density. The results are reported using T-scores and Z-scores.

  • The T-score compares your score to that of healthy 30-year-old adults. If you have a T-score of -1 or less, you have a greater risk of having a fracture.

  • If the T-score is -2.5 or less you will receive the diagnosis of osteoporosis.

  • The Z-score compares your bone mineral density to those of the same sex, weight, and age. It is used for those whose bone mass has not yet peaked, premenopausal women, and men older than 50.

Other methods of measuring bone density include X-ray, ultrasound, and CT scan. 

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How Can a Physical Therapist Help?

Your physical therapist can develop a specific program based on your individual needs to help improve your overall bone health, keep your bones healthy, and help you avoid fracture. Your physical therapist may teach you:

  • Specific exercises to build bone or decrease the amount of bone loss

  • Proper posture to protect your spine from fracture

  • Proper alignment during activities of daily living

  • How to improve your balance so as to reduce your risk of falling

  • How to adjust your environment to protect your bone health

Healthy bone is built and maintained through a healthy lifestyle. Your physical therapist will teach you specific exercises to meet your particular needs.

The exercise component for bone building or slowing bone loss is very specific and similar for all ages. Bone grows when it is sufficiently and properly stressed, just as muscle grows when challenged by more than usual weight. Two types of exercise are optimal for bone health: weight-bearing and resistance.

It is best for a physical therapist to provide your individual bone-building prescription to ensure that you are neither overexercising nor underexercising. Typically, exercises are performed 2 to 3 times a week as part of an overall fitness program.

Weight-bearing exercises

  • Dancing

  • Jogging (if your bone density is higher than -3.0)

  • Racquet sports

  • Heel drops

  • Stomping

Resistance exercises

  • Weight lifting in proper spine and lower-extremity alignment

  • Use of exercise bands

  • Gravity resistance (eg, push-ups, prone trunk extension with cushion to protect lowest ribs, single-leg heel raises, squats, lunges, sustained standing yoga poses in neutral spine position)

  • Exercises that reduce or stabilize kyphosis (hunchback)

  • Balance exercises

If you are diagnosed with osteoporosis or low bone density, your physical therapist will work with you to:

  • Build bone or lessen the amount of bone loss at areas most vulnerable to fracture through exercise—hip, spine, shoulder, arms.

  • Improve your dynamic balance to avoid falls.

  • Improve your posture.

  • Adjust your work and living environments to limit risk.

  • Help you avoid exercises and movements that may contribute to spinal fracture, including any type of sit-up or crunch, and excessive spinal or hip twisting.

Conservative treatment of a fracture includes bed rest and appropriate pain treatment. Your physical therapist will work with you to:

  • Decrease your pain through positioning and other pain-relieving modalities. Individualized physical therapist regimens can help reduce pain without the need for medications, such as opioids.

  • Provide appropriate external devices, such as bracing, to promote healing and improve posture.

  • Decrease your risk of a fall, strengthen your muscles, and improve your postural alignment.

  • Avoid exercises that involve too much forward or side bending or twisting.

  • Avoid water or endurance exercises, as they have been shown to negatively affect bone density.

If your pain lasts longer than 6 weeks following a spinal fracture, you can discuss surgical options, such as vertebroplasty or kyphoplasty, with your physical therapist, primary care physician, and surgeon.

Children and adolescents. Physical therapists can educate families and youth groups on proper exercise and posture, and about the need to move daily to build bone strength and prevent bone loss. Children with health issues such as spina bifida, diabetes, Crohn's disease, and cerebral palsy are at a greater risk for bone disease and can particularly benefit from the guidance of a physical therapist. Proper physical conditioning is crucial for children and adolescents: the majority of bone is built during adolescence and peaks by the third decade of life.

Middle-aged and older adults. As people age, they may begin to notice postural, balance, and strength changes. Physical therapists work with middle-aged and older adults to:

  • Develop individualized exercise programs to promote bone growth or lessen bone loss

  • Improve dynamic balance to avoid falls

  • Improve posture

  • Improve the strength of back muscles

  • Improve hip strength and mobility

Can this Injury or Condition be Prevented?

Osteoporosis can be prevented by building adequate bone density through childhood, adolescence, and early adulthood. Building strong bones requires an adequate intake of calcium and vitamin D, and regular exercise.

There are steps to take to improve bone health at any age. An active lifestyle that includes resistance and weight-bearing exercise is important to maintain healthy bone. It is also important to avoid habits that promote bone loss, such as smoking, excessive alcohol consumption, and an inadequate intake of calcium in your diet. Maintaining good body mechanics and posture also contribute to good bone health. We have no control over the genetic tendencies we have inherited, but we can choose to manage osteoporosis through proper medication, diet, and appropriate exercise.

As with any health issue, an overall healthy lifestyle is important for staying well.

Real Life Experiences

Anna is a 69-year-old retired legal secretary. She has enjoyed her early years of retirement, taking long walks in beautiful settings across the United States. Two years into her retirement, however, she began having knee pain during some of her walks, which gradually grew worse. Last year, she had a total knee replacement due to arthritis. She now walks with a cane because of chronic knee and ankle pain, and has experienced a loss of balance. She also has developed a rounded upper back, and low back pain. She seeks the help of a physical therapist.

Anna's physical therapist performs an assessment that includes a medical review for osteoporosis risk factors and for other health issues. He evaluates her range of motion and strength, testing her arms, legs, and trunk—especially her upper back. He tests the flexibility of her spine and her balance, her walking ability, and her risk of falling. Anna's walking style is uneven and she leans heavily on her cane. A DXA scan reveals that Anna has lost bone density in her spine and both hips. A vertebral fracture assessment X-ray shows that she has painless compression fractures of her spine. Her physical therapist diagnoses osteoporosis of the spine.

Anna first works with her physical therapist to improve her posture and knee function through flexibility and strengthening exercises, so she can walk more normally while working on her balance to lower her fall risk. She tells him her main goal is to be able to take walks in the park again.

Anna’s physical therapist teaches her safe trunk movement to avoid spinal fracture. Anna agrees to wear a dynamic trunk brace 2 hours a day to help make her posture more upright. She practices weight-bearing exercises with considerations for her arthritis, and learns resistive strengthening exercises for her spine and hip. Anna's physical therapist designs a gentle home-exercise program for her as well.

By her last visit, the flexibility and strength of Anna’s trunk and legs and her tolerance of physical activity have improved. The quality of her walking and dynamic balance are measurably improved, and her risk of falling has decreased. Anna feels much more confident about managing her condition.

Just this past week, Anna joined a therapeutic senior walking group that meets at the local botanic garden twice a week. She is thrilled to be enjoying gentle walks in nature again, and looks forward to coordinating other activities with her new group of friends!

This story was based on a real-life case. Your case may be different. Your physical therapist will tailor a treatment program to your specific case.

What Kind of Physical Therapist Do I Need?

All physical therapists are prepared through education and experience to treat those with osteoporosis. However, if you have a diagnosis of osteoporosis or low bone density, you may want to consider:

  • A physical therapist who is a board-certified clinical specialist or who completed a residency or fellowship in orthopedic physical therapy or geriatric physical therapy. This physical therapist has advanced knowledge, experience, and skills that may apply to your condition.

  • A physical therapist who specializes in the treatment of osteoporosis.

You can find physical therapists with these and other credentials by using Find a PT, the online tool by the American Physical Therapy Association that can help you search for physical therapists with specific clinical expertise in your geographic area.

General tips when you're looking for a physical therapist (or any other health care provider):

  • Get recommendations from family and friends or from other health care providers.

  • When you contact a physical therapy clinic for an appointment, ask about the physical therapists' experience in helping people who have osteoporosis.

Further Reading

The American Physical Therapy Association (APTA) believes that consumers should have access to information that can help them make health care decisions and also prepare them for a visit with their health care provider.

The following websites are important and reputable resources to obtain more information about improving your bone health:

National Osteoporosis Foundation. Accessed March 28, 2018.   

American Bone Health. Accessed March 28, 2018.

American Bone Health. FORE fracture risk calculator. Accessed March 28, 2018.

Osteoporosis Canada. Accessed March 28, 2018.

Osteoporosis Canada. Too fit to fracture series. Accessed March 28, 2018.

National Bone Health Alliance. Accessed March 28, 2018.

Own the Bone. Accessed March 28, 2018.

National Osteoporosis Foundation and Pilates Anytime. Safe movement video series. Accessed March 28, 2018.

MedBridge. Osteoporosis education courses for physical therapists. Accessed March 28, 2018.

Office of the US Surgeon General. The 2004 Surgeon General’s report on bone health and osteoporosis. Accessed March 28, 2018. 

Physical Activity Guidelines Advisory Committee, US Dept of Health and Human Services. Physical Activity Guidelines Advisory Committee Report, 2008Washington, DC: US Department of Health and Human Services. Published June 2008. Accessed March 28, 2018. 

The following articles provide some of the best scientific evidence related to physical therapy treatment of osteoporosis and fracture prevention. The articles report recent research and give an overview of the standards of practice both in the United States and internationally. The article titles are linked either to a Pub Med* abstract of the article or to free full text, so that you can read it or print out a copy to bring with you to your health care provider.

Watson SL, Weks BK, Weis LJ, Harding AT, Horan SA, Beck BR. High-intensity resistance and impact training improves bone mineral density and physical function in postmenopausal women with osteopenia and osteoporosis: the LIFTMOR randomized controlled trial. J Bone Miner Res. 2018;33(2):211–220. Article Summary in PubMed.

Beck BR, Daly RM, Singh MA, Taaffe DR. Exercise and Sports Science Australia (ESSA) position statement on exercise prescription for the prevention and management of osteoporosis. J Sci Med Sport. 2017;20(5):438–445. Article Summary in PubMed.

Sözen T, Özışık L, Başaran NÇ. An overview and management of osteoporosis. Eur J Rheumatol. 2017;4(1):46–56. Free Article.

Giangregorio LM, McGill S, Wark JD, et al. Too fit to fracture: outcomes of a Delphi consensus process on physical activity and exercise recommendations for adults with osteoporosis with or without vertebral fractures. Osteoporos Int. 2015;26(3):891–910. Free Article.

Bansal S, Katzman WB, Giangregorio LM. Exercise for improving age-related hyperkyphotic posture: a systematic review. Arch Phys Med Rehabil. 2014;95(1):129–140. Free Article.

Clark EM, Carter L, Gould VC, Morrison L, Tobias JH. Vertebral fracture assessment (VFA) by lateral DXA scanning may be cost-effective when used as part of fracture liaison services or primary care screening. Osteoporos Int. 2014;25(3):953–964. Article Summary in PubMed.

Siris ES, Adler R, Bilezikian J, et al. The clinical diagnosis of osteoporosis: a position statement from the National Bone Health Alliance Working Group. Osteoporos Int. 2014;25(5):1439–1443. Free Article.

Silva BC, Boutroy S, Zhang C, et al. Trabecular bone score (TBS): a novel method to evaluate bone microarchitectural texture in patients with primary hyperparathyroidism. J Clin Endocrinol Metab. 2013;98(5):1963–1970. Free Article.

Cheung AM, Giangregorio L. Mechanical stimuli and bone health: what is the evidence? Curr Opin Rheumatol. 2012;24:561–566. Article Summary in PubMed.

Pfeifer M, Kohlwey L, Begerow B, Minne HW. Effects of two newly developed spinal orthoses on trunk muscle strength, posture, and quality-of-life in women with postmenopausal osteoporosis: a randomized trial. Am J Phys Med Rehabil. 2011;90:805–815. Article Summary on PubMed.

Kasukawa Y, Miyakoshi N, Hongo M, et al. Relationships between falls, spinal curvature, spinal mobility and back extensor strength in elderly people. J Bone Miner Metab. 2010;28:82–87. Article Summary in PubMed.

Nikander R, Kannus P, Dastidar M, et al. Targeted exercises against hip fragility. Osteoporos Int. 2009;20:1321–1328. Article Summary in PubMed.

Hongo M, Itoi E, Sinaki M, et al. Effect of low-intensity back exercise on quality of life and back extensor strength in patients with osteoporosis: a randomized controlled trial. Osteoporos Int. 2007;18:1389–1395. Article Summary in PubMed.

Vainionpaa A, Korpelainen R, Leppaluoto J, Jamsa T. Effects of high-impact exercise on bone mineral density: a randomized controlled trial in premenopausal women. Osteoporos Int. 2005;16:191–197. Article Summary in PubMed.

*PubMed is a free online resource developed by the National Center for Biotechnology Information (NCBI). PubMed contains millions of citations to biomedical literature, including citations in the National Library of Medicine's MEDLINE database.

Authored by Mary Saloka Morrison, PT, DScPT, MHS. Reviewed by the MoveForwardPT.com editorial board.



Total Shoulder Replacement (Arthroplasty)

Total shoulder arthroplasty (TSA), often called a total shoulder replacement, is a surgical procedure in which part or all of the shoulder joint is replaced. It is estimated that 53,000 people in the United States have shoulder replacement surgery each year, according to the Agency for Healthcare Research and Quality. That number compares to the more than 900,000 Americans a year who have knee and hip replacement surgery. Physical therapists can help patients who undergo a TSA return to their previous levels of physical activity, including fitness training, or participation in sports like swimming or golf.

What is Total Shoulder Arthoplasty?

Total shoulder arthroplasty is a surgical procedure in which part or all of the shoulder joint is replaced. It is performed on the shoulder when medical interventions, such as other conservative surgeries, medication, and physical therapy no longer provide pain relief. The decision to have a TSA is made following consultation with your orthopedic surgeon and your physical therapist.

A shoulder replacement may be needed if you have any of the following conditions affecting the shoulder, causing severe shoulder pain and limiting your ability to use the affected shoulder:

A TSA involves removing the ends of the bone at the shoulder joint, and replacing them with artificial parts. The upper part of the arm bone (humerus) is shaped like a ball; it is called the "head" of the humerus. During a TSA, the head of the humerus is replaced by a metal ball. The socket that the head of the humerus sits in is called the glenoid fossa. During a TSA, the socket is replaced by a plastic cup.

Due to various physical limitations, your orthopedic surgeon may decide that you are a candidate for another form of TSA, such as:

  • Shoulder hemiarthroplasty, where only the head of the humerus is replaced with a metal ball.

  • Reverse TSA, where the metal ball and plastic socket are reversed. This procedure is recommended when the rotator cuff muscles of the shoulder are damaged. The plastic socket is attached to the top of the humerus, and the metal ball is attached to the socket. This procedure allows another shoulder muscle, called the deltoid, to take over for the damaged rotator cuff muscles, improving functional range of motion, strength, and stability of the shoulder

ShoulderReplacement-SM.jpg

How Can a Physical Therapist Help?

Physical therapy plays a vital role in ensuring a safe recovery by improving shoulder function, and limiting pain following a TSA. Your physical therapist will work with you prior to and following your surgery, to help you safely return to your previous levels of activity, including performing household chores, job duties, and recreational activities.

 

Before Surgery

The better physical condition your shoulder is in prior to surgery, the better your recovery will be. Your physical therapist will teach you exercises to build shoulder strength, and improve your shoulder and upper back movement to keep the shoulder as strong and mobile as possible up until the time of surgery.

After Surgery

Your physical therapist will educate you about precautions to take after surgery, such as wearing a sling to perform all activities, and gradually beginning to safely move your arm. If you are a smoker, quitting smoking will improve your healing process.

After your TSA, you will likely stay in the hospital for 2 to 3 days. If you have other medical conditions, such as diabetes or heart disease, your hospital stay may be a few days longer. Your shoulder will be placed in a sling for the next 2 to 6 weeks; you will be advised to not move your shoulder on your own.

Your physical therapy will begin within a day or two of your surgery. A hospital physical therapist will visit your room to teach you how to perform simple tasks like brushing your teeth, and tell you what movements (such as pushing, pulling, or reaching with the affected arm) you simply cannot perform. Your physical therapist will teach you how to get in and out of bed safely, how to get the sling on and off, and how to get dressed while keeping your shoulder in a safe position. You will also learn how to minimize pain and swelling in the area by applying an ice pack, and elevating the upper arm.

You may need some help from friends or family members with daily activities for the first few days or weeks after your surgery. You will not be able to drive for the first few weeks after surgery.

 

As You Recover

When you are discharged from the hospital, continuation of physical therapy is essential. Your surgeon and physical therapist will work as a team to ensure your safe recovery. Your physical therapist will teach you exercises that may include:

Range-of-Motion Exercises. It is important to not move your shoulder suddenly or with any force for the first 2 to 6 weeks following surgery, to allow proper healing. Your physical therapist will passively move your shoulder in different directions to allow you to safely begin regaining movement. Your physical therapist will also teach you gentle exercises to perform at home. You will also learn range-of-motion exercises for the elbow and hand, so these joints do not get stiff from being held in a sling. Squeezing a ball or putty will help keep your grip strong, while your shoulder recovers. You will use ice packs on the shoulder and elevate your arm on pillows to allow gravity to help reduce the swelling in the shoulder, as instructed by your physical therapist.

Strengthening Exercises. As your shoulder mobility returns within a few weeks or months, your physical therapist will guide you through a shoulder strengthening program. You may use resistive bands and weights to perform gentle strengthening exercises.

Functional Training. Your physical therapist will help you regain everyday shoulder movements, such as reaching into a cupboard, reaching behind your body to tuck in your shirt, or reaching across your body to fasten a seat belt.

Job and Sport-Specific Training. Your physical therapist will design a personalized program to enable you to resume your job tasks without pain. These may include reaching, pushing, or carrying movements. You will also receive sport-specific training if you are planning to return to a sport. Your physical therapist will create a specialized home or fitness-center exercise program based on your individual needs, to be continued long after formal physical therapy has been completed.

Can this Injury or Condition be Prevented?

If you begin noticing your shoulder is painful and you are losing the ability to move your shoulder, a physical therapist can help. A properly designed exercise program can delay or even help you avoid surgery. A physical therapist will teach you specific, safe exercises to improve your shoulder flexibility and strength, and teach you how to manage your pain. Proper nutrition and physical activity will keep all of your joints healthy. Avoiding smoking is essential for proper healing and overall recovery from any injury.

Real Life Experiences

Charles is a 59-year-old golfer and swimmer with a history of osteoarthritis that began when he was 45 years old. Recently, Charles began to notice an increase in pain and difficulty when he reached overhead with his right arm. He also noticed that he couldn't throw a ball like he used to, and his shoulder was hurting during his golf swing and swim stroke. Just this month, Charles began to have difficulty shifting gears while driving, and realized that he could no longer lift his arm to reach into the cupboard to get his coffee cup. He called his doctor.

Charles's doctor took his medical history and thoroughly examined his shoulder. He diagnosed severe shoulder arthritis. He referred Charles to an orthopedic surgeon, who scheduled Charles for a TSA. Charles had a presurgery consultation with his physical therapist to learn what to expect from his recovery after surgery. His physical therapist explained how to wear and use a sling, and how to manage any pain or swelling. He also showed Charles the exercises that he would be performing.

The first day after his surgery, Charles' hospital physical therapist visited his room to teach him some deep-breathing exercises to keep his lungs inflated and reduce any risk of developing complications, such as pnemonia. She taught him how to properly use his sling, and guided him through a few gentle elbow and hand exercises. She also showed him how to safely get in and out of bed and a chair, without putting pressure on his right shoulder.

The second day after surgery, Charles' physical therapist taught him how to remove the sling safely to perform gentle pendulum exercises that helps to keep the shoulder from getting stiff. He learned how to avoid using his right shoulder at all other times, and to keep it in the sling, except when doing the pendulum exercises, and gentle elbow and hand exercises. He learned safe techniques for washing and other activities of daily living, including putting on a shirt.

The third day after surgery was Charles' last day in the hospital. His physical therapist helped him make arrangements for outpatient physical therapy.

Charles began his outpatient physical therapy just days after his TSA. His physical therapist performed passive movements with his right shoulder to ensure that it regained full mobility. She designed a home-exercise program for him, continuing the pendulum exercises and active elbow and hand exercises, as well as conservative shoulder blade squeezes.

As his shoulder strength and movement began to be restored, Charles' physical therapist added "active assisted" exercises (movement patterns assisted by a pulley or by the opposite shoulder) to gently increase his right shoulder mobility. She taught Charles how to squeeze a tennis ball a few times a day to improve his grip strength. Charles also learned how to apply an ice pack, and elevate his right shoulder at home and after each physical therapy session.

Eight weeks following his TSA, Charles was able to reach his right arm farther overhead than he was able to before his surgery!

After 12 weeks, under the guidance of his physical therapist, Charles has more shoulder motion and much less pain than he had prior to his TSA. He is able to slowly return to golf and swimming by performing his guided exercises, which target specific muscles needed to safely return to these activities. He began with gently swinging a golf club, and now he is able to perform a full golf swing.

Now, 4 months after his TSA, Charles reaches into his cupboard each Saturday morning for his coffee cup, and enjoys a healthy breakfast before heading out to the golf course for a pain-free round of golf. His scores are better than in many recent years, and he plans to lead his team to a league championship!

What Kind of Physical Therapist Do I Need?

All physical therapists are prepared through education and experience to treat a total shoulder arthroplasty condition/injury. However, you may want to consider:

  • A physical therapist who is experienced in treating people with an orthopedic condition/injury. Some physical therapists have a practice with an orthopedic, manual therapy, and sports medicine focus.

  • A physical therapist who is a board-certified clinical specialist, or who completed a residency or fellowship in orthopedics physical therapy. This therapist has advanced knowledge, experience, and skills that may apply to your condition.

You can find physical therapists who have these and other credentials by using Find a PT, the online tool built by the American Physical Therapy Association to help you search for physical therapists with specific clinical expertise in your geographic area.

General tips when you're looking for a physical therapist (or any other health care provider):

  • Get recommendations from family and friends or from other health care providers.

  • When you contact a physical therapy clinic for an appointment, ask about the physical therapists' experience in helping people who have underlying shoulder or orthopedic conditions.

  • During your first visit with the physical therapist, be prepared to describe your symptoms in as much detail as possible, and say what makes your symptoms worse.

Further Reading

The American Physical Therapy Association (APTA) believes that consumers should have access to information that could help them make health care decisions, and also prepare them for their visit with their health care provider.

The following articles provide some of the best scientific evidence related to physical therapy treatment ofcervical radiculopathy. The articles report recent research and give an overview of the standards of practice both in the United States and internationally. The article titles are linked either to a PubMed* abstract of the article or to free full text, so that you can read it or print out a copy to bring with you to your health care provider.

ScienceDaily.  Published July 13, 2009. Accessed February 11, 2015

Golant A, Christoforou D, Zuckerman JD, Kwon YW. Return to sports after shoulder arthroplasty: a survey of surgeons' preferences. J Shoulder Elbow Surg. 2012;21(4):554–560. Article Summary in PubMed.

Schumann K, Flury MP, Schwyzer HK, Simmen BR, Drerup S, Goldhahn J. Sports activity after anatomical total shoulder arthroplasty. Am J Sports Med. 2010;38(10):2097–2105. Article Summary in PubMed.

Boardman ND III, Cofield RH, Bengtson KA, Little R, Jones MC, Rowland CM. Rehabilitation after total shoulder arthroplasty. J Arthroplasty. 2001;16(4):483–486. Article Summary in PubMed.

Wirth MA, Rockwood CA Jr. Complications of total shoulder-replacement arthroplasty. J Bone Joint Surg Am. 1996;78(4):603–616. Article Summary in PubMed.

*PubMed is a free online resource developed by the National Center for Biotechnology Information (NCBI). PubMed contains millions of citations to biomedical literature, including citations in the National Library of Medicine’s MEDLINE database.

Authored by Julie A. Mulcahy, PT, MPT. Reviewed by the MoveForwardPT.com editorial board.

 

De Quervain’s Tendinitis

De Quervain's (dih-kwer-VAINS) tendinitis is a condition that causes pain and tenderness at the thumb side of the wrist, at the base of the thumb and forearm. Pain is worsened with grasping or extending the thumb (pulling it back like "thumbing a ride"). People of all ages can develop this condition, which usually happens when the tendons are strained by prolonged or repetitive use of the hand, rapid or forceful hand use, or use of the hand or arm in an awkward position. Tendons at the wrist become irritated and thickened, resulting in pain when moving the thumb and grasping objects. Common forms of treatment for De Quervain’s include splinting and range-of-motion exercises. Injection for cortisone by a doctor is common treatment. Persistent cases may require surgery.

What is De Quervain’s Tendinitis?

De Quervain's tendinitis is a common condition involving tendons of the wrist. Tendons are tough cords or bands of connective tissue that attach muscles to a bone. The thumb and wrist extensor tendons (Abductor Pollicus Longus and Extensor Pollicus Brevis) are encased in a "sheath" or a tunnel at the wrist, which keeps the tendons in place. De Quervain's tendinitis can occur gradually or suddenly, when the tendons become inflamed or thickened from overload or repetitive use, and have difficulty sliding through the extensor tunnel.

Risk factors for developing De Quervain's tendinitis include:

  • Chronic overuse of the hand.

  • Excessive use of the thumb from texting and gaming.

  • Being female (women are 8 to 10 times more likely to develop this condition than men).

  • Pregnancy.

  • Using the hand or arm in a position that feels awkward.

  • Participation in sports that stress the hand and wrist, such as golf and tennis.

  • Age greater than 40 years.

  • Race; members of the black community may be more likely to experience this problem.

How Does it Feel?

A person who has De Quervain's tendinitis may:

  • Feel localized tenderness, pain, and, swelling at the wrist near where the thumb is attached to the forearm.

  • Have difficulty pinching or grasping with the thumb or hand.

  • Feel pain when moving the wrist from side to side or twisting it.

  • Experience limited motion and feeling of weakness in the thumb.

  • Have difficulty flexing the thumb.

  • Notice a "catching" or "snapping" sensation with movement of the thumb (a less common symptom).

Active use of the hand with activities, such as writing, opening jars, lifting a child, hammering, sports, and any workplace or home activity that involves pinching or grasping with the thumb, can provoke the symptoms of pain, stiffness, and weakness.

Note: Other conditions of the wrist and hand can cause symptoms similar to those stated here. Your physical therapist will help to identify any underlying problems of your joints, tissues, or nerves that may be causing similar symptoms.

How Is It Diagnosed?

Your physical therapist will ask you how and when you first experienced symptoms, and what it feels like at the present time. Your therapist will perform a physical exam that will include feeling for tender spots, measuring the flexibility and range of motion of the thumb and wrist, and testing the strength of the thumb muscles and grip. Your physical therapist will also perform a Finkelstein test, which gently stretches the tendons on the thumb side of the wrist through the extensor tunnel. Pain during this test is common with De Quervain’s tendinitis.

Your physical therapist will also perform other tests to rule out any underlying conditions that may mimic De Quervain's symptoms.

How Can a Physical Therapist Help?

If your physical therapist confirms De Quervain’s Tendinitis from an evaluation, they will work with you to develop an individualized plan with you for this condition.

Your physical therapist will review and evaluate how you use your hand and wrist for functional activity. The review will include your daily activities, work, and sports activities. The physical therapist will try to help you identify what activities or positions that you use that may contribute to the problem. They will instruct you how to make changes in your function to help healing and reduce risk of the problem in the future.

Specific instructions may include avoiding repetitive thumb and/or wrist movements, avoid flexing the thumb, and avoid moving the hand toward the pinkie finger as much as possible. You should also avoid forceful hand movements, and any movements or activities that increase pain.

The therapist may provide a wrist splint to position your wrist and thumb for rest, and to provide compression to help pain and swelling.

Your therapist may also work with you to reduce pain and inflammation.

Ultrasound therapy may be applied to improve pain. This treatment uses ultrasonic sound waves applied over the involved area to improve circulation, reduce swelling, and aide healing of the tissues and tendons.

Iontophoresis is another option to reduce swelling and pain. Iontophoresis is a type of electrical stimulation that is used to administer medication to the problem area through your skin.

Ice or heat may be recommended for short term pain relief. Your therapist will advise you for what is best for your condition.

Exercise is prescribed to improve range of motion and prevent stiffness. Early on, exercise is restricted to avoid aggravating the condition. As the condition improves, exercises will be progressed to improve strength for functional activity, as well as improve active range of motion of the thumb and wrist.

If your symptoms do not respond to conservative care, your physical therapist will refer you to a physician who will determine if you need medication, injection, or surgical care for further recovery.

How Can a Physical Therapist Help Before & After Surgery?

If your De Quervain's problem does require surgery, your physical therapist may fit a splint to your hand and wrist after the procedure. Your physical therapist will help you to control any swelling, maintain and improve your hand and wrist flexibility, build your strength, and improve your range of motion, allowing you to safely return to your preinjury activity levels.

Can this Injury or Condition be Prevented?

It may be possible to prevent De Quervain's tendinitis. Some risk factors cannot be controlled, such as gender, race, or age; however, physical therapists recommend that you:

  • Avoid chronic overuse of the hand.

  • Avoid or restrict overly forceful use of the wrist.

  • Avoid excessive use of the thumbs for texting and gaming.

  • Avoid putting the wrist and hand in awkward positions while using the hand or arm.

  • Train and condition in sports, such as golf and tennis to minimize wrist and thumb strain.

Your physical therapist can teach you correct and safe hand and wrist positions to maintain during your daily home, work, and sport activities.

Real Life Experiences

Janet is a mother of a 2-year-old boy, and is expecting her second child in 3 months. Her part-time job as a secretary requires her to spend 90% of her work day typing on a keyboard. Recently, Janet noticed her right wrist near her thumb was starting to feel sore after work. When she got home, she had trouble picking up her child because of the pain she felt on the thumb side of her wrist. On a recent weekend, Janet spent a lot of time painting to get her new nursery ready. On Monday morning she felt a constant pain in her wrist and forearm that was worse with grasping. She could hardly pick up her coffee cup. She was unable to work. She called her physical therapist.

Janet's physical therapist performed an evaluation of her wrist and hand. He found swelling and tenderness of the thumb extensor tendons. Gently bending the wrist to the "pinkie side" and flexing the thumb increased her pain. The Finkelstein test confirmed De Quervain’s tendinitis. He also noticed her hand and wrist movements were limited.

Janet's physical therapist treated the area with ultrasound to reduce the pain and swelling, and fitted her with a wrist-thumb spica splint to limit use of the affected tendons, and to provide compression. He showed her how to perform gentle movements of the thumb for stiffness in a way that did not increase her symptoms. He cautioned her to avoid lifting and typing as much as possible for 2 weeks. He also recommended ice to the area for 10 minutes, 2 to 3 times a day, to reduce pain and swelling.

Janet felt improvement after her first treatment. She returned for treatment 2 times a week for ultrasound, soft-tissue massage, and modified exercises.

Two weeks later, Janet reported that her pain was no longer constant, and when present, it felt 50% better. She still experienced pain when lifting her child and using the keyboard for longer than 30 minutes. At her physical therapist's suggestion, Janet modified her work habits; for example, she began using a voice dictation program to reduce the amount of time she spent typing. She was happy to note that holding her coffee cup, and similar activities of daily living were no longer painful.

Janet kept using her splint daily with activity throughout her rehabilitation, and continued to restrict any activities that created or increased her pain symptoms. She also made changes to her workspace as recommended by her physical therapist, and changed the position of her hands to reduce joint stress at her wrist and hand during work.

Four weeks after her initial visit with the physical therapist, Janet's pain was minimal and only occurred with movements that stressed the thumb side of the wrist, such as holding a gallon of milk. She continues her home exercise program for strengthening her wrist, thumb, and grip. She continues to use her splint intermittently with activity. She feels stronger and more confident lifting her child, and is gradually returning to her full activity levels.

What Kind of Physical Therapist Do I Need?

All physical therapists are prepared through education and experience to treat De Quervain's tendinitis. However, you may want to consider:

  • A physical therapist who is experienced in treating people with hand conditions, sports injuries, or repetitive stress injuries of the upper limb.

  • Physical therapists who have a practice with a focus on hand rehabilitation.

  • A physical therapist who is a board-certified clinical specialist, or who has completed a residency or fellowship in Orthopedic or hand therapy. This therapist has advanced knowledge, experience, and skills that may apply to your condition.

You can find physical therapists who have these and other credentials by using Find a PT, the online tool built by the American Physical Therapy Association to help you search for physical therapists with specific clinical expertise in your geographic area.

General tips when you're looking for a physical therapist (or any other health care provider):

  • Get recommendations from family and friends or from other health care providers.

  • When you contact a physical therapy clinic for an appointment, ask about the physical therapists' experience in helping people who have De Quervain's tendinitis.

  • During your first visit with the physical therapist, be prepared to describe your symptoms in as much detail as possible, and say what makes your symptoms worse.

Further Reading

The American Physical Therapy Association (APTA) believes that consumers should have access to information that could help them make health care decisions and also prepare them for their visit with their health care provider.

The following articles provide some of the best scientific evidence related to physical therapy treatment of De Quervain’s tendinitis. The articles report recent research and give an overview of the standards of practice both in the United States and internationally. The article titles are linked either to a PubMed* abstract of the article or to free full text, so that you can read it or print out a copy to bring with you to your health care provider.

Ashurst JV, Turco DA, Lieb BE. Tenosynovitis caused by texting: an emerging disease. J Am Osteopath Assoc. 2010;110(5):294–296. Free Article

Consensus on a Multidisciplinary Treatment Guideline for deQuervain Disease: Results From the European HANDGUIDE Study, Huisstede BMA, Coert JH, Friden J, Hoogvliet P. Physical Therapy 2014; 94:1095-1110.

Frontera WR, Silver JK, Rizzo TD Jr. Essentials of Physical Medicine and Rehabilitation: Musculoskeletal Disorders, Pain, and Rehabilitation. 2nd ed. Philadelphia, PA: Saunders Elsevier Publishers; 2008:129-132. 

De Quervain’s tendinitis: MedlinePlus Medical Encyclopedia. Accessed May 12, 2014.

*PubMed is a free online resource developed by the National Center for Biotechnology Information (NCBI). PubMed contains millions of citations to biomedical literature, including citations in the National Library of Medicine’s MEDLINE database.

Authored by Mary Kay Zane, PT, OCSReviewed by the MoveForwardPT.com editorial board.



Frozen Shoulder (Adhesive Capsulitis)

Often called a stiff or “frozen shoulder,” adhesive capsulitis occurs in about 2% to 5% of the American population. It affects women more than men and is typically diagnosed in people over the age of 45. Of the people who have had adhesive capsulitis in 1 shoulder, it is estimated that 20% to 30% will get it in the other shoulder as well. Physical therapists help people with adhesive capsulitis address pain and stiffness, and restore shoulder movement in the safest and most effective way possible.

What is Frozen Shoulder (Adhesive Capsulitis)?

Adhesive capsulitis is the stiffening of the shoulder due to scar tissue, which results in painful movement and loss of motion. The actual cause of adhesive capsulitis is a matter for debate. Some believe it is caused by inflammation, such as when the lining of a joint becomes inflamed (synovitis), or by autoimmune reactions, where the body launches an "attack" against its own substances and tissues. Other possible causes include:

  • Reactions after an injury or surgery

  • Pain from other conditions, such as arthritis, a rotator cuff tear, bursitis, or tendinitis, that has caused a person to stop moving the shoulder

  • Immobilization of the arm, such as in a sling, after surgery or fracture

Often, however, there is no clear reason why adhesive capsulitis develops.

 

FrozenShoulder_SM.jpg

How Does it Feel?

Most people with adhesive capsulitis have worsening pain and a loss of movement. Adhesive capsulitis can be broken down into 4 stages; your physical therapist can help determine what stage you are in.

Stage 1: "Prefreezing"

During stage 1 of its development, it may be difficult to identify your problem as adhesive capsulitis. You've had symptoms for 1 to 3 months, and they're getting worse. Movement of the shoulder causes pain. It usually aches when you're not using it, but the pain increases and becomes "sharp" with movement. You'll begin to limit shoulder motion during this period and protect the shoulder by using it less. The movement loss is most noticeable in "external rotation" (this is when you rotate your arm away from your body), but you might start to lose motion when you raise your arm or reach behind your back. Pain is the hallmark feature of this stage; you may experience pain during the day and at night.

Stage 2: "Freezing"

By this stage, you've had symptoms for 3 to 9 months, most likely with a progressive loss of shoulder movement and an increase in pain (especially at night). The shoulder still has some range of movement, but it is limited by both pain and stiffness.

Stage 3: "Frozen"

Your symptoms have persisted for 9 to 14 months, and you have a greatly decreased range of shoulder movement. During the early part of this stage, there is still a substantial amount of pain. Toward the end of this stage, however, pain decreases, with the pain usually occurring only when you move your shoulder as far you can move it.

Stage 4: "Thawing"

You've had symptoms for 12 to 15 months, and there is a big decrease in pain, especially at night. You still have a limited range of movement, but your ability to complete your daily activities involving overhead motion is improving at a rapid rate.

How Is It Diagnosed?

Often, physical therapists don't see patients with adhesive capsulitis until well into the freezing phase or early in the frozen phase. Sometimes, people are being treated for other shoulder conditions when their physical therapist notices the signs and symptoms of adhesive capsulitis. Your physical therapist will perform a thorough evaluation, including an extensive health history, to rule out other diagnoses. Your physical therapist will look for a specific pattern in your decreased range of motion called a "capsular pattern" that is typical with adhesive capsulitis. In addition, your physical therapist will consider other conditions you might have, such as diabetes, thyroid disorders, and autoimmune disorders, that are associated with adhesive capsulitis.

How Can a Physical Therapist Help?

Your physical therapist's overall goal is to restore your movement, so you can perform your daily activities. Once the evaluation process has identified the stage of your condition, your physical therapist will create an individualized exercise program tailored to your specific needs. Exercise has been found to be most effective for those who are in stage 2 or higher. Your treatment may include:

Stages 1 and 2

Exercises and manual therapy. Your physical therapist will help you maintain as much range of motion as possible and will help reduce your pain. Your therapist may use a combination of range-of-motion exercises and manual therapy (hands-on) techniques to maintain shoulder movement.

Modalities. Your physical therapist may use heat and ice treatments (modalities) to help relax the muscles prior to other forms of treatment.

Home-exercise program. Your physical therapist will give you a gentle home-exercise program designed to help reduce your loss of motion. Your therapist will warn you that being overly aggressive with stretching in this stage may make your shoulder pain worse.

Your physical therapist will match your treatment activities and intensity to your symptoms, and educate you on appropriate use of the affected arm. Your therapist will carefully monitor your progress to ensure a safe healing procedure is followed. 

Pain medication. Sometimes, conservative care cannot reduce the pain of adhesive capsulitis. In that case, your physical therapist may refer you for an injection of a safe anti-inflammatory and pain-relieving medication. Research has shown that although these injections don’t provide longer-term benefits for range of motion and don’t shorten the duration of the condition, they do offer short-term pain reduction.

Stage 3

The focus of treatment during phase 3 is on the return of motion. Treatment may include:

Stretching techniques. Your physical therapist may introduce more intense stretching techniques to encourage greater movement and flexibility.

Manual therapy. Your physical therapist may take your manual therapy to a higher level, encouraging the muscles and tissues to loosen up.

Strengthening exercises. You may begin strengthening exercises targeting the shoulder area as well as your core muscles. Your home-exercise program will change to include these exercises.

Stage 4

In the final stage, your physical therapist will focus on the return of "normal" shoulder body mechanics and your return to normal, everyday, pain-free activities. Your treatment may include:

Stretching techniques. The stretching techniques in this stage will be similar to previous ones you’ve learned, but will focus on the specific directions and positions that are limited for you. 

Manual therapy. Your physical therapist may perform manual therapy techniques in very specific positions and ranges that are problematic for you. They will focus on eliminating the last of your limitations.

Strength training. Your physical therapist will prescribe specific strengthening exercises related to any weakness that you may have to help you perform your work or recreational tasks. 

Return to work or sport. Your physical therapist will address movements and tasks that are required in your daily and recreational life.

Can this Injury or Condition be Prevented?

The cause of adhesive capsulitis is debatable, with no definitive cause. Therefore, to date, there is no known method of prevention. The onset of the condition is usually gradual, with the disease process needing to "run its course." However, the sooner you contact your physical therapist, the sooner you will receive appropriate information on how to most effectively address your symptoms. 

Real Life Experiences

Cheryl is 47-year-old office manager who swims and hikes on the weekends. A few months ago, Cheryl began having pain in her left shoulder when she reached up to file archived reports at work. At first she ignored it, but then noticed her shoulder was aching after work and sometimes at night. She began to limit her movement due to pain. Just this week, she chose not to visit her local pool for her regular swim. She decided to contact a physical therapist.

Cheryl’s physical therapist took her health history, and asked her to describe when the pain began, and how her current symptoms are affecting her. Cheryl reports no accident or trauma, and that the pain has slowly increased over the past few months. She notes that she has to make adjustments at work because she can’t lift her arm above shoulder level, and that the pain is now affecting her sleep. Her physical therapist conducts a thorough physical examination and diagnoses stage 2 frozen shoulder (adhesive capsulitis).

He begins Cheryl’s rehabilitation with heat treatments to relax her muscles, and designs an individualized home-exercise program to address her symptoms and help stall any loss of motion. He encourages Cheryl to perform her home exercises every day.

Cheryl’s treatments during this phase consist of gentle movements performed by her physical therapist (manual therapy), to help maintain the shoulder joint’s current range of motion. At this point, he focuses treatment not on increasing the shoulder’s range of motion, but on mobilizing the joint to reduce pain and reduce the amount of movement that is lost.

When Cheryl progresses into stage 3 ("frozen") adhesive capsulitis, her visits to the physical therapist are increased. He uses stretching and manual therapy techniques to improve her range of motion. He updates Cheryl’s home-exercise program to match her current limitations and function.

After a few more weeks of treatment, Cheryl reports minimal pain, and her range of motion is beginning to increase. Her treatment is reduced to weekly visits, and then to twice monthly visits. She begins to slowly return to swimming; her physical therapist prescribes a safe and appropriate program to follow, as she resumes her activities. 

After 2 more months of treatment, Cheryl’s range of motion is normal, and her pain has stopped. She has happily returned to her regular swimming schedule, and feels stronger than she has in years! Cheryl's physical therapist credits her excellent recovery to her full participation in her treatment and home-exercise programs.

This story was based on a real-life case. Your case may be different. Your physical therapist will tailor a treatment program to your specific case.

What Kind of Physical Therapist Do I Need?

All physical therapists are prepared through education and experience to treat people who have frozen shoulder, or adhesive capsulitis. You may want to consider:

  • A physical therapist who is experienced in treating people with orthopedic, or musculoskeletal, problems.

  • A physical therapist who is a board-certified clinical specialist or who completed a residency or fellowship in orthopaedic physical therapy, manual physical therapy, or specializes in the treatment of the upper extremity. This therapist has advanced knowledge, experience, and skills that may apply to your condition.

You can find physical therapists who have these and other credentials by using Find a PT, the online tool built by the American Physical Therapy Association to help you search for physical therapists with specific clinical expertise in your geographic area.

General tips when you're looking for a physical therapist:

  • Get recommendations from family and friends or from other health care providers.

  • When you contact a physical therapy clinic for an appointment, ask about the physical therapist's experience in helping people with frozen shoulder.

  • During your first visit with the physical therapist, be prepared to describe your symptoms in as much detail as possible, and say what makes your symptoms worse.

Further Reading

The American Physical Therapy Association (APTA) believes that consumers should have access to information that could help them make health care decisions and also prepare them for their visit with their health care provider.

The following articles provide some of the best scientific evidence related to physical therapy treatment of adhesive capsulitis. The articles report recent research and give an overview of the standards of practice for treatment of adhesive capsulitis both in the United States and internationally. The article titles are linked either to a PubMed abstract of the article or to free full text, so that you can read it or print out a copy to bring with you to your health care provider.

Jain TK, Sharma NK. The effectiveness of physiotherapeutic interventions in the treatment of frozen shoulder/adhesive capsulitis: a systematic review. J Back Musculoskelet Rehabil. 2014;27:247–273. Article Summary in PubMed.

Russell S, Jariwala A, Conlon R, et al. A blinded, randomized, controlled trial assessing conservative management strategies from frozen shoulder. J Shoulder Elbow Surg. 2014;23:500–507. Article Summary in PubMed.

Rill BK, Fleckenstein CM, Levy MS, et al. Predictors of outcome after nonoperative and operative treatment of adhesive capsulitis.Am J Sports Med. 2011;39:567–574. Article Summary in PubMed.

Neviaser AS, Hannafin JA. Adhesive capsulitis: a review of current treatment. Am J Sports Med. 2010;38:2346–2356. Article Summary in PubMed.

Jewell DV, Riddle DL, Thacker LR. Interventions associated with an increased or decreased likelihood of pain reduction and improved function in patients with adhesive capsulitis: a retrospective cohort study. Phys Ther. 2009;89:419–429. Free Article.

Kelley MJ, McClure PW, Leggin BG. Frozen shoulder: evidence and a proposed model guiding rehabilitation. J Ortho Sports Phys Ther. 2009;39:135-148. Article Summary in PubMed.

Levine WN, Kashyap CP, Bak SF, et al. Nonoperative management of idiopathic adhesive capsulitis. J Shoulder Elbow Surg. 2007;16:569–573. Article Summary in PubMed.

Sheridan MA, Hannafin JA. Upper extremity: emphasis on frozen shoulder. Orthop Clin North Am. 2006;37:531–539. Article Summary in PubMed.

Diercks RL, Stevens M. Gentle thawing of the frozen shoulder: a prospective study of supervised neglect versus intensive physical therapy in seventy-seven patients with frozen shoulder syndrome followed up for two years. J Shoulder Elbow Surg.2004:13:499–502. Article Summary in PubMed.

Reviewed by the MoveForwardPT.com editorial board.



Osgood-Schlatter Disease

Osgood-Schlatter disease occurs when there is irritation to the top, front portion of the shin bone (tibia) where the tendon attached to the kneecap (patella) meets the shin bone. It occurs when there is an increased amount of stress placed upon the bones where the tendons attach. This is most often the result of increased activity levels by an adolescent athlete.

Our musculoskeletal system is made up of bones and surrounding soft tissue structures, including muscles, ligaments (which connect bone to bone), and tendons (which connect muscle to bone). These structures all play a role in helping us move.

During adolescence our bodies grow at a rapid rate. As our bodies develop, our bones are growing longer. Throughout this phase, our growth plates (epiphyseal plates) are susceptible to injury. A growth plate is the site at the end of a bone where new bone tissue is made and bone growth occurs. Females typically experience the most rapid growth between approximately 11 to 12 years of age, and males typically experience this growth surge between approximately 13 and 14 years of age. Males experience OS more frequently than females, likely due to an increased rate of sports participation.

Structures in our body might become irritated if they are asked to do more than they are capable of doing. Injuries can occur in an isolated event, but OS disease is most likely the cumulative effect of repeated trauma. OS is most frequently experienced in adolescents who regularly participate in running, jumping, and "cutting" (rapid changes in direction) activities.

When too much stress is present (ie, from rapid growth) and when the body is overworked (ie, either too much overall volume of exercise, or too much repetition), the top of the shin can become painful and swollen. As this condition progresses, the body’s response to bone stress can be an increase in bone production; an adolescent may begin to develop a boney growth that feels like a bump on the front of the upper shin.

OS can start as mild soreness, but can progress to long-lasting pain and limited function, if not addressed early and appropriately.

How Does it Feel?

With Osgood-Schlatter, you may experience:

  • Gradually worsening pain below your knee, at the top of the shin bone.

  • Pain that worsens with exercise.

  • Swelling and tenderness at the top of the shin.

  • A boney growth at the top of the shin.

  • Loss of strength in the quadriceps muscle (connecting the hip to the knee).

  • Increased tightness in the quadriceps muscle.

  • Loss of knee motion.

  • Discomfort with daily activities that use your knee, like kneeling, squatting, or walking up and down stairs.

How Is It Diagnosed?

Diagnosis of OS begins with a thorough medical history, including specific questions regarding athletic participation (sports played, frequency of practices/games, positions). Your physical therapist will assess different measures, such as sensation, motion, strength, flexibility, tenderness, and swelling. Your physical therapist will perform several tests specific to the knee joint, and may ask you to briefly demonstrate the activities or positions that cause your pain, such as walking, squatting, and stepping up or down stairs.

Because the knee and hip are both involved in these aggravating activities, your physical therapist will likely examine your hip as well. Other nearby areas, such as your feet and core, will also be examined to determine whether they, too, might be contributing to your knee condition.

If your physical therapist suspects there may be a more involved injury than increased stress-related irritation (ie, if there is a recent significant loss of motion or strength, or severe pain when the knee is moved), your therapist will likely recommend a referral to an orthopedic physician for diagnostic imaging, such as ultrasound, x-ray, or MRI.

How Can a Physical Therapist Help?

Once other conditions have been ruled out and OS is diagnosed, your physical therapist will work with you to develop an individualized treatment plan tailored to your specific knee condition and your goals. The goal of physical therapy is to accelerate your recovery and return to pain-free activity. There are many physical therapy treatments that have been shown to be effective in treating OS, and among them are:

Range of Motion Therapy. Your physical therapist will assess the motion of your knee and its surrounding structures, and design gentle exercises to help you work through any stiffness and swelling to return to a normal range of motion.

Strength Training. Your physical therapist will teach you exercises to strengthen the muscles around the knee so that each muscle is able to properly perform its job, and stresses are eased so the knee joint is properly protected.

Manual Therapy.Physical therapists are trained in manual (hands-on) therapy. If needed, your physical therapist will gently move your kneecap or patellar tendon and surrounding muscles as needed to improve their motion, flexibility, and strength. These techniques can target areas that are difficult to treat on your own. 

Pain Management.Your physical therapist may recommend therapeutic modalities, such as ice and heat, or a brace to aid in pain management.

Functional Training.Physical therapists are experts at training athletes to function at their best. Your physical therapist will assess your movements and teach you to adjust them to relieve any extra stress on the front of your knee.

Education. The first step to addressing your knee pain is rest. Your physical therapist will explain why this is important and develop a plan for your complete rehabilitation.

Can this Injury or Condition be Prevented?

Fortunately, there is much that can be done to prevent the cascade of events that lead to OS. Physical therapists focus on:

  • Educating coaches, parents, and athletes on guidelines for sports participation, explaining common causes of overuse injuries, and providing strategies for prevention.

  • Educating athletes on the risks of playing through pain.

  • Scheduling adequate rest time to recover between athletic events.

  • Tracking a young athlete’s growth curves (height, weight, BMI) to identify periods of increased injury risk.

  • Developing an athlete-specific flexibility and strengthening routine to be followed throughout the athletic season.

  • Encouraging consultation with a physical therapist whenever symptoms appear.

Real Life Experiences

Caleb is a 13-year-old boy who has been playing basketball since he was in the first grade. When younger, Caleb played only during the winter season. Over the course of the last year, however, he has attended 2 basketball camps during the summer, played on his middle-school team during the winter, and is now playing AAU basketball in the spring.

Caleb also chose to join the track team this spring, competing in the high jump and sprint events to improve his basketball skills. Over the past 3 months, Caleb has grown 2 inches, and both he and his basketball coaches are excited about his recent growth.

Recently, Caleb has been busy playing in weekly AAU tournaments with 1 to 2 track meets during the week. But when he got home from track practice on Monday, he told his dad that his leg was hurting. He said that it had begun getting sore while playing basketball over the weekend, but he didn’t want to tell his coach because he wanted to continue to play. Now he feels like the top of his shin is tender to touch, and he is unable to fully bend his knee without increased pain.

His dad realizes that this is more than the expected postactivity soreness; he immediately calls their local physical therapist.

Caleb's physical therapist takes his health history and performs an extensive examination. It becomes clear that Caleb has not scheduled appropriate rest times between his athletic activities, and that he is experiencing a growth spurt. The physical examination reveals that the top of Caleb’s shin is very tender, the area around his knee is swollen, and he has lost knee motion and strength. OS is diagnosed.

Together, Caleb and his physical therapist, father, and basketball and track coaches develop a treatment plan to help him return to pain-free sport participation. It begins with a 2-week period of rest where Caleb performs only minimal running exercise, and works regularly with his physical therapist on stretching, strengthening, balance, and coordination exercises, and on improving his squatting movements.

While at basketball practice, Caleb continues to work on his ball handling and free-throw shooting, activities that won't increase his knee pain.

After 2 weeks, when his knee is less tender, Caleb, his physical therapist, and his coaches develop a plan for his gradual return to full participation in track and basketball. They help Caleb understand how important it is to be honest about his knee pain, and to communicate with his coach if it starts to bother him again.

A month later, Caleb is back participating in all his track and basketball activities. He has changed his routine to allow for adequate warm-up time before and after each practice, and sufficient rest periods between activities. He makes sure his dad or coaches are keeping track of how much time he spends at practice and at rest.

Caleb decides to spend more time during the week working on his stretching, so he can reduce any risk of pain as he continues to grow. At the end of the season, Caleb’s AAU team wins the state championship—and he sets a new personal-best record in both the high jump and the 100-meter sprint!

What Kind of Physical Therapist Do I Need?

All physical therapists are prepared through education and clinical experience to treat a variety of conditions or injuries. You may want to consider:

  • A physical therapist who is experienced in treating people with orthopedic or musculoskeletal injuries.

  • A physical therapist who is a board-certified specialist or has completed a residency in orthopedic or sports physical therapy, as the therapist will have advanced knowledge, experience, and skills that apply to an athletic population.

You can find physical therapists that have these and other credentials by using Find a PT, the online tool built by the American Physical Therapy Association to help you search for physical therapists with specific clinical expertise in your geographic area.

General tips when you're looking for a physical therapist (or any other health care provider):

  • Get recommendations from family and friends or from other health care providers.

  • When you contact a physical therapy clinic for an appointment, ask about the physical therapists' experience in helping young athletes with knee pain.

  • During your first visit with the physical therapist, be prepared to describe your symptoms in as much detail as possible, and report activities that make your symptoms worse.

Further Reading

The American Physical Therapy Association (APTA) believes that consumers should have access to information that could help them make health care decisions, and also prepare them for a visit with their health care provider.

The following articles provide some of the best scientific evidence related to physical therapy treatment of athletic injuries. The articles report recent research and give an overview of the standards of practice both in the United States and internationally. The article titles are linked either to a PubMed* abstract of the article or to free full text, so that you can read it or print out a copy to bring with you to your health care provider.

Whitmore A. Osgood-Schlatter disease. JAAPA. 2013;26(10):51–52. Article Summary on PubMed.

Maffulli N, Longo UG, Spiezia F, Denaro V. Aetiology and prevention of injuries in elite young athletes. Med Sport Sci. 2011;56:187–200. Article Summary on PubMed.

Stein CJ, Micheli LJ. Overuse injuries in youth sports. Phys Sportsmed. 2010;38(2):102–108. Article Summary on PubMed.

* PubMed is a free online resource developed by the National Center for Biotechnology Information (NCBI). PubMed contains millions of citations to biomedical literature, including citations in the National Library of Medicine’s MEDLINE database.

 Authored by Allison Mumbleau, PT, DPT, SCS. Reviewed by the MoveForwardPT.com editorial board.



Plantar Fasciitis

Plantar fasciitis is a condition causing heel pain. Supporting the arch, the plantar fascia, a thick band of tissue connecting the heel to the ball of the foot, can become inflamed or can tear. You experience pain when you put weight on your foot—particularly when taking your first steps in the morning. The pain can be felt at the heel, or along the arch and the ball of the foot.

Plantar fasciitis is a common foot condition. It occurs in as many as 2 million Americans per year and 10% of the population over their lifetimes.

Factors that contribute to the development of plantar fasciitis include:

  • Age (over 40 years)

  • A job, sport, or hobby that involves prolonged standing or other weight-bearing activity

  • Rapid increases in length or levels of activity, such as beginning a new running program or changing to a job that requires a lot more standing or walking than you are accustomed to

  • Decreased calf muscle flexibility

  • Increased body weight (Body Mass Index greater than 30)

  • Tendency to have a flat foot (pronation)

Plantar fasciitis affects people of all ages, both athletes and non-athletes. Men and women have an equal chance of developing the condition.

Treatment generally reduces pain and restores your ability to put weight on your foot again.

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What is Plantar Fasciitis?

Plantar fasciitis is a condition causing heel pain. Supporting the arch, the plantar fascia, a thick band of tissue connecting the heel to the ball of the foot, can become inflamed or can tear. The condition develops when repeated weight-bearing activities put a strain on the plantar fascia. People who are diagnosed with plantar fasciitis also may have heel spurs, a bony growth that forms on the heel bone. However, people with heel spurs may not experience pain.

Plantar fasciitis occurs most frequently in people in their 40s but can occur in all age groups.

The condition can develop in athletes who run a great deal and in non-athletes who are on their feet most of the day, such as police officers, cashiers, or restaurant workers.

Signs and Symptoms

The onset of symptoms of plantar fasciitis frequently occurs with a sudden increase in activity. You might feel a stabbing pain on the underside of your heel, and a sensation of tightness and/or tenderness along your arch.

People with plantar fasciitis may experience pain:

  • In the morning, when stepping out of bed and taking the first steps of the day

  • With prolonged standing

  • When standing up after sitting for awhile

  • After an intense weight-bearing activity such as running

  • When climbing stairs

  • When walking barefoot or in shoes with poor support

As your body warms up, your pain may actually decrease during the day but then worsen again toward the end of the day because of extended walking. Severe symptoms may cause you to limp.

How Is It Diagnosed?

The physical therapist’s diagnosis is based on your health and activity history and a clinical evaluation. Your therapist also will take a medical history to make sure that you do not have other possible conditions that may be causing the pain. Sharing information about the relationship of your symptoms to your work and recreation, and reporting any lifestyle changes, will help the physical therapist diagnose your condition and tailor a treatment program for your specific needs.

To diagnose plantar fasciitis, your therapist may conduct the following physical tests to see if symptoms occur:

  • Massaging and pressing on the heel area (palpation)

  • Gently stretching the ankle to bend the top of the foot toward the leg (dorsiflexion)

  • Gently pressing the toes toward the ankle

How Can a Physical Therapist Help?

Physical therapists are trained to evaluate and treat plantar fasciitis.

When you are diagnosed with plantar fasciitis, your physical therapist will work with you to develop a program to decrease your symptoms that may include:

  • Stretching exercises to improve the flexibility of your ankle and the plantar fascia

  • Use of a night splint to maintain correct ankle and toe positions

  • Selection of supportive footwear and/or shoe inserts that minimize foot pronation and reduce stress to the plantar fascia

  • Application of ice to decrease pain and inflammation

  • Iontophoresis (a gentle way to deliver medication through the skin)

  • Taping of the foot to provide short-term relief

Research shows that most cases of plantar fasciitis improve over time with these conservative treatments, and surgery is rarely required.

Can this Injury or Condition be Prevented?

Guidelines for the prevention or management of plantar fasciitis include:

  • Choosing shoes with good arch support

  • Replacing your shoes regularly, so that they offer arch support and provide shock absorption to your feet

  • Using a thick mat if you must stand in one place for much of the day

  • Applying good principles to your exercise program, such as including a warm-up and gradually building up the intensity and duration of your exercises to avoid straining the plantar fascia

  • Stretching your calves and feet before and after running or walking

  • Maintaining a healthy body weight

Real Life Experiences

Jason has worked as a cook in a restaurant kitchen for 5 years. He has gradually gained about 25 pounds over those years. He began to develop pain in both his heels about 2 months ago. He does not exercise.

Jason asks a friend who has received physical therapy for advice. His friend suggests he see a physical therapist to find the cause of his heel pain.

Jason's physical therapist conducts a detailed history, asking questions about his health, lifestyle, and work, and performs a thorough evaluation. Jason says that his heel pain is worst when he gets up in the morning. After a shower and walking around for a while, his pain diminishes. However, when he is cooking at the restaurant during the evening shift, his heel pain returns, extending to the balls of his feet. Due to food debris in the restaurant kitchen, Jason says he wears old beat-up sneakers to work.

After conducting a physical examination, Jason's therapist diagnoses plantar fasciitis. She teaches Jason several stretches to perform twice a day and designs a home exercise program that will fit his goals and lifestyle. The therapist recommends he choose a shoe with a good arch support and replace them when they are worn out. She also suggests an orthotic (shoe insert) to place into his new shoes. She instructs him to apply ice to the bottom of his feet several times throughout the day. The therapist does not prescribe a night splint at this time, because Jason has had symptoms for less than 3 months. The therapist recommends that for his general health, Jason begin a low-impact exercise program, including swimming and using an exercise bike. This will help him lose the excess weight he has gained without further aggravating his plantar fasciitis.

Jason follows the advice of his physical therapist. He purchases new footwear for work and performs the stretching exercises and icing as instructed. After 2 weeks, he is 90% pain-free. Jason keeps his follow-up visit with his physical therapist 1 month later to review his condition and adjust his home program.

What Kind of Physical Therapist Do I Need?

All physical therapists are prepared through education and experience to treat plantar fasciitis. However, you may want to consider:

  • A physical therapist who is experienced in treating people with orthopedic and sports injuries, particularly those with experience working with the ankle and foot

  • A physical therapist who is a board-certified clinical specialist or who completed a residency or fellowship in orthopedic or sports physical therapy, meaning that this therapist has advanced knowledge, experience, and skills that may apply to your condition

You can find physical therapists who have these and other credentials by using Find a PT, the online tool built by the American Physical Therapy Association to help you search for physical therapists with specific clinical expertise in your geographic area.

General tips when you're looking for a physical therapist (or any other health care provider):

  • Get recommendations from family and friends or from other health care providers.

  • When you contact a physical therapy clinic for an appointment, ask about the physical therapists' experience in helping people who have heel pain.

  • During your first visit with the physical therapist, be prepared to describe your symptoms in as much detail as possible, and say what makes your symptoms worse.

Further Reading

The American Physical Therapy Association (APTA) believes that consumers should have access to information that could help them make health care decisions and also prepare them for their visit with their health care provider.

The following articles provide some of the best scientific evidence related to physical therapy treatment of plantar fasciitis. The articles report recent research and give an overview of the standards of practice both in the United States and internationally. The article titles are linked either to a PubMed* abstract of the article or to free access of the full article, so that you can read it or print out a copy to bring with you to your health care provider.

Cole C, Seto C, Gazewood J. Plantar fasciitis: evidence-based review of diagnosis and therapy. Am Fam Physician. 2005;72:2237–2242. Free Article.

Irving DB, Cook JL, Young MA, Menz HB. Obesity and pronated foot type may increase the risk of chronic plantar heel pain: a matched case-control study. BMC Musculoskelet Disord. 2007;8:41. Free Article.

McPoil TG, Martin RL, Cornwall MW, et al. Heel pain—plantar fasciitis: clinical practice guildelines linked to the International Classification of Function, Disability and Health from the Orthopaedic Section of the American Physical Therapy Association [erratum in: J Orthop Sports Phys Ther. 2008;38:648]. J Orthop Sports Phys Ther. 2008;38:A1–A18. .

Riddle DL, Pulisic M, Pidcoe P, Johnson RE. Risk factors for plantar fasciitis: a matched case-control study [erratum in: J Bone Joint Surg Am. 2003;85-A:1338]. J Bone Joint Surg Am. 2003;85-A:872–877.  Article Summary on PubMed.

Riddle DL, Schappert SM. Volume of ambulatory care visits and patterns of care for patients diagnosed with plantar fasciitis: a national study of medical doctors. Foot Ankle Int. 2004;25:303–310. Article Summary on PubMed.

Scher DL, Belmont PJ Jr, Bear R, et al. The incidence of plantar fasciitis in the United States military. J Bone Joint Surg Am. 2009;91:2867–872. Article Summary on PubMed.

*PubMed is a free online resource developed by the National Center for Biotechnology Information (NCBI). PubMed contains millions of citations to biomedical literature, including citations in the National Library of Medicine's MEDLINE database.

Authored by Shaw Bronner, PT, PhD, OCS. Reviewed by the MoveForwardPT.com editorial board.

Hip Impingement

Hip impingement involves a change in the shape of the surface of the hip joint that predisposes it to damage, resulting in stiffness and pain. Hip impingement is a process that may precede hip osteoarthritis. It most often occurs in young, active people. A recent study found that 87% of teens and adults with hip pain showed evidence of hip impingement on diagnostic images taken of their hip joints. To treat hip impingement, physical therapists prescribe stretches and strengthening exercises to better balance the muscles around the hip to protect it, and use manual therapies to help restore range of motion and increase comfort.

What is Hip Impingement?

There are 2 types of hip impingement; they may occur alone or together.

Pincer-Type Impingement

  • In pincer-type impingement, the hip socket (acetabulum), which is usually angled forward, may be angled toward the back, or protruding bone may be present on the pelvis side of the hip joint making the socket a deeper recess that covers more of the ball or head of the femur bone.

  • The overgrown bone or incorrect angle of the socket causes the labrum, a rim of connective tissue around the edge of the hip socket, to be pinched. Over time, this extra pressure to the labrum when flexing (moving the leg forward) leads to wear and tear that can cause inflammation and could result in a tear. If this condition persists, eventually the cartilage that lines the hip joint can become worn and form holes.

  • This condition affects men and women equally; symptoms often begin early, appearing at any time between 15 to 50 years of age.

 

Cam-Type Impingement

  • In cam-type impingement, the shape of the bone around the head of the femur—the ball at the top of the bone in the thigh—is misshapen. It can vary from the normal round ball shape, or have overgrown bone formed at the top and front. The nickname “pistol grip” deformity is given to the appearance of the bony overgrowth on x-rays.

  • The overgrown or misshapen bone contacts the cartilage that lines the hip socket, and can cause it to peel away from the bone in the socket. The labrum can become worn, frayed, or torn as well.

  • This condition affects men to women at a ratio of 3 to 1; symptoms often manifest during the teen years and 20s.

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Signs and Symptoms

Hip impingement may cause you to experience:

  • Stiffness or deep aching pain in the front or side of the hip or front of the upper thigh while resting.

  • Sharp, stabbing pain when standing up from a chair, squatting, rising from a squat, running, "cutting," jumping, twisting, pivoting, or making lateral motions.

  • Hip pain described in a specific location by making a "C" with the thumb and hand and placing it on the fold at the front and side of the hip, known as the "C-sign."

  • Pain that most often starts gradually, but can also remain after another injury resolves.

  • Pain that increases with prolonged sitting or forward leaning.

  • Feeling less flexible at the hips, including a decreased ability to turn your thigh inward on the painful side.

How Is It Diagnosed?

Your physical therapist will evaluate the range of motion (movement) of the hip and surrounding joints, and test the strength of the muscles in that area. Your therapist will feel the hip joint and surrounding muscles to evaluate their condition. The examination will include observing how you move, standing from a sitting position, walking, running, or squatting, as appropriate. Your physical therapist may perform special tests to help determine whether the hip is the source of your symptoms. For instance, the therapist may gently roll your leg in and out (the “log roll” test), or bend your hip up and in while turning the lower leg out to the side (the "FADDIR" test) to assess your condition.

If further diagnosis is needed, your doctor may order diagnostic tests to help identify any joint changes, including x-rays, magnetic resonance imaging (MRI), or diagnostic injections. Hip impingement can occur at the same time as low back, buttock, or pelvic pain, or from conditions such as bursitis or groin strain. The final diagnosis of hip impingement may take some time, especially when other conditions are present.

How Can a Physical Therapist Help?

Without Surgery

When an active person develops hip pain, but does not have severe symptoms or joint damage, the recommended treatment is physical therapy. The following interventions can help decrease pain, improve movement, and avoid the progression of hip impingement and the need for surgery:

  • Improving the strength of your hips and trunk. Strengthening of the hips and trunk can reduce abnormal forces on the already injured joint and help with strategies to compensate.

  • Improving hip muscle flexibility and joint mobility. Stretching tight muscles can reduce abnormal forces that cause pain with motion. Joint mobilization may help ease pain from the hip joint; however, these treatments do not always help range of motion, especially if the shape of the bone at the hip joint has changed.

  • Improving tolerance of daily activities. Your physical therapist can consider your job and recreational activities and offer advice regarding maintaining postures that are healthier for your hip and activity modification. Often this involves limiting the amount of bending at the hip to avoid further hip damage.

 

Following Surgery

Surgery for hip impingement is performed with arthroscopy. This is a minimally invasive type of surgery, where the surgeon makes small incisions in the skin and inserts pencil-sized instruments into the joint to repair damage. The surgeon may perform 1 or several techniques during your procedure as needed. The surgeon may remove or reshape the bone on the pelvis or femur side of the joint, and repair or remove the damaged labrum or cartilage of the hip joint.

Postsurgical physical therapy varies based on the procedure performed. It may include:

  • Ensuring your safety as you heal. Your physical therapist may recommend that you limit the amount of weight you put on the operated leg if there was a repair of the labrum. You may wear a brace to help limit the amount of bending at the hip. You might also use crutches to avoid overloading the leg if the bone on the femur was reshaped.

  • Improving your range of motion, strength, and balance. Your physical therapist will guide you through safe range-of-motion, strengthening, and balance activities to improve your movement as quickly as possible while allowing the surgical site to heal properly.

  • Instructions on returning to an active lifestyle. Most people return to normal daily activities about 3 months after surgery, and to high-level activities and sports 4 to 6 months after surgery. Your physical therapist will recommend a gradual return to activity based on your condition—research shows that 60% to 90% of athletes return to their previous playing ability depending on the surgical procedure performed and the sport.

Can this Injury or Condition be Prevented?

Currently there are no recommendations to prevent hip impingement. Despite a major increase in research to learn more about hip impingement, there is a great deal that is unknown. For instance, many active young people whose x-rays show hips as being abnormal do not have pain despite continuing to live active lives and participate in sports.

However, there is evidence that physical therapy interventions along with anti-inflammatory drugs can decrease pain, slow joint damage, and improve function. This is particularly important in those with mild hip impingement, those who are attempting to avoid surgery, and those who are not candidates for surgery.

Real Life Experiences

Lindsay is an active high school senior who plays shortstop for her school's softball team. Over the last several months, she has had progressively worsening pain on the front and side of her left hip. It started as an occasional sharp pain when she fielded ground balls at practice, and it eventually developed into aching and stiffness of the hip while resting. Lindsay occasionally develops hip pain while sitting in class or at the movies. In the past couple of weeks, she has found it hard to lean forward to tie her shoes. Her mom has been worrying about her pain and takes Lindsay to her physical therapist.

At the evaluation, the physical therapist finds that Lindsay has weakness around her hip and trunk muscles, decreased hip mobility, pain when flexing the hip, pain returning to a standing position after squatting, and decreased balance when standing on her affected leg. Her physical therapist diagnoses mild hip impingement in her left hip. Lindsay sees her physical therapist 1-2 times a week for the next 6 weeks.

Her treatments focus on developing a home program for strengthening her hips and trunk, and the therapist uses manual therapy for the hip to improve her comfort and allow her to perform more activities. The therapist works with Lindsay to change how she moves when standing from a seated position, and also to modify how she moves when playing the infield in softball. Lindsay also spends less time in the positions that bother her hip in the weight room and on the practice field, following recommendations from her physical therapist. After 3 weeks, the majority of her pain has subsided, and by 6 weeks, she is playing in games pain-free.

Lindsay meets her goal of finishing her senior year with the softball team. However, she is considering other ways to stay active after she graduates that don’t involve bending forward as much.

This story was based on a real-life case. Your case may be different. Your physical therapist will tailor a treatment program to your specific case.

What Kind of Physical Therapist Do I Need?

All physical therapists are prepared through education and experience to treat patients who have hip impingement. You may want to consider:

  • A physical therapist who is experienced in treating people with musculoskeletal problems. Some physical therapists have a practice with a sports or orthopaedic focus.

  • A physical therapist who is a board-certified clinical specialist or who completed a residency or fellowship in sports or orthopaedic physical therapy. This therapist has advanced knowledge, experience, and skills that may apply to your condition.

You can find physical therapists who have these and other credentials by using Find a PT, the online tool built by the American Physical Therapy Association to help you search for physical therapists with specific clinical expertise in your geographic area.

General tips when you're looking for a physical therapist (or any other health care provider):

  • Get recommendations from family and friends or from other health care providers.

  • When you contact a physical therapy clinic for an appointment, ask about the physical therapists' experience in helping people with hip impingement.

  • During your first visit with the physical therapist, be prepared to describe your symptoms in as much detail as possible, and say what makes your symptoms worse.

Further Reading

The American Physical Therapy Association (APTA) believes that consumers should have access to information that could help them make health care decisions and also prepare them for their visit with their health care provider.

The following articles provide some of the best scientific evidence related to physical therapy treatment of problems related to hip impingement. The articles report recent research and give an overview of the standards of practice for treatment both in the United States and internationally. The article titles are linked either to a PubMed* abstract of the article or to free full text, so that you can read it or print out a copy to bring with you to your health care provider.

Byrd JW. Femoroacetabular impingement in athletes, part I: cause and assessment. Sports Health. 2010;2:321-333. Free Article.

Byrd JW. Femoroacetabular impingement in athletes, part II: treatment and outcomes. Sports Health. 2010;2:403-409. Free Article.

Enseki KR, Martin RL, Draovitch P, et al. The hip joint: arthroscopic procedures and postoperative rehabilitation. J Orthop Sports Phys Ther. 2006:36:516-525. Article Summary in PubMed.

*PubMed is a free online resource developed by the National Center for Biotechnology Information (NCBI). PubMed contains millions of citations to biomedical literature, including citations in the National Library of Medicine’s MEDLINE database.

Authored by Jennifer Miller, PT, MPT, SCS. Reviewed by the MoveForwardPT.com editorial board.



Rotator Cuff Tear

What is a Rotator Cuff Tear?

The "rotator cuff" is a group of 4 muscles and their tendons (tissues that attach muscles to bones), which connects the upper arm bone, or humerus, to the shoulder blade. The important job of the rotator cuff is to keep the shoulder joint stable. Sometimes, the rotator cuff becomes inflamed or irritated due to heavy lifting, repetitive arm movements, or trauma such as a fall. A rotator cuff tear occurs when injuries to the muscles or tendons cause tissue damage or disruption.

Rotator cuff tears are called either "full thickness" or partial thickness," depending on how severe they are.

  • Full-thickness tears extend from the top to the bottom of a rotator cuff muscle/tendon.

  • Partial-thickness tears affect at least some portion of a rotator cuff muscle/tendon, but do not extend all the way through.

Tears often develop as a result of either a traumatic event or long-term overuse of the shoulder. These conditions are commonly called “acute” or “chronic.”

  • Acute rotator cuff tears are those that occur suddenly, often due to traumas, such as a fall or lifting of a heavy object.

  • Chronic rotator cuff tears are much slower to develop. These tears are often the result of repeated actions with the arms working above shoulder level, such as with ball-throwing sports or certain work activities.

People with chronic rotator cuff injuries often have a history of rotator cuff tendon irritation that causes shoulder pain with movement. This condition is known as shoulder impingement syndrome.

Rotator cuff tears also may occur in combination with injuries or irritation of the biceps tendon at the shoulder, or with labral tears (to the ring of cartilage at the shoulder joint). Your physical therapist will explain the particular details of your rotator cuff tear.

 

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How Does it Feel?

People with rotator cuff tears can experience:

  • Pain over the top of the shoulder or down the outside of the arm

  • Shoulder weakness

  • Loss of shoulder motion

  • A feeling of weakness or heaviness in the arm

  • Inability to lift the arm to reach up, or reach behind the back

  • Inability to perform common daily activities due to pain and limited motion

How Is It Diagnosed?

To help pinpoint the cause of your shoulder pain, your physical therapist will complete a thorough examination that will include learning details of your symptoms, assessing your ability to move your arm, identifying weakness, and performing special tests that may indicate a rotator cuff tear. For instance, your physical therapist may raise your arm, move your arm out to the side, or raise your arm and ask you to resist a force, all at specific angles of elevation.

In some cases, the results of these tests might indicate the need for a referral to an orthopedist or other professional for imaging tests, such as ultrasound imaging, magnetic resonance imaging (MRI), or a computed tomography (CT) scan.

How Can a Physical Therapist Help?

Once a rotator cuff tear has been diagnosed, you will work with your orthopedist and physical therapist to decide if you should have surgery or if you can try to manage your recovery without surgery.

If you don't need surgery, your physical therapist will work with you to restore your range of motion, muscle strength, and coordination, so that you can return to your regular activities. In some cases, you may learn to modify your physical activity so that you put less stress on your shoulder.

If you decide to have surgery, your physical therapist can help you both before and after the procedure.

Regardless of which treatment you have—physical therapy only, or surgery and physical therapy—early treatment can help you speed the healing process and avoid permanent damage.

If You Have an Acute Injury

If a rotator cuff tear is suspected following a trauma, seek the attention of a physical therapist or other health care provider to rule out the possibility of serious life- or limb-threatening conditions. Once serious injury is ruled out, your physical therapist will help you manage your pain and will prepare you for the best course of treatment.

If You Have a Chronic Injury

A physical therapist can help manage the symptoms of chronic rotator cuff tears as well as improve how your shoulder works. For large rotator cuff tears that can't be fully repaired, physical therapists can teach special strategies to improve shoulder movement. However, if physical therapy and conservative treatment alone do not improve your function, surgical options may exist.

If You Have Surgery

If your condition is severe, you may require surgery to restore use of the shoulder; physical therapy will be an important part of your recovery process. The repaired rotator cuff is vulnerable to reinjury following shoulder surgery; working with a physical therapist is crucial to safely regaining full use of the injured arm. After the surgical repair, you will need to wear a sling to keep your shoulder and arm protected as the repair heals. Your physical therapist will apply treatments during this phase of your recovery to reduce pain and gently begin to restore movement. Once you are able to remove the sling for exercise, your physical therapist will begin your full rehabilitation program.

Your physical therapist will design a treatment program based on both the findings of the evaluation and your personal goals. Your physical therapist will guide you through your postsurgical rehabilitation, which will progress from gentle range-of-motion and strengthening exercises to activity- or sport-specific exercises.

Your treatment program most likely will include a combination of exercises to strengthen the rotator cuff and other muscles that support the shoulder joint. The time line for your recovery will vary depending on the surgical procedure and your general state of health, but return to sports, heavy lifting, and other strenuous activities might not begin until 4 months after surgery and full return may not occur until 9 months to 1 year after surgery. Following surgery, your shoulder will be susceptible to reinjury. It is extremely important to follow the postoperative instructions provided by your surgeon and physical therapist.

Your rehabilitation will typically be divided into 4 phases:

  • Phase I (maximal protection). Phase 1 of treatment lasts for the first few weeks after your surgery, when your shoulder is at the greatest risk of reinjury. During this phase, your arm will be in a sling. You will likely need assistance or need strategies to accomplish everyday tasks, such as bathing and dressing. Your physical therapist will teach you gentle range-of-motion and isometric strengthening exercises, provide hands-on treatments (manual therapy), such as gentle massage, offer advice on reducing your pain, and may use techniques such as cold compression and electrical stimulation to relieve pain.

  • Phase II (moderate protection). This next phase has the goal of restoring mobility to the shoulder. You will reduce the use of your sling, and your range-of-motion and strengthening exercises will become more challenging. Exercises will be added to strengthen the "core" muscles of your trunk and shoulder blade (scapula), and the rotator-cuff muscles that provide additional support and stability to your shoulder. You will be able to begin using your arm for daily activities, but will still avoid heavy lifting. Your physical therapist may use special hands-on mobilization techniques during this phase to help restore your shoulder's range of motion.

  • Phase III (return to activity). This phase has the goal of restoring your strength and joint awareness to equal that of your other shoulder. At this point, you should have full use of your arm for daily activities, but you will still be unable to participate in activities such as sports, yard work, or physically strenuous work-related tasks. Your physical therapist will advance the difficulty of your exercises by adding weight or by having you use more challenging movement patterns. A modified weight-lifting/gym-based program may also be started during this phase.

  • Phase IV (return to occupation/sport). This phase will help you return to work, sports, and other higher-level activities. During this phase, your physical therapist will instruct you in activity-specific exercises to meet your needs. For certain athletes, this may include throwing and catching drills. For others, it may include practice in lifting heavier items onto shelves, or instruction in proper positioning for everyday tasks such as raking, shoveling, or doing housework.

Can this Injury or Condition be Prevented?

A physical therapist can help you reduce the worsening of the symptoms of a rotator cuff tear and may decrease your risk of worsening a tear, especially if you seek assistance at the first sign of shoulder pain or discomfort. To avoid developing a rotator cuff tear from an existing shoulder problem, it is imperative to stop performing actions that could make it worse. Your physical therapist can help you strengthen your rotator cuff muscles, train you to avoid potentially harmful positions, and determine when it is appropriate for you to return to your normal activities.

To maintain shoulder health and prevent rotator cuff tears, physical therapists recommend that you:

  • Avoid repeated overhead arm positions that may cause shoulder pain. If your job requires such movements, seek out the advice of a physical therapist to learn arm positions that may be used with less risk.

  • Apply rotator-cuff muscle and shoulder-blade strengthening exercises into your normal exercise routine. The strength of the rotator cuff is just as important as the strength of any other muscle group. To avoid potential harm to the rotator cuff, general strengthening and fitness programs may improve shoulder health.

  • Practice good posture. A forward position of the head and shoulders has been shown to alter shoulder-blade position and create shoulder impingement syndrome.

  • Avoid sleeping on your side with your arm stretched overhead, or lying on your shoulder. These positions can begin the process that causes rotator cuff damage and may be associated with increasing your pain level.

  • Avoid smoking; it can decrease the blood flow to your rotator cuff.

  • Consult a physical therapist at the first sign of symptoms.

Real Life Experiences

Jonathan is a 55-year-old professor who leads a relatively sedentary lifestyle. Recently, with the help of a colleague, he decided to repaint his house. Over the past 3 weeks, he has spent hours a day on a ladder, reaching overhead to scrape old paint and apply new coats. Starting 2 weeks ago, Jonathan began to feel pain in his shoulder after working an hour or so each day. Now, every time he raises his right arm overhead, he feels a sharp pain in his shoulder area. He admits that the pain has been steadily getting worse, and now his arm feels weak. He decides to stop his painting project and call a physical therapist.

Jonathan’s physical therapist takes his health history, noting his lack of daily exercise, and has him describe his symptoms, when they started, and what they now prevent him from doing. He examines Jonathan’s shoulder and arm using the procedures described above. Based on the findings from the examination, Jonathan’s physical therapist suspects that he may have a rotator cuff tear. He advises Jonathan to avoid all activities that require reaching overhead, and to protect the irritated muscles and tendons by performing actions, such as resting his elbow on an armrest when sitting. He refers Jonathan to a physician for an MRI. The test results confirm a diagnosis of a partial-thickness rotator cuff tear.

Jonathan’s physical therapist begins his treatment by teaching him gentle movement and strengthening exercises, and shows him how to apply ice to the shoulder at home to help decrease any irritation and pain. During phase 1 of treatment, he teaches Jonathan specific exercises to help restore pain free range-of-motion and activation of the rotator cuff muscles. 

During phase 2 of Jonathan’s rehabilitation, his physical therapist prescribes exercises to strengthen his rotator cuff and shoulder blade muscles, and addresses any remaining limitations in motion with manual therapy (hands-on treatment) techniques. He teaches Jonathan new movements to improve his posture and his ability to raise his arm without making his symptoms worse.

As Jonathan progresses, his physical therapist adds shoulder exercises that are performed in various positions, functional activities for the arm, and core strengthening exercises. He encourages Jonathan to start taking daily walks and explore other gym-based activities.

Six weeks after starting physical therapy, Jonathan has restored his ability to raise his arm over his head and feels stronger and more fit than he has in years. He has returned to his house painting, with the guidance of his physical therapist. He limits the time spent reaching overhead, adjusts his movements to protect his shoulder at all times, takes daily walks, and performs strengthening exercises to maintain his new-found fitness.

Just this week, a few of Jonathan’s students surprise him by showing up to complete his house-painting project themselves! Jonathan invites them to join him for regular “walk and talk” sessions, where they discuss current class topics while improving their overall fitness.

This story was based on a real-life case. Your case may be different. Your physical therapist will tailor a treatment program to your specific case.

What Kind of Physical Therapist Do I Need?

All physical therapists are prepared through education and experience to treat patients who have a rotator cuff tear, but you may want to consider:

  • A physical therapist who is experienced in treating people with musculoskeletal problems. Some physical therapists have a practice with an orthopedic focus.

  • A physical therapist who is a board-certified clinical specialist or who completed a residency or fellowship in orthopedic physical therapy has advanced knowledge, experience, and skills that may apply to your condition.

You can find physical therapists who have these and other credentials by using Find a PT, the online tool built by the American Physical Therapy Association to help you search for physical therapists with specific clinical expertise in your geographic area.

General tips when you're looking for a physical therapist (or any other health care provider):

  • Get recommendations from family and friends or from other health care providers.

  • When you contact a physical therapy clinic for an appointment, ask about the physical therapists' experience in helping people with labral tears.

  • During your first visit with the physical therapist, be prepared to describe your symptoms in as much detail as possible, and say what makes your symptoms worse.

Further Reading

The American Physical Therapy Association (APTA) believes that consumers should have access to information that could help them make health care decisions and also prepare them for their visit with their health care provider.

APTA has determined that the following articles provide some of the best scientific evidence for how to treat rotator cuff tear. The articles report recent research and give an overview of the standards of practice for treatment both in the United States and internationally. The article titles are listed by year and are linked either to a PubMed* abstract of the article or to free access of the full article, so that you can read it or print out a copy to bring with you to your health care provider.

Kukkonen J, Joulkainen A, Lehtinen J, et al. Treatment of nontraumatic rotator cuff tears: a randomized controlled trial with two years of clinical and imaging follow-up [published correction appears in: J Bone Joint Surg Am. 2016]. J Bone Joint Surg Am. 2015; 97:1729–1737. Article Summary in PubMed.

Eljabu W, Klinger HM, von Knoch M. The natural history of rotator cuff tear: a systematic review. Arch Orthop Trauma Surg.2015;135:1055–1061. Article Summary in PubMed.

Longo UG, Franceschi F, Berton A, et al. Conservative treatment and rotator cuff tear progression. Med Sport Sci. 2012;57:90–99. Article Summary in PubMed.

Düzgün I, Baltacı G, Atay OA. Comparison of slow and accelerated rehabilitation protocol after arthroscopic rotator cuff repair: pain and functional activity.Acta Orthop Traumatol Turc. 2011;45:23–33. Free Article.

Pedowitz RA, Yamaguchi K, Ahmad CS, et al. Optimizing the management of rotator cuff problems.J Am Acad Orthop Surg. 2011;19:368–379. Article Summary in PubMed.

Parsons BO, Gruson KI, Chen DD, et al. Does slower rehabilitation after arthroscopic rotator cuff repair lead to long-term stiffness? J Shoulder Elbow Surg. 2010;19:1034-1039. Article Summary in PubMed.

Oh JH, Kim SH, Ji HM, et al. Prognostic factors affecting anatomic outcome of rotator cuff repair and correlation with functional outcome. Arthroscopy. 2009;25:30-39. Article Summary in PubMed.

Millar AL, Lasheway PA, Eaton W, Christensen F. A retrospective, descriptive study of shoulder outcomes in outpatient physical therapy.J Orthop Sports Phys Ther. 2006;36:403–414. Article Summary in PubMed.

*PubMed is a free online resource developed by the National Center for Biotechnology Information (NCBI).  PubMed contains millions of citations to biomedical literature, including citations in the National Library of Medicine’s MEDLINE database.

Authored by Charles Thigpen, PT, ATC, PhD, and Lane Bailey, PT, DPT. Reviewed by the 
MoveForwardPT.com editorial board.

Medial Collateral Ligament (MCL) Injury

The medial collateral ligament (MCL) is the most commonly damaged ligament in the knee. The MCL can be sprained or torn as a result of a blow to the outer side of the knee, by twisting the knee, or by quickly changing directions while walking or running. MCL injury most often occurs in athletes, although nonathletes can also be affected. A physical therapist treats an MCL sprain or tear to reduce pain, swelling, stiffness, and any associated weakness in the knee or lower extremity.

What is an MCL Injury?

The MCL is a small, thick band of tissue on the inner side of the knee joint. It connects two bones—the thighbone and the shin bone—preventing the knee from bending inward toward the other knee. When the knee is hit on the outer side of the leg (eg, the left side of the left leg), or if the knee is twisted violently, the MCL can overstretch resulting in a partial or complete tear. MCL injuries commonly occur in football players who get "clipped" or hit on the outer side of the knee. Other causes may include twisting and turning while skiing, blows received on the soccer field, trauma experienced in a car accident, or simply turning the knee sharply while the foot is planted on the ground. Healing times vary from a couple of weeks to a couple of months, depending on the severity of the injury.

How Does it Feel?

When you experience an MCL injury, you may feel:

  • Pain on the inner side of the knee

  • Swelling and bruising at the inner side of the knee

  • Swelling that spreads to the rest of the knee joint in 1 or 2 days following injury

  • Stiffness in the knee

  • Difficulty or pain when trying to bend or straighten the knee

  • An unstable feeling, as though the knee may give out or buckle

  • Pain or difficulty walking, sitting down, rising from a chair, or climbing stairs

Signs and Symptoms

With an MCL injury, you may experience

  • A "popping" sound as the injury occurs

  • Pain and swelling in your knee

  • Difficulty moving your knee

  • Difficulty bearing weight on your leg for walking or getting up from a chair

How Is It Diagnosed?

If you see your physical therapist first, the therapist will conduct a thorough evaluation that includes taking your health history. Your therapist will also ask you detailed questions about your injury, such as:

  • Did you feel pain or hear a "pop" when you injured your leg?

  • Did you turn your leg with your foot planted on the ground?

  • Did you change direction quickly while running?

  • Did you receive a direct hit to the leg while your foot was planted on the ground?

  • Did you see swelling around the knee in the first 2 to 3 hours following the injury?

  • Does your knee feel like buckling or giving way when you try to use it?

Your physical therapist also will perform special tests to help determine the likelihood that you have an MCL injury. Your therapist will gently press on the outside of your knee while it is slightly bent as well as when it is fully straight to test the strength of the ligament. The therapist will also check the inner side of your knee for tenderness and swelling and measure for swelling with a tape measure. The therapist may use additional tests to determine if other parts of your knee are injured, and will also observe how you are walking.

To provide a definitive diagnosis, your therapist may collaborate with an orthopedic physician or other health care provider. The orthopedic physician may order further tests, such as magnetic resonance imaging (MRI), to confirm the diagnosis and to rule out other damage to the knee. It also helps to determine whether surgery is required. MRI is not required in all cases but may be ordered. Your therapist or doctor may recommend a knee brace, a knee immobilizer, or crutches to reduce pain if the MCL injury is severe.

How Can a Physical Therapist Help?

Your physical therapist will work with you to design a specific treatment program that will speed your recovery, including exercises and treatments you can do at home. Physical therapy will help you return to your normal lifestyle and activities.

The First 24-48 Hours

Your physical therapist may advise you to:

  • Rest the area by avoiding walking or any activity that causes pain. Crutches and a knee brace may be recommended to reduce further strain on the MCL when walking.

  • Apply ice packs to the area for 15-20 minutes every 2 hours.

  • Compress the area with an elastic bandage wrap.

  • Consult with a physician for further services such as medication or diagnostic tests.

 

Reduce Pain

Your physical therapist may use different types of treatments and technologies to control and reduce your pain, including ice, heat, ultrasound, electrical stimulation, taping, exercises, and hands-on therapy such as massage.

Improve Motion

Your physical therapist will choose specific activities and treatments to help restore normal movement in the knee and leg. These might begin with passive motions that the therapist performs for you to gently move your leg and knee joint, and progress to active exercises and stretches that you do yourself.

Improve Strength

Certain exercises will aid healing at each stage of recovery; your physical therapist will choose and teach you the correct exercises and equipment to steadily restore your strength and agility. These may include using cuff weights, stretchy bands, weight-lifting equipment, and cardio-exercise equipment such as treadmills or stationary bicycles.

Improve Balance

Regaining your sense of balance is important after an injury. Your physical therapist will teach you exercises to improve your balance skills.

Speed Recovery Time

Normal healing of time is a few weeks to a few months, depending on which tissues are injured and how severely they are injured. Your physical therapist is trained and experienced in choosing the right treatments and exercises to help you heal, return to your normal lifestyle, and reach your goals faster than you are likely to do on your own.

Return to Activities

Your physical therapist will discuss your goals with you and use them to set your work, sport, and homelife recovery goals. The therapist will design your treatment program to help you reach those goals in the safest, fastest, and most effective way possible. Your physical therapist will apply hands-on therapy, such as massage, and teach you exercises, work retraining activities, and sport-specific techniques and drills to help you achieve your goals.

Prevent Future Injury

Your physical therapist can recommend a home exercise program to strengthen and stretch the muscles around your knee, upper leg, and abdomen to help prevent future injury. These may include strength and flexibility exercises for the leg, knee, and core muscles.

If Surgery Is Necessary

Surgery is rarely necessary in the case of an MCL injury. If surgery is needed, you will follow a recovery program over several weeks guided by your physical therapist, who will help you minimize pain, regain motion, strength, and return to normal activities as quickly as possible after surgery.

Can this Injury or Condition be Prevented?

To help prevent a recurrence of the injury, your physical therapist may advise you to:

  • Learn how to not let your knees collapse in toward each other when jumping, running, or turning quickly

  • Practice balance and agility exercises and drills

  • Always warm up before starting a sport or heavy physical activity

  • Follow a consistent strength and flexibility exercise program to maintain good physical conditioning, even in a sport's off-season

  • Wear shoes that are in good condition and fit well

Real Life Experiences

Mark is a 35-year-old accountant who is an avid bowler on the weekends. He lives with his 100-lb Rottweiler dog. One morning, as Mark was quickly turning a corner into the kitchen to grab a ringing phone, his dog ran the other way and accidentally hit Mark’s knee on the outer side of his right leg. Mark lost his balance and fell sideways. His right foot got caught underneath the dog as his body fell to the right, forcing the outer side of the knee to buckle and the inner side of the knee to overstretch. Mark felt a sharp pain on the inner side of his knee, and fell to the ground. Mark felt immediate tenderness on the inner side of his knee, and he could not straighten or bend it.

Mark was able to see his physical therapist that day. The physical therapist performed special tests on the ligaments and cartilage in the knee. She found that just the MCL was injured, and that it was a mild sprain. She immediately applied ice and electrical stimulation to the area for 20 minutes. She wrapped Mark’s knee with a compressive wrap and instructed him to keep it elevated when he was sitting or lying down. She gave Mark crutches and taught him how to use them.

When Mark returned for his next visit, the physical therapist began gently moving the knee to reduce the stiffness. She taught Mark some exercises he could do at home to start improving his muscle strength. She helped him use equipment in the clinic to gently move, stretch, and strengthen his knee and leg.

Mark received physical therapy treatments for 2 weeks, after which he was able to walk and climb stairs with only a little discomfort. His therapist taught him a variety of balance and endurance exercises. By the third week, he was able to return to bowling, and walk around sharp corners in his house, while keeping a watchful eye on his energetic dog!

This story was based on a real-life case. Your case may be different. Your physical therapist will tailor a treatment program to your specific case.

What Kind of Physical Therapist Do I Need?

All physical therapists are prepared through education and experience to treat MCL injury. However, you may want to consider:

  • A physical therapist who is experienced in treating people with orthopedic injuries. Some physical therapists have a practice with an orthopedic focus.

  • A physical therapist who is a board-certified clinical specialist or who has completed a residency or fellowship in orthopedic or sports physical therapy. This therapist has advanced knowledge, experience, and skills that may apply to your condition.

You can find physical therapists that have these and other credentials by using Find a PT, the online tool developed by the American Physical Therapy Association to help you search for physical therapists with specific clinical expertise in your geographic area.

General tips when you're looking for a physical therapist (or any other health care provider):

  • Get recommendations from family and friends or from other health care providers.

  • When you contact a physical therapy clinic for an appointment, ask about the physical therapists' experience in helping people who have your type of injury.

  • During your first visit with the physical therapist, be prepared to describe your symptoms in as much detail as possible, and say what makes your symptoms worse.

Further Reading

The American Physical Therapy Association (APTA) believes that consumers should have access to information that could help them make health care decisions and also prepare them for their visit with their health care provider.

The following articles provide some of the best scientific evidence related to physical therapy treatment of MCL injury. The articles report recent research and give an overview of the standards of practice both in the United States and internationally. The article titles are linked either to a PubMed* abstract of the article or to free full text, so that you can read it or print out a copy to bring with you to your health care provider.

Frommer C, Masaracchio M. The use of patellar taping in the treatment of a patient with a medial collateral ligament sprain. N Am J Sports Phys Ther. 2009;4(2):60-69. Free Article.

Hunt SE, Herrera C, Cicerale S, et al. Rehabilitation of an elite olympic class sailor with MCL injury. N Am J Sports Phys Ther. 2009;4(3):123-131. Free Article.

Edson CJ. Conservative and postoperative rehabilitation of isolated and combined injuries of the medial collateral ligament.Sports Med Arthrosc. 2006;14(2):105-110. Article Summary on PubMed.

Azar FM. Evaluation and treatment of chronic medial collateral ligament injuries of the knee. Sports Med Arthrosc. 2006;14(2):84-90. Article Summary on PubMed.

Fung DT, Ng GY, Leung MC, Tay DK. Effects of a therapeutic laser on the ultrastructural morphology of repairing medial collateral ligament in a rat model. Lasers Surg Med. 2003;32(4):286-293. Article Summary on PubMed.

Reider B. Medial collateral ligament injuries in athletes. Sports Med. 1996;21(2):147-156. Article Summary on PubMed.

Paletta GA, Warren RF. Knee injuries and Alpine skiing: treatment and rehabilitation. Sports Med. 1994;17(6):411-423. ArticleSummary on PubMed.

*PubMed is a free online resource developed by the National Center for Biotechnology Information (NCBI).  PubMed contains millions of citations to biomedical literature, including citations in the National Library of Medicine’s MEDLINE database.

 Authored by Andrea Avruskin, PT, DPT. Reviewed by the MoveForwardPT.com editorial board.

Female Athlete Triad

Female athlete triad (triad) is a syndrome that can manifest across a broad spectrum, but involves the interrelationship between 3 measurable factors: (1) how much energy a woman has available to use for activity (energy availability), (2) the quality and strength of her bones (bone mineral density), and (3) her menstrual cycle. Clinically, imbalances in any one of these areas can lead to eating problems, osteopenia/osteoporosis, and/or menstrual dysfunction. The prevalence of all 3 components of female athlete triad among high school, collegiate, and elite athletes in the United States can be as high as 16%; the prevalence of any one component of the triad in this population can be as high as 60%.

What is Female Athlete Triad?

Female athlete triad is a syndrome that can involve both the physical and mental aspects of health. It develops in female athletes based on 3 factors: energy availability, bone mineral density, and the menstrual cycle.

Energy availability is calculated by how much energy you gain from dietary sources, minus the amount of energy you expend during activity. Typically, with triad poor energy availability is the driving force behind abnormal bone density and menstrual dysfunction. Poor energy availability is caused by poor nutrition; it can occur with or without the presence of an eating disorder. Nutrients act to provide the necessary source of fuel for bones and muscles. Poor nutrition also can have a negative effect on the part of the brain that controls hormones that regulate the menstrual cycle. Optimal energy availability supports bone health specifically by maintaining estrogen levels. Estrogen is an important hormone that has a protective effect on bone by supporting the balance between bone building and bone loss. Therefore, lack of estrogen can impact bone density and may increase the risk of bone stress injuries.

Bone mineral density (BMD) defines 1 aspect of bone health. When your bones are not supplied with necessary nutrients or are stressed too much through overexercising, they may begin to weaken. This weakening can lead to osteopenia (lower than normal BMD) and further, osteoporosis (a loss of bone strength that predisposes a person to increased risk of fractures). When a person has low BMD, she may be at an increased long-term risk of bone mineral loss and fracture as she ages.

Menstrual dysfunction refers to abnormal menstrual periods. This spectrum can range from oligomenorrhea (inconsistent menstrual cycles) to amenorrhea (absence of a menstrual period) in females who are of a reproductive age.

Female athletes are at an increased risk of developing triad due to the high demand that athletics place on the female body physically, as well as the increasing societal pressures for performance and image. For example, a female runner may feel that altering or restricting caloric intake will make her a faster runner, therefore gaining an edge on the competition and earning greater success in her sport. Triad can be present in any female athlete, from the elite athlete striving to reach high-performance goals, to the adolescent female whose body is going through normal changes related to puberty. In any case, there are physical and psychological aspects of this syndrome that affect its extent, impact, and treatment.

How Does it Feel?

Female athlete triad is not caused by a sudden traumatic injury; therefore, no immediate symptoms typically appear. Instead, symptoms related to the 3 components of triad may develop over time, ranging from months to years.

A female athlete may begin experiencing the following symptoms, conditions, or changes (separately or together) that may indicate she is developing female athlete triad:

  • Low energy during school, work, or exercise

  • Irregular or absent menstrual cycles

  • Stress-related bone injuries (stress reactions or fractures)

  • Difficulty concentrating

  • An unexplained drop in performance

  • Changes in eating habits

  • Altered sleeping patterns

  • An unusually high focus on performance or image

  • Experiencing high levels of stress

How Is It Diagnosed?

A multidisciplinary team of medical providers typically diagnoses female athlete triad. The team may include medical doctors, nutritionists, physical therapists, certified athletic trainers, and psychologists. However, nonmedical individuals, such as parents, friends, coaches, teammates, teachers, and work colleagues can also be resources to help identify female athletes who demonstrate signs of triad, as these are all people who spend time with the athlete. Often, the athlete does not realize that she has low energy availability or any of the symptoms of triad; therefore, it often becomes the responsibility of a health care professional to educate a patient and her parents and coaches.

If it is suspected that an athlete may be demonstrating 1 or more components of triad, a proper screening interview can help identify the components, including questions about menstrual status and history, history of stress or bone injury, and eating disorder tendencies. These questions may include:

  • Have you ever had a stress fracture?

  • Do you have menstrual periods?

  • Are you trying to or has anyone recommended that you gain or lose weight?

  • Are you on a special diet?

  • Have you ever been diagnosed with an eating disorder?

To diagnose triad, a number of medical and psychological tests and consultations may be recommended, including:

  • Diagnostic imaging of bone health (ie, X-ray, bone density scan [DEXA])

  • Referral to a nutritionist for dietary assessment

  • Referral to a primary care or family medical doctor for monitoring of menstrual function or related medical tests (eg, blood tests, assessment of the natural stages of development, such as the onset of puberty)

  • Referral to a physical therapist for functional assessment (ie, motion, strength, movement quality)

Because triad involves multiple components of health, an athlete who is able to receive care from all relevant health care practitioners has the best chance of developing a comprehensive plan to return to good health and athletic participation/performance.

How Can a Physical Therapist Help?

Physical therapists are trained to identify signs and symptoms of female athlete triad and initiate multidisciplinary care as appropriate and needed. The physical therapist can assist with prevention and the promotion of health, wellness, and fitness, in addition to providing rehabilitation following an injury. Primary prevention includes proper screening of any female athlete for triad, asking questions such as those stated above, and referring the athlete to other appropriate health care professionals.

Physical therapists are also trained to understand the implications that triad may have on exercise prescription. For example, an athlete with a stress fracture due to low BMD should not perform jumping and running movements. Once an athlete's symptoms are resolved, her physical therapist can design an individualized return-to-activity program that encourages a safe, progressive level of activity. A physical therapist also can identify if an athlete is at an increased risk of overuse injury or abnormal loading of the bone or a joint.

Physical therapists are trained to educate athletes and their families about triad, and work with athletes to prevent or resolve the condition—guiding them back to safe, optimal performance levels. In many cases, this attention to and care for a female athlete's overall health can improve her performance in athletics and in school as well, and boost her overall self-esteem. Many athletes report that they are more confident, stronger, and better equipped to achieve their goals when they feel they have strong support and a plan for sustained health.

Can this Injury or Condition be Prevented?

The Female Athlete Triad is a very preventable condition.

The most effective approach to prevention is education. As both the level of female participation in competitive sports and the incidence of the Triad have risen over the last 2 decades, a stronger emphasis has been put on educating athletes, parents, and coaches on strategies to prevent the development of causal factors for the Triad. It is important to begin educating young female athletes as early as middle-school age on topics such as healthy eating, smart physical training, recovery and rest, and taking care of their bodies.

Coaches should monitor training and its impact on the overall health of the athlete by encouraging pain-free participation in sports; they may also track training and performance in order to notice any abnormal health or behavioral signs. Individuals involved in the life of a female athlete should promote an open, honest, and safe environment for the athlete so that she feels comfortable discussing challenges or issues she may be facing without the risk of external pressure or judgment.

Real Life Experiences

Jenna is a 17-year-old junior in high school who runs cross-country and track, and swims on a competitive, year-round swim team. Jenna is a very talented athlete. She has been swimming since age 5; last year, with encouragement of her coaches, she decided to start running to improve her fitness for swimming. She immediately ranked in the top 5 runners on the school’s cross-country team. Jenna recently started receiving phone calls from college swim coaches. It has been her dream to earn a scholarship to swim in college, and as she begins to feel like it may be a real possibility, she commits to training harder than ever for both running and swimming.

For several weeks, Jenna practices both sports every day, rushing from the track to the pool with no time to rest or grab a snack. The junior year is the hardest academic year at her school; she has been swamped with homework and only gets around 5 hours of sleep each night.

After finishing in the top 10 at the state cross-country meet in November, Jenna started 2-a-day swim practices without taking any time off. During her weight-room sessions, she began to notice her shin was growing very sore with each workout, and that she wasn’t able to increase her weights like she did last season. Her shin didn’t bother her in the pool, but she had a hard time completing workouts and hitting her running times. She just felt tired all the time, and began to grow discouraged and unmotivated. Her mom took her to see a physical therapist.

Jenna's physical therapist asked her specific questions about her training. Jenna felt comfortable being honest with her. Jenna mentioned that she had started skipping lunch so that she wouldn’t feel lethargic for practice, and rarely had time to eat a full dinner because of her homework load. She told her physical therapist that she was beginning to feel like her chances of getting a college scholarship were slipping away.

Jenna and her physical therapist had a long discussion about the best plan to help her return to good health and achieve her goals. Her physical therapist helped her see that her desire to perform at a high level had become out of balance with her ability to take care of her body. She encouraged Jenna not to feel guilty, but to feel positive about her opportunity to address her challenges. She told Jenna that she may have to rest for a few weeks to begin to restore her full strength. Jenna was frustrated by the situation, but excited to work toward returning to full health. They discussed the plan with her coaches and parents, and everyone was on board.

Jenna's physical therapist referred her to an orthopedic physician for evaluation of her bone health, as well as to a nutritionist to evaluate her diet and come up with a proper fueling plan that met the high physical demands of swimming and running. After resting for several weeks, Jenna began her physical therapy. Her physical therapist designed an individualized program to restore and enhance her strength, endurance, and movement quality. She and her coaches worked on a training plan that would allow adequate rest and recovery.

By the national swim meet that March, Jenna was in the best shape of her life and placed first in her event, setting a new personal-best time. That summer, the college of her choice called with a scholarship offer. Jenna felt happy and healthy entering her senior year, excited for the adventures ahead!

This story was based on a real-life case. Your case may be different. Your physical therapist will tailor a treatment program to your specific case.

What Kind of Physical Therapist Do I Need?

All physical therapists are prepared through education and experience to identify female athlete triad. However, you may want to consider:

  • A physical therapist who is experienced in working with people who have female athlete triad. Some physical therapists have a practice with an orthopedic or musculoskeletal focus.

  • A physical therapist who is a board-certified clinical specialist or who completed a residency or fellowship in orthopedic or sports physical therapy. This physical therapist has advanced knowledge, experience, and skills that may apply to your condition.

You can find physical therapists who have these and other credentials by using Find a PT, the online tool built by the American Physical Therapy Association to help you search for physical therapists with specific clinical expertise in your geographic area.

General tips when you're looking for a physical therapist (or any other health care provider):

  • Get recommendations from family and friends or from other health care providers.

  • When you contact a physical therapy clinic for an appointment, ask about the physical therapists' experience in helping people with female athlete triad.

  • During your first visit with the physical therapist, be prepared to describe your symptoms in as much detail as possible.

Further Reading

The American Physical Therapy Association (APTA) believes that consumers should have access to information that could help them make health care decisions and also prepare them for their visit with their health care provider.

The following articles provide some of the best scientific evidence related to physical therapy treatment of female athlete triad. The articles report recent research and give an overview of the standards of practice both in the United States and internationally. The article titles are linked either to a PubMed* abstract of the article or to free full text, so that you can read it or print out a copy to bring with you to your health care provider.

Goolsby M, Boniquit N. Bone health in athletes: the role of exercise, nutrition, and hormones. Sports Health. 2017;9(2):108–117. Free Article.

Stickler L, Hoogenboom BJ, Smith L. The female athlete triad: what every physical therapist should know. Int J Sports Phys Ther. 2015;10(4):563–571. Free Article.

Nazem TG, Ackerman KE. The female athlete triad. Sports Health. 2012;4(4):302–311. Free Article.

Nichols JF, Rauh MJ, Lawson MJ, Ji M, Barkai HS. Prevalence of the female athlete triad syndrome among high school athletes. Arch Pediatr Adolesc Med. 2006;160(2):137–142. Free Article.

Donaldson ML. The female athlete triad: a growing health concern. Orthop Nurs. 2003;22(5):322–324. Article Summary on PubMed.

Female Athlete Triad Coalition.  Accessed April 11, 2018.

International Society of Sports Nutrition.  Accessed March 29, 2018.

* PubMed is a free online resource developed by the National Center for Biotechnology Information (NCBI). PubMed contains millions of citations to biomedical literature, including citations in the National Library of Medicine’s MEDLINE database.

Authored by Laura Stanley, PT, DPT, board-certified clinical specialist in sports physical therapy. Updated by Valerie Bobb, PT, DPT, board-certified women's health specialist in physical therapy. Reviewed by the MoveForwardPT.com editorial board.


Shoulder Labral Tear

An unstable shoulder joint can be the cause or the result of a labral tear. "Labral" refers to the ring of cartilage (glenoid labrum) that surrounds the base of the shoulder joint. Injuries to the labrum are common, can cause a great deal of pain, and may make it hard to move your arm. A labral tear can occur from a fall or from repetitive work activities or sports that require you to use your arms raised above your head. Some labral tears can be managed with physical therapy; in severe cases, surgery may be required to repair the torn labrum.

The ring of cartilage called the glenoid labrum provides extra support for the shoulder joint, helping to keep it in place. A shoulder labral tear occurs when part of this ring is disrupted, frayed, or torn. Tears may lead to shoulder pain, an unstable shoulder joint, and, in severe cases, dislocation of the shoulder. Likewise, a shoulder dislocation can result in labral tears.

When you think of the shoulder joint, picture a golf ball (the head of the upper-arm bone, or humerus) resting on a golf tee (the glenoid fossa, a shallow cavity or socket located on the shoulder blade, or scapula). The labrum provides a rim for the socket (golf tee) so that the humerus (golf ball) does not easily fall off. If the labrum is torn, it is harder for the humerus to stay in the socket. The end result is that the shoulder joint becomes unstable and prone to injury.

Because the biceps tendon attaches to the shoulder blade through the labrum, labral tears can occur when you put extra strain on the biceps muscle, such as when you throw a ball. Tears also can result from pinching or compressing the shoulder joint, when the arm is raised overhead.

There are 2 types of labral tears:

  • Traumatic labral tears usually occur because of a single incident, such as a shoulder dislocation or an injury from heavy lifting. People who use their arms raised over their heads—such as weight lifters, gymnasts, and construction workers—are more likely to experience traumatic labral tears. Activities where the force occurs at a distance from the shoulder, such as striking a hammer or swinging a racquet, can cause a traumatic labral tear. Falling on an outstretched arm also can cause this type of tear.

  • Nontraumatic labral tears most often occur because of muscle weakness or shoulder joint instability. When the muscles that stabilize the shoulder joint are weak, more stress is put on the labrum, leading to a tear. People with nontraumatic tears tend to have more "looseness" or greater mobility throughout all their joints, which might be a factor in the development of a tear.

LabralTear_SM.jpg

How Does it Feel?

A shoulder labral tear may cause you to feel:

  • Pain over the top of your shoulder

  • "Popping," "clunking," or "catching" with shoulder movement, because the torn labrum has "loose ends" that are flipped or rolled within the shoulder joint during arm movement, and may even become trapped between the upper arm and shoulder blade

  • Shoulder weakness, often on one side

  • A sensation that your shoulder joint will pop out of place

How Is It Diagnosed?

Not all shoulder labral tears cause symptoms. In fact, when tears are small, many people function without any symptoms. However, healing may be difficult due to the lack of blood supply available to a torn labrum. The shoulder with a labral tear may pop or click without being painful, but if the tear progresses, it is likely to lead to pain and weakness.

If your physical therapist suspects that you have a labral tear, your physical therapist will review your health history and perform an examination that is designed to test the condition of the glenoid labrum. The tests will place your shoulder in positions that may recreate some of your symptoms, such as "popping," "clicking," or mild pain, to help your physical therapist determine whether your shoulder joint is unstable. Magnetic resonance imaging (MRI) also may be used to complete the diagnosis. Some labral tears may be difficult to diagnose with certainty without arthroscopic surgery. Your physical therapist may consult with an orthopedic surgeon if necessary.

How Can a Physical Therapist Help?

When shoulder labral tears cause minor symptoms but don’t cause shoulder instability, they usually are treated with physical therapy. Your physical therapist will educate you about positions and activities to avoid, and tailor a treatment plan for your recovery. Your treatment may include:

Manual therapy. Your physical therapist may provide gentle manual (hands-on) therapy to decrease your pain and begin to restore movement in the shoulder area.

Strengthening exercises. Improving the strength of the muscles of the shoulder will help you decrease the stresses placed on the torn labrum and allow for better healing. Your physical therapist may design rotation exercises that target the muscles of the shoulder joint, and shoulder-blade (scapular) exercises to provide stability to the shoulder joint itself.

Stretching exercises. An imbalance in the muscles or a decrease in flexibility can result in poor posture or excessive stress within the shoulder joint. Your physical therapist may prescribe stretching exercises—such as gentle stretches of the chest (pectoralis) muscles—to improve the function of the muscles surrounding the shoulder. Your physical therapist also may introduce middle-back (thoracic) stretches to allow your body to rotate or twist to the side, so the shoulder joint doesn’t have to stretch further to perform tasks, such as swinging a racquet or golf club.

Postural exercises. Your physical therapist will assess your posture, and teach you specific exercises to ensure your shoulders are positioned properly for daily tasks. A forward-head and rounded-shoulder posture puts the shoulders at risk for injury.

Education. Education is an important part of any physical therapy treatment plan. Your physical therapist will help you understand your injury, the reasons for modifying your activities, and the importance of doing your exercises to decrease your risk of future injury.

Home-exercise program. A home-exercise program is an important companion to treatment in the physical therapy clinic. Your physical therapist will identify the stretching and strengthening exercises that will help you steadily improve your shoulder function and meet your work, home, and activity goals.

Following Surgery

In more severe cases, when conservative treatments are unable to completely relieve the symptoms of a labral tear, surgery may be required to reattach the torn labrum. Following surgery, your physical therapist will design a treatment program based on your specific needs and goals, and work with you to help you safely return to your daily activities.

A surgically repaired labrum takes 9 to 12 months to completely heal. Immediately following surgery, your physical therapist will teach you ways to avoid putting excessive stress or strain on the repaired labrum.

As the labrum heals, your physical therapist will introduce resistance and strengthening exercises, such as those listed above, to your treatment plan, to address your specific needs, and help you slowly and safely return to performing daily tasks that require force or lifting. Your physical therapist is trained to gradually introduce movements in a safe manner to allow you to return to your usual activities without re-injuring the repaired tissues.

Can this Injury or Condition be Prevented?

Forceful activities performed with the arms raised overhead may increase the likelihood of developing a labral tear. To avoid putting excessive stress on the labrum, you need to develop strength in the muscles that surround the shoulder and scapula. Your physical therapist can:

  • Design exercises to help you strengthen your shoulder and shoulder blade muscles

  • Show you how to avoid potentially harmful positions

  • Train you to properly control your shoulder movement and modify your activities to reduce your risk of sustaining a labral injury

  • Provide posture education to help you avoid placing unnecessary forces on the shoulder

  • Help you increase your shoulder and middle-back flexibility


What Kind of Physical Therapist Do I Need?

All physical therapists are prepared through education and experience to treat patients who have a shoulder labral tear, but you may want to consider:

  • A physical therapist who is experienced in treating people with musculoskeletal problems. Some physical therapists have a practice with an orthopedic focus.

  • A physical therapist who is a board-certified clinical specialist or who completed a residency or fellowship in orthopedics physical therapy has advanced knowledge, experience, and skills that may apply to your condition.

You can find physical therapists who have these and other credentials by using Find a PT, the online tool built by the American Physical Therapy Association to help you search for physical therapists with specific clinical expertise in your geographic area.

General tips when you're looking for a physical therapist (or any other health care provider):

  • Get recommendations from family and friends or from other health care providers.

  • When you contact a physical therapy clinic for an appointment, ask about the physical therapists' experience in helping people with labral tears.

  • During your first visit with the physical therapist, be prepared to describe your symptoms in as much detail as possible, and say what makes your symptoms worse.

Further Reading

The American Physical Therapy Association (APTA) believes that consumers should have access to information that could help them make health care decisions and also prepare them for their visit with their health care provider.

APTA has determined that the following articles provide some of the best scientific evidence for how to treat labral tears. The articles report recent research and give an overview of the standards of practice for treatment both in the United States and internationally. The article titles are linked either to a PubMed* abstract of the article or to free access of the full article, so that you can read it or print out a copy to bring with you to your health care provider.

Mazzocca AD, Cote MP, Solovyova O, et al. Traumatic shoulder instability involving anterior, inferior, and posterior labral injury: a prospective clinical evaluation of arthroscopic repair of 270° labral tears. Am J Sports Med. 2011;39:1687-1696.  Article Summary on PubMed.

Dodson CC, Altchek DW. SLAP lesions: an update on recognition and treatment. J Orthop Sports Phys Ther. 2009;39:71-80. Article Summary on PubMed.

Keener JD, Brophy RH. Superior labral tears of the shoulder: pathogenesis, evaluation, and treatment. J Am Acad Orthop Surg. 2009;17:627-637. Article Summary on PubMed.

 *PubMed is a free online resource developed by the National Center for Biotechnology Information (NCBI).  PubMed contains millions of citations to biomedical literature, including citations in the National Library of Medicine’s MEDLINE database.”

Authored by Charles Thigpen, PhD, PT, ATC and Lane Bailey, PT, DPT, CSCS. Reviewed by the MoveForwardPT.com editorial board.

 


Hip Bursitis

Hip bursitis is a painful condition that affects 15% of women and 8.5% of men of all ages in the United States. The condition tends to develop more in middle-aged and elderly individuals. Hip bursitis can have many causes, but the most common is a repetitive activity, such as walking or running on an uneven surface, which creates friction in the hip area. Athletes often develop hip bursitis after running up and down hills repetitively. The condition can also be caused by abnormal walking, such as limping, due to an uneven leg length, or arthritis in the back, hip, knee, or other joints in the leg. It can also occur without any specific cause. Physical therapy can be an effective treatment for hip bursitis to reduce pain, swelling, stiffness, and any associated weakness in the hip, back, or lower extremity.

Hip bursitis (also called trochanteric bursitis) occurs when one or both of the 2 bursae (fluid-filled sacs on the side of the hip) become damaged, irritated, or inflamed. Bursitis (“-itis” means “inflammation of”) means the bursa has become irritated and inflamed, usually causing pain. Normally, the bursa acts as a cushion for muscles and tendons that are close to it. Certain positions, motions, or disease processes can cause constant friction or stress on the bursa, leading to the development of bursitis. When the bursa becomes injured, those muscles and tendons don’t glide smoothly over it, and they can become painful.

Hip bursitis can be caused by:

  • Repetitive motions (running up and down hills or stairs)

  • Muscle weakness

  • Incorrect posture

  • Direct trauma (being hit or falling on the side of the hip)

  • Differences in the length of each leg

  • Hip surgery or replacement

  • Bone spurs in the hip

  • Infection

  • Diseases, such as rheumatoid arthritis, gout, psoriasis, or thyroid disease

  • Muscles or tendons in the hip area rubbing the bursa and causing irritation

How Does it Feel?

With hip bursitis, you may experience:

  • Pain on the outer side of the hip, thigh, buttock, or outside of the leg.

  • Pain when you push on the outer side of the hip with your fingers.

  • Pain when lying on the affected hip.

  • Pain when climbing stairs.

  • Pain that worsens when getting up from sitting, such as from a low chair or car seat.

  • Pain when walking or running.

  • Pain when lifting the leg up to the side.

  • Pain when sitting with legs crossed.

How Is It Diagnosed?

If you see your physical therapist first, the physical therapist will conduct a thorough evaluation that includes taking your health history. Your physical therapist also will ask you detailed questions about your condition, such as:

  • How and when did you notice the pain?

  • Have you been performing any repetitive activity?

  • Did you receive a direct hit to the hip or fall on it? 

Your physical therapist will perform special tests to help determine the likelihood that you have hip bursitis. Your physical therapist will gently press on the outer side of the hip to see if it is painful to the touch, and may use additional tests to determine if other parts of your hip are injured. Your physical therapist also will observe how you are walking.

Your physical therapist will test and screen for other, more serious conditions that could cause lateral hip pain. To provide a definitive diagnosis, your physical therapist may collaborate with an orthopedic physician or other health care provider, who may order further tests (eg, an x-ray) to confirm the diagnosis and rule out other damage to the hip, such as a fracture.

How Can a Physical Therapist Help?

Your physical therapist will work with you to design a specific treatment program that will speed your recovery, including exercises and treatments that you can do at home. Physical therapy will help you return to your normal lifestyle and activities. The time it takes to heal the condition varies, but results can be achieved in 2 to 8 weeks or less, when a proper stretching and strengthening program is implemented.

During the first 24 to 48 hours following your diagnosis, your physical therapist may advise you to:

  • Rest the area by avoiding walking or any activity that causes pain.

  • Apply ice packs to the area for 15 to 20 minutes every 2 hours.

  • Consult with a physician for further services, such as medication or diagnostic tests.

Your physical therapist will work with you to:

Reduce Pain and Swelling. If repetitive activities have caused the hip bursitis, your physical therapist will help you understand how to avoid or modify your activities to allow healing to begin. Your physical therapist may use different types of treatments and technologies to control and reduce your pain and swelling, including ice, heat, ultrasound, electrical stimulation, taping, exercises, and hands-on therapy, such as specialized massage.

Improve Motion. Your physical therapist will choose specific activities and treatments to help restore normal movement in the hip and leg. These might begin with "passive" motions that the physical therapist performs for you to gently move your hip joint, and progress to active exercises and stretches that you do yourself.

Improve Flexibility. Your physical therapist will determine if any leg or spinal muscles are tight, help you to stretch them, and teach you how to stretch them.

Improve Strength. Hip bursitis is often related to weak or injured hip muscles. Certain exercises will aid healing at each stage of recovery; your physical therapist will choose and teach you the correct exercises and equipment to steadily restore your strength and agility. These may include using cuff weights, stretch bands, weight-lifting equipment, and cardio-exercise equipment, such as treadmills or stationary bicycles.

Improve Balance. Regaining your sense of balance is important after an injury. Your physical therapist will teach you exercises to improve your balance skills.

Learn a Home-Exercise Program. Your physical therapist will teach you strengthening and stretching exercises to perform at home. These exercises will be specific for your needs; if you do them as prescribed by your physical therapist, you can speed your recovery.

Return to Activities. Your physical therapist will discuss your activity goals with you and use them to set your work, sport, and home-life recovery goals. Your treatment program will help you reach your goals in the safest, fastest, and most effective way possible. Your physical therapist will teach you exercises, work retraining activities, and sport-specific techniques and drills that match your lifestyle.

Speed Recovery Time. Your physical therapist is trained and experienced in choosing the best treatments and exercises to help you safely heal, return to your normal lifestyle, and reach your goals faster than you are likely to do on your own.

If Surgery Is Necessary

Surgery is not commonly required for hip bursitis. However, if surgery is needed, you will follow a recovery program over several weeks guided by your physical therapist. Your physical therapist will help you minimize pain, regain motion and strength, and return to normal activities in the safest and speediest manner possible.

Can this Injury or Condition be Prevented?

Your physical therapist can recommend a home-exercise program to strengthen and stretch the muscles around your knee, upper leg, and abdomen to help prevent future injury. These may include strength and flexibility exercises for the leg, knee, and core muscles.

To help prevent a recurrence of the injury, your physical therapist may advise you to:

  • Follow a consistent flexibility and strengthening exercise program, especially for the hip muscles, to maintain good physical conditioning, even in a sport's off-season.

  • Always warm up before starting a sport or heavy physical activity.

  • Gradually increase any athletic activity, rather than suddenly increasing the activity amount or intensity.

  • Obtain a professionally fitted shoe insert, if your legs are different lengths.

  • Learn and maintain correct posture.

Real Life Experiences

John is a 30-year-old dentist who enjoys running, biking, and triathlon training. He recently decided to add CrossFit training to his exercise routine, and joined an aggressive CrossFit gym. After running stairs intensely during 1 session, John felt pain developing on the outside of his right hip a few hours later. He realized that he was limping. By the end of the day, he was having trouble climbing stairs because of the hip pain. He contacted his physical therapist.

John's physical therapist asked him how and when he felt the pain. She observed him walking, and noted his limp. She gently touched the soft tissues on the outside of his hip, and noted the tenderness he felt when she pushed right over the bony spot on the outer side of the hip. She tested the strength and flexibility in his hip and back. She concluded that his hip bursa was irritated and inflamed, and that he had some tight and weak muscles in the area. She diagnosed hip bursitis. She asked John about his goals, which he said were to get rid of the pain, walk normally, and return to his previous level of exercising as well as his CrossFit club activities.

John's physical therapist began his treatment by gently stretching the muscles she had found were tight. Next, she applied ice and electrical stimulation to the area to help halt and reverse the inflammation process. She discussed with John the importance of “relative rest” for the hip area, meaning he should avoid activities like stair running, lunges, and squats for a few days, until his pain subsided.

When John returned for his next treatment, he was already feeling less pain. His physical therapist noted that his limp was almost gone. She started teaching John strengthening exercises for the muscle weakness she had found in his hip and back muscles. Only light weights were used to avoid causing new pain. As John improved, the weights were steadily increased.

Two weeks later, John's physical therapist added light jogging to John’s program, which he was able to do without increasing his pain. During the third week, John was improved enough to add lunges. By the fourth week, he was able to begin jogging up stairs in short sessions.

By the fifth week, John was able to rejoin his CrossFit club, although he was mindful to increase his workouts slowly and gradually, especially when it came to running stairs. He learned from his physical therapist to avoid any sudden increases in exercise. John also incorporated some of the special strengthening exercises he learned from his physical therapist into his warm-up and workout.

When he met his physical therapist at the store 6 months later, John was happy to report he was functioning at his top fitness level, and by following the advice he learned from her, he had prevented any recurrence of hip bursitis.

What Kind of Physical Therapist Do I Need?

All physical therapists are prepared through education and experience to treat hip bursitis. However, you may want to consider:

  • A physical therapist who is experienced in treating people with orthopedic injuries. Some physical therapists have a practice with an orthopedic focus.

  • A physical therapist who is a board-certified clinical specialist, or who completed a residency or fellowship in orthopedic or sports physical therapy. This therapist has advanced knowledge, experience, and skills that may apply to your condition.

You can find physical therapists who have these and other credentials by using Find a PT, the online tool built by the American Physical Therapy Association to help you search for physical therapists with specific clinical expertise in your geographic area.

General tips when you're looking for a physical therapist (or any other health care provider):

  • Get recommendations from family and friends or from other health care providers.

  • When you contact a physical therapy clinic for an appointment, ask about the physical therapists' experience in helping people who have your type of injury.

  • During your first visit with the physical therapist, be prepared to describe your symptoms in as much detail as possible, and say what makes your symptoms worse.

Further Reading

The American Physical Therapy Association (APTA) believes that consumers should have access to information that could help them make health care decisions and also prepare them for their visit with their health care provider. The following articles provide some of the best scientific evidence related to physical therapy treatment of hip bursitis. The articles report recent research and give an overview of the standards of practice both in the United States and internationally. The article titles are linked either to a PubMed* abstract of the article or to free full text, so that you can read it or print out a copy to bring with you to your health care provider.

Haviv B. Update on trochanteric bursitis of the hip. OA Orthopaedics. 2013;1(1):10. Article summary not available.

Lustenberger DP, Ng VY, Best TM, Ellis TJ. Efficacy of treatment of trochanteric bursitis: a systematic review. Clin J Sport Med. 2011;21(5):447–453. Free Article.

Segal NA, Felson DT, Torner JC, et al. Greater trochanteric pain syndrome: epidemiology and associated factors. Arch Phys Med Rehabil. 2007;88(8):988–992. Free Article.

Jones DL, Erhard RE. Diagnosis of trochanteric bursitis versus femoral neck stress fracture. Phys Ther. 1997;77(1):58–67. Free Article.

Butcher JD, Salzman KL, Lillegard WA. Lower extremity bursitis [erratum in: Am Fam Physician. 1996;54(2):468]. Am Fam Physician. 1996;53(7):2317–2324.

Hammer WI. The use of transverse friction massage in the management of chronic bursitis of the hip or shoulder. J Manipulative Physiol Ther. 1993;16(2):107–111. Article Summary in PubMed.

Sears B. Physical therapy for hip pain. About.com website. Accessed December 9, 2014.

Physical therapy management of trochanteric bursitis. Morphopedics website. Accessed December 9, 2014.

Trochanteric bursitis. Cleveland Clinic website. Accessed December 9, 2014.

University of Washington Orthopedics and Sports Medicine. Bursitis, tendinitis, and other soft tissue rheumatic syndromes. Accessed December 9, 2014.

*PubMed is a free online resource developed by the National Center for Biotechnology Information (NCBI). PubMed contains millions of citations to biomedical literature, including citations in the National Library of Medicine’s MEDLINE database.

Authored by Andrea Avruskin, PT, DPT. Reviewed by the MoveForwardPT.com editorial board.



What Is Vertigo?

Vertigo is the sensation of spinning—even when you're perfectly still, you might feel like you're moving or that the room is moving around you. Most causes of vertigo involve the inner ear ("vestibular system"). A number of conditions can produce vertigo, such as:

  • Inner ear infections or disorders

  • Migraines

  • Tumors, such as acoustic neuroma

  • Surgery that removes or injures the inner ear or its nerves

  • Head injury that results in injury to the inner ears

  • A hole in the inner ear

  • Stroke

You also might have:

  • Nausea

  • Vomiting

  • Sweating

  • Abnormal eye movements

One of the most common forms of vertigo is benign paroxysmal positional vertigo, an inner-ear problem that causes short periods of a spinning sensation when your head is moved in certain positions.

How Is It Diagnosed?

Your physical therapist will use your answers to the following questions to help identify the cause of your vertigo and to determine the best course of treatment:

  • When did you first have vertigo (the sensation of spinning)?

  • What are you doing when you have vertigo (turning your head, bending over, standing perfectly still, rolling in bed)?

  • How long does the vertigo last(seconds, minutes, hours, days)?

  • Have you had vertigo before?

  • Do you have hearing loss, ringing, or fullness in your ears?

  • Do you have nausea with the spinning?

  • Have you had any changes in your heart rate or breathing?

Your physical therapist will perform tests to determine the causes of your vertigo and also to assess your risk of falling. Depending on the results of the tests, your therapist may recommend further testing or consultation with your physician.

How Can a Physical Therapist Help?

Based on your physical therapist's evaluation and your goals for recovery, the therapist will customize a treatment plan for you. The specific treatments will depend on the cause of your vertigo. Your therapist's main focus is to help you get moving again and manage the vertigo at the same time. Treatment may include specialized head and neck movements or other exercises to help eliminate your symptoms. Conditions such as benign paroxysmal positional vertigo have very specific tests and treatments.

If you have dizziness and balance problems after your vertigo has stopped, your physical therapist can develop a treatment plan that targets those problems. Your physical therapist will teach you strategies to help you cope with your symptoms:

  • Do certain activities or chores around the house cause you to become dizzy? Your therapist will show you how to do those activities in a different way to help reduce the dizziness.

  • Have simple activities become difficult and cause fatigue and more dizziness? Your therapist will help you work through these symptoms right away so you can get moving again and return to your roles at home and at work more quickly.

Physical therapy treatments for dizziness can take many forms. The type of exercise that your therapist designs for you will depend on your unique problems and might include:

  • Exercises to improve your balance

  • Exercises to help the brain "correct" differences between your inner ears

  • Exercises to improve your ability to focus your eyes and vision

In addition, your physical therapist might prescribe exercises to improve your strength, your flexibility, and your heart health—with the goal of improving your overall physical health and well being.

What Kind of Physical Therapist Do I Need?

All physical therapists are prepared through education and experience to treat people with dizziness. You may want to consider:

  • A physical therapist who is experienced in treating people with neurological problems. Some physical therapists have a practice with a neurological vestibular rehabilitation focus.

  • A physical therapist who is a board-certified clinical specialist or who completed a residency or fellowship in neurological physical therapy. This therapist has advanced knowledge, experience, and skills that may apply to your condition.

You can find physical therapists who have these and other credentials by using Find a PT, the online tool built by the American Physical Therapy Association to help you search for physical therapists with specific clinical expertise in your geographic area.

General tips when you're looking for a physical therapist (or any other health care provider):

  • Get recommendations from family and friends or from other health care providers.

  • When you contact a physical therapy clinic for an appointment, ask about the physical therapists' experience in helping people with inner ear injury.

  • During your first visit with the physical therapist, be prepared to describe your symptoms in as much detail as possible, and say what makes your symptoms worse.

Further Reading

The American Physical Therapy Association (APTA) believes that consumers should have access to information that could help them make health care decisions and also prepare them for their visit with their health care provider.

The following articles provide some of the best scientific evidence about physical therapy treatments for vertigo. The articles report recent research and give an overview of the standards of practice for treatment both in the United States and internationally. The article titles are linked either to a PubMed abstract of the article or to free full text, so that you can read it or print out a copy to bring with you to your health care provider.

Hillier SL, McDonnell M. Vestibular rehabilitation for unilateral peripheral vestibular dysfunction. Cochrane Database Syst Rev. 2011;16;(2):CD005397. Systematic Review. Article Summary on PubMed.

Helminski JO, Zee DS, Janssen I, Hain TC. Effectiveness of particle repositioning maneuvers in the treatment of benign paroxysmal positional vertigo: a systematic review.Phys Ther. 2010;90:663–678. Free Article.

Scherer MR, Schubert MC. Traumatic brain injury and vestibular pathology as a comorbidity after blast exposure. Phys Ther. 2009;89:980-992. Free Article.

Cohen HS, Sangi-Haghpeykar H. Canalith repositioning variations for benign paroxysmal positional vertigo. Otolaryngol Head Neck Surg. 2010;143:405–412. Free Article.

*PubMed is a free online resource developed by the National Center for Biotechnology Information (NCBI). PubMed contains millions of citations to biomedical literature, including citations in the National Library of Medicine’s MEDLINE database.

Authored by Melissa S. Bloom, PT, DPT; Bob Wellmon, PT, PhD, NCS; and APTA's Neurology Section. Reviewed by the MoveForwardPT.com editorial board.



Degenerative Disk Disease

What Is Degenerative Disk Disease?

Your spine is made up of 33 vertebrae that are stacked on top of one another. Between each of these vertebrae is a rubbery piece of cartilage called an "intervertebral disk." (See images: Degenerative Disk Disease - Cervical | Lumbar.) Imagine the disk as a tire, with gelatin filling the hole in the tire. The tire is called the "annulus," and the gelatin is called the "nucleus." When we're young—under 30 years of age—the disk is made mostly of gelatin. As we age, and sometimes with injury, we start to lose some of that gelatin and the volume of the disk decreases, resulting in less space between the vertebrae. The disk becomes flatter and less flexible, leaving less space between each set of vertebrae. Sometimes bone spurs form in response to this degeneration of the disk, which could make the spine stiff. Often, this flattening and additional stiffness to the spine is not at all painful.  However, in some cases, when the rough surfaces of the vertebral joints rub together, pain and inflammation may result. The nerve root, the point where a spinal nerve exits the spine and extends to other parts of the body, may become irritated or compressed.

Disk degeneration may occur throughout several regions of the spine, or it may be limited to 1 disk. Degeneration does not always lead to pain. For some people, however, it can cause a great deal of pain and disability.

You are more likely to develop DDD if you:

  • Smoke
  • Are obese
  • Do heavy physical work
  • Don't get very much exercise
DDD_Cervical_md.jpg

 

How Does it Feel?

With DDD, you may experience mild to intense neck and back pain—or no pain at all:

  • A degenerative disk in the neck may cause pain in the arm, shoulder, or neck.
  • A degenerative disk in the low back may cause pain in the back, buttocks, or legs.

The pain is often made worse by sitting, bending, and reaching. It may be worse first thing in the morning and after staying in any one position for a long time.

In severe cases, when DDD results in pressure on the nerve root, it can lead to numbness, tingling, and even weakness in the arms or legs.

How Is It Diagnosed?

Your physical therapist will conduct a thorough evaluation that includes a review of your medical history, and will use screening tools to determine the likelihood of DDD. For example, your physical therapist may:

  • Ask you very specific questions about the location and behavior of your pain, weakness, and other symptoms
  • Ask you to fill out a body diagram to indicate specific areas of pain, numbness, and tingling
  • Perform tests of muscle strength and sensation to determine the presence of pressure on the nerve
  • Examine your posture and observe how you walk and perform other activities
  • Measure the range of motion of your spine and your arms and legs
  • Use manual (hands-on) therapy to evaluate the mobility of the joints and muscles in your spine
  • Test the strength of important muscle groups

If you have muscle weakness, loss of sensation, or severe pain, diagnostic tests, such as an X-ray or MRI, may be needed. However, X-ray evidence of wearing in the joints of the spine is found in people with back pain as well as in many who have never experienced back pain. Studies have shown that disc degeneration is present in 40% of individuals under the age of 30 and present in over 90% of those aged 50 to 55 years. Do not panic if your X-ray or MRI shows “problems” with your discs; these are normal changes that happen from the age of 20 years and onward. Physical therapists work closely with physicians and other health care providers to make certain that an accurate diagnosis is made and the appropriate treatment is provided.

Research shows that in all but the most extreme cases (usually involving muscle weakness or high levels of pain), conservative care, such as physical therapy, has better results than surgery. Research also shows that results from conservative care and surgery are the same after 18 months post operatively.

After the evaluation, if your physical therapist suspects you have DDD and there are no major medical problems, treatment can begin right away.

How Can a Physical Therapist Help?

Your physical therapist's overall purpose is to help you continue to participate in your daily activities and life roles. Your physical therapist will design a treatment program based on both the findings of the evaluation and your personal goals. The treatment program may include:

Stretching and flexibility exercises. Your physical therapist will teach you specific exercises to improve movement in the joints and muscles of your spine, arms, and legs. Improving motion in a joint is often the key to pain relief.

Strengthening exercises. Strong trunk muscles provide support for your spinal joints, and strong arm and leg muscles help take some of the workload off your spinal joints.

Aerobic exercise. Regular aerobic exercise, such as walking, swimming, or taking a low-impact aerobics class, has been shown to help relieve pain, promote a healthy body weight, and improve overall strength and mobility—all important factors in managing DDD.

This might sound like a lot of exercise, but don't worry, research shows that the more exercise you can handle, the quicker you'll get rid of your pain and other symptoms.

Your treatment program may also include:

Manual therapy. Your physical therapist may apply manual (hands-on) therapy, such as massage, to improve movement in stiff joints and tight muscles that may be contributing to your symptoms.

Posture and body mechanics education. Your physical therapist may show you how to make small changes in how you sit, stand, bend, and lift—even in how you sleep—to help relieve your pain and help you manage your condition on your own.

Note: Studies show that recurrence of neck and low back pain is common when a condition such as DDD is not properly treated. Regular performance of the exercises your physical therapist chooses for you is extremely important to make sure your pain does not return.

Can this Injury or Condition be Prevented?

DDD is a natural result of aging. However, you can make choices that lessen its impact on your life and slow its progression. Your local physical therapy clinic can offer you advice on staying strong and fit. Some physical therapy clinics conduct regular educational seminars to help people in the community learn to take care of their backs and necks. Your physical therapist can help you develop a fitness program that takes into account your DDD. There are some exercises that are better than others for people with DDD, and your physical therapist will choose the right ones for you. For instance:

  • Exercising in water can often be a great way to stay physically active when other forms of exercise are painful.
  • Exercises involving repetitive twisting and bending need to be performed with some caution. If you start to notice some aching or pain after exercising, consult with a health care professional, such as a physical therapist, who can improve the way you move—and help reduce or eliminate your back or neck symptoms.
  • Weight-training exercises, though important, need to be done with proper form to avoid stress to the back and neck. Your physical therapist will work with you to ensure your weight training is safe and effective.

What Kind of Physical Therapist Do I Need?

All physical therapists are prepared through education and experience to treat people who have DDD. You may want to consider:

  • A physical therapist who is experienced in treating people with pain, orthopedic, or musculoskeletal, diagnoses.
  • A physical therapist who is a board-certified clinical specialist or who completed a residency or fellowship in orthopaedic physical therapy. This therapist has advanced knowledge, experience, and skills that may apply to your condition.
  • You can find physical therapists who have these and other credentials by using Find a PT, the online tool built by the American Physical Therapy Association to help you search for physical therapists with specific clinical expertise in your geographic area.

General tips when you're looking for a physical therapist:

  • Get recommendations from family and friends or from other health care providers.
  • When you contact a physical therapy clinic for an appointment, ask about the physical therapist's experience in helping people with DDD.
  • During your first visit with the physical therapist, be prepared to describe your symptoms in as much detail as possible, and say what makes your symptoms worse.

Further Reading

The American Physical Therapy Association (APTA) believes that consumers should have access to information that could help them make health care decisions and also prepare them for their visit with their health care provider.

The following articles provide some of the best scientific evidence related to physical therapy treatment of degenerative disk disease. The articles report recent research and give an overview of the standards of practice for treatment of DDD both in the United States and internationally. The article titles are linked either to a PubMed abstract of the article or to free full text, so that you can read it or print out a copy to bring with you to your health care provider.

Macedo LG, Maher CG, Latimer J, McAuley JH. Motor control exercise for persistent, nonspecific low back pain: a systematic review. Phys Ther. 2009;89:9–25. Free Article.

Beattie PF. Current understanding of lumbar intervertebral disc degeneration: a review with emphasis upon etiology, pathophysiology, and lumbar magnetic resonance imaging findings. J Orthop Sports Phys Ther. 2008;38:329–340. Free Article.

Chou R, Qaseem A, Snow V, et al. Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society [published correction appears in: Diagnosis and treatment of low back pain. Ann Intern Med. 2008]. Ann Intern Med. 2007;147:478–491. Free Article.

Roh JS, Teng AL, Yoo JU, et al. Degenerative disorders of the lumbar and cervical spine. Orthop Clin North Am. 2005:36:255–262. Article Summary on PubMed.

Authored by Chris Bise, PT, DPT. Reviewed by the MoveForwardPT.com editorial board.

Thoracic Outlet Syndrome

Thoracic Outlet Syndrome (TOS) is a potentially painful and disabling condition of the upper extremity. It results from the compression of structures in the thoracic outlet, a space just above the first rib, and behind the clavicle (collar bone). Due to the range of signs and symptoms that can lead to a diagnosis of TOS, the incidence rates of the condition currently are unknown. Physical therapists work with individuals who have TOS to ease their symptoms and restore their upper-body function.

How Does it Feel?

Because TOS generally is classified based upon the type of structures compressed, the symptoms experienced may vary. However, more than 90% of TOS cases are thought to be neurogenic (nerve compression) in nature (categories 3 and 4 below).

Arterial TOS

  • Pain in the hand; rarely in shoulder or neck
  • Coldness or cold intolerance
  • Numbness and tingling

Venous TOS

  • Pain in the arm
  • Swelling in the arm
  • Change in arm coloration (appears bluish)
  • Feeling of heaviness in the arm
  • Numbness and tingling in fingers and hands

True Neurogenic TOS

  • Pain, numbness, and tingling in the hand, arm, shoulder, and often the neck
  • Headaches
  • Numbness and tingling of the arm, often waking the individual up at night
  • Hand clumsiness
  • Intolerance to cold
  • Hand coldness and color changes

Disputed Neurogenic TOS

  • Pain, numbness and tingling in the hand, arm, shoulder and often the neck
  • Headaches
  • Numbness and tingling of the arm, often waking the individual up at night
  • Hand clumsiness
  • Intolerance to cold
  • Hand coldness and color changes
  • Symptoms greater at night vs day
  • Tests may come back normal (hence, the term "disputed").

How Is It Diagnosed?

Diagnosis of TOS begins with a thorough health history and clinical examination.

Your physical therapist will likely check for color changes in the affected area, and gently attempt to provoke symptoms by moving the affected limb in different directions.

You also may be referred for diagnostic testing, such as a Doppler ultrasound, which can confirm arterial and venous TOS, or nerve conduction velocity testing to help confirm a true neurogenic TOS.

Your physical therapist may be the first to recognize an onset of TOS, because of its effects on your physical function. Your physical therapist may ask you:

  • When did you begin experiencing these symptoms, and when are they the worst?
  • Have you noticed any change in your symptoms when the temperature changes?
  • Have you noticed any significant changes in your ability to perform physical tasks that require hand movements?
  • Have you noticed any changes in the appearance of your arm or hand?

In addition, your physical therapist will rule out other conditions, which may mimic this disorder. Your therapist may ask you to fill out a questionnaire in order to better understand your physical state, and to screen for the presence of other conditions.

How Can a Physical Therapist Help?

Once you have received a diagnosis of TOS, your physical therapist will work with you to develop a treatment plan to help ease the discomfort, and improve your ability to perform daily activities. Most research on this condition recommends a treatment plan that involves physical therapy to help ease your symptoms and improve function.

Physical therapy treatments may include:

Manual Therapy. Manual (hands-on) therapy may be applied to manipulate or mobilize the nerves of the arm to help reduce symptoms, such as pain and numbness/tingling. Your physical therapist also may attempt to gently mobilize your first rib and/or collar bone.

Movement and Strengthening Exercises. Your physical therapist will teach you muscle-strengthening exercises to improve movement and strength in the affected area.

Education. Your physical therapist will teach you strategies that can help minimize your symptoms while performing your daily functional activities.

Activity modification and postural strategies: Your physical therapist will teach you positions and strategies to place less stress on the structures involved with TOS.

Can this Injury or Condition be Prevented?

While some cases of TOS cannot be prevented, such as those due to anatomical variations, congenital conditions, trauma, or space-occupying lesions, others may be avoidable. Understanding risk factors that could make you more likely to develop this condition is the first step in prevention.

Your physical therapist will work with you to develop strategies to help you better understand and manage your risk factors and symptoms. As with many conditions, education is key. Understanding strategies, such as methods of reducing symptoms while performing activities, can help you live a full and functional life after the onset of TOS.

Real Life Experiences

George is a 45-year-old used-car salesman who takes potential customers on test drives in a crowded city area. Recently on a test drive, his customer ran a red light and the vehicle was struck by another motorist on the passenger side, where George was sitting. George was shaken up, although the police assured him the actual collision was minor.

George was taken to the emergency room following the accident, and received an X-ray, which was negative for a fracture of his clavicle. Fearing that he may be having a heart attack, he also followed up with his primary care physician, who was able to rule that out as well.

Over the next few days, George felt pain on his right side, and numbness and tingling down his right arm. His symptoms seemed to be worse at night. He called in sick to work, fearing he could be injured further on the job. He called his physical therapist.

George's physical therapist conducted a full physical examination. During the exam, George reported that he felt very anxious about the recent event, and wasn’t sure he'd be able to trust taking customers on test drives anymore.    

George's physical therapist noticed the presence of a rounded shoulder and forward-head posture, as she examined him. She was able to provoke George’s symptoms by gently placing his arm in particular positions, and gently pressing in the region of George’s first rib. She carefully checked for any other conditions that could be causing his symptoms. She told George that she suspected neurogenic TOS.

She developed a strategy for physical therapy that was best for him, consisting of activities and exercises to increase his strength, confidence, and function, while also easing his pain. She showed him postural activities to reduce compressive forces on his nerves. She also helped him with "nerve gliding" activities (encouraging his nerves to glide normally as his joints moved) to improve the function of the affected nerves.

Despite the complexity of the condition, George did well with his personalized course of physical therapy. Following several weeks of treatment and exercise, he was able to return to work without symptoms, and with a new-found confidence that he could ride in a car with customers again. With his physical therapist's ongoing help, George has returned to his normal activities of daily living.

This story highlights an individualized experience of TOS. Your case may be different. Your physical therapist will tailor a treatment program to your specific needs.

What Kind of Physical Therapist Do I Need?

All physical therapists are prepared through education and clinical experience to treat a variety of conditions or injuries.  You may want to consider:

  • A physical therapist who is experienced in treating people with TOS.
  • A physical therapist who is a board-certified clinical specialist or who completed a residency or fellowship in physical therapy. This therapist has advanced knowledge, experience, and skills that may apply to your condition.

You can find physical therapists who have these and other credentials by using Find a PT, the online tool built by the American Physical Therapy Association to help you search for physical therapists with specific clinical expertise in your geographic area.

General tips when you're looking for a physical therapist (or any other health care provider):

  • Get recommendations from family and friends or from other health care providers.
  • When you contact a physical therapy clinic for an appointment, ask about the physical therapists' experience in helping people with TOS.
  • During your first visit with the physical therapist, be prepared to describe your symptoms in as much detail as possible. Keeping a journal highlighting when you experience pain will help the physical therapist identify the best treatment approach.

Further Reading

The American Physical Therapy Association (APTA) believes that consumers should have access to information that could help them make health care decisions, and also prepare them for their visit with their health care provider.

The following articles provide some of the best scientific evidence related to physical therapy treatment of TOS. The articles report recent research and give an overview of the standards of practice both in the United States and internationally. The article titles are linked either to a PubMed* abstract of the article or to free full text, so that you can read it or print out a copy to bring with you to your health care provider.

Hooper TL, Denton J, McGalliard MK, Brismée JM, Sizer PS Jr. Thoracic outlet syndrome: a controversial clinical condition; part 1: anatomy and clinical examination/diagnosis. J Man Manip Ther. 2010:18(2):74–83. Free Article. Article Summary in PubMed.

Hooper TL, Denton J, McGalliard MK, Brismée JM, Sizer PS Jr. Thoracic outlet syndrome: a controversial clinical condition; part 2: non-surgical and surgical management. J Man Manip Ther. 2010;18z(3):132–138. Free Article. Article Summary in PubMed.

Watson LA, Pizzari T, Balster S. Thoracic outlet syndrome part 2: conservative management of thoracic outlet. Man Ther. 2010;15(4):305–314. Article Summary in PubMed.

Vanti C, Natalini L, Romeo A, Tosarelli D, Pillastrini P. Conservative treatment of thoracic outlet syndrome: a review of the literature. Eura Medicophys. 2007;43(1):55–70. Article Summary in PubMed.

*PubMed is a free online resource developed by the National Center for Biotechnology Information (NCBI). PubMed contains millions of citations to biomedical literature, including citations in the National Library of Medicine's MEDLINE database.

Authored by Joseph Brence, PT, DPT, FAAOMPT, COMT, DACReviewed by the MoveForwardPT.com editorial board.

Achilles Tendinopathy

Achilles tendinopathy is an irritation of the Achilles tendon. Achilles tendon pain is one of the most common types of pain felt behind the heel and up the back of the ankle when walking or running. Although Achilles tendinopathy affects both active and inactive individuals, 24% of athletes develop the condition, and an estimated 50% of runners will experience Achilles tendon pain in their running careers. In all individuals, Achilles tendinopathy can result in a limited ability to walk, climb stairs, or participate in recreational activities. Physical therapists help people with Achilles tendinopathy reduce pain in the affected area, and restore strength, flexibility, and mobility to the injured tendon and eliminate swelling when present.

Achilles Tendinopathy

Achilles tendinopathy is an irritation of the Achilles tendon, a thick band of tissue along the back of the lower leg that connects the calf muscles to the heel. The term “tendinopathy” refers to any problem with a tendon, either short- or long-term. The Achilles tendon transmits force from the calf muscles down to the foot when a person pushes the foot off the ground (eg, runs or jumps), and helps control the position of the ankle when the foot touches back down on the ground (eg, lands). Achilles tendinopathy results when the demand placed on the Achilles tendon is greater than its ability to function. The condition can occur after a single incident (acute injury) or after repetitive irritation or "microtrauma" (chronic injury). Most often, Achilles tendon pain is the result of repetitive trauma to the tendon that can result in chronic Achilles tendinopathy—a gradual breakdown of the tissue—and is most often treated with physical therapy.

Achilles tendinopathy is linked to several different factors, including:

  • Calf muscle tightness
  • Calf muscle weakness
  • Abnormal foot structure
  • Abnormal foot mechanics
  • Improper footwear
  • A change in an exercise routine or sport activity
  • Obesity

Pain can be present at any point along the tendon; the most common area to feel tenderness is just above the heel (known as midportion Achilles tendinopathy), although it may also be present where the tendon meets the heel (known as insertional Achilles tendinopathy).

AchilleTendonInjury-SM.jpg

How Does it Feel?

With Achilles tendinopathy, you may experience:

  • Tenderness in the heel or higher up in the Achilles tendon with manually applied pressure
  • Pain and stiffness with walking, at its worst with the first several steps
  • Tightness in the calf
  • Swelling in the back of the ankle

How Is It Diagnosed?

Your physical therapist will review your medical history and complete a thorough examination of your heel, ankle, and calf. Your physical therapist will assess your foot posture, strength, flexibility, and movement. This process may include watching you stand in a relaxed stance, walk, squat, step onto a stair, or do a heel raise. The motion and strength in other parts of your leg also will be assessed.

Your physical therapist may also ask questions regarding your daily activities, exercise regimens, and footwear, to identify other contributing factors to your condition.

Imaging techniques, such as X-ray or MRI, are often not needed to diagnose Achilles tendinopathy. Although it is unlikely that your condition will ultimately require surgery, your physical therapist will consult with other medical professionals, such as an orthopedist, to determine the best plan of treatment for your specific condition if it does not respond to conservative care.

How Can a Physical Therapist Help?

Physical therapy promotes recovery from Achilles tendinopathy by addressing issues such as pain or swelling of the affected area, and any lack of strength, flexibility, or body control. You and your physical therapist will work together to develop an individualized treatment program to help you achieve your specific goals in the safest and most effective way possible. Your treatment may include:

Education. Your physical therapist will work with you to identify any possible external factors causing your pain, such as faulty footwear or inappropriate movements or exercises. Your physical therapist will assess your footwear and recommend improvements, and develop a personalized exercise program to help ensure a pain-free return to your desired activities.

Pain management. Many pain-relief strategies may be implemented, such as applying ice to the area, putting the affected leg in a brace, using heel lifts, or using therapies such as iontophoresis (a medicated patch placed on the skin that is electrically charged and used to decrease pain and inflammation), or therapeutic ultrasound. These strategies can reduce the need for pain medication, including opioids.

Manual therapy. Your physical therapist may apply hands-on treatments to gently move your muscles and joints in order to improve their motion and function. These techniques often address areas that are difficult to treat on your own.

Range-of-motion treatments. Your ankle, foot, or knee joint may be moving improperly, causing increased strain on the Achilles tendon. Self-stretching and manual therapy techniques (massage and movement) applied to the lower body to help restore and normalize motion in the foot, ankle, knee, and hip can decrease this tension and restore full range of motion.

Gentle exercise. Loading of the tendon (applying weight or resistance to it) through exercise is beneficial for recovery from Achilles tendinopathy. You may begin by performing gentle strengthening exercises in a seated position (eg, pushing and pulling on a resistive band with your foot). You then may advance to exercises in a standing position (eg, standing heel raises).

Muscle-strengthening exercises. Muscle weakness or imbalance can result in excessive strain on the Achilles tendon. Based on your specific condition, your physical therapist will design an individualized, progressive, lower-extremity resistance program for you to help correct any weakness-associated movement errors that may be contributing to your pain.

Functional training. Once your pain eases and your strength and motion improve, you will need to safely transition back into more demanding activities. To minimize the tension placed on the Achilles tendon and your risk of repeated injury, it is important to teach your body safe, controlled movements. Based on your goals and movement assessment, your physical therapist will create a series of activities that will help you learn how to use and move your body correctly to safely perform the tasks required to achieve your goals.

If additional interventions are needed, such as injections, minimally invasive tendon procedures, or surgery, your physical therapist will work with you after your procedure to help you regain motion, strength, and function.

Can this Injury or Condition be Prevented?

Maintaining appropriate lower-extremity mobility and muscular strength, and paying particular attention to your exercise routine—especially changes in an exercise surface, the volume of exercises performed, and your footwear—are the best methods for preventing Achilles tendinopathy.

When you have experienced an injury, your physical therapist will help guide you through a process that will progressively reintegrate more demanding activities into your routine without aggravating your Achilles tendon. Keep in mind that returning to high-level activities too soon after injury can lead to another episode of pain.

What Kind of Physical Therapist Do I Need?

All physical therapists are prepared through education and experience to treat Achilles tendinopathy. However, you may want to consider:

  • A physical therapist who is experienced in treating people with Achilles tendinopathy. Some physical therapists have a practice with an orthopedic or musculoskeletal focus.
  • A physical therapist who is a board-certified orthopaedic clinical specialist or who completed a residency or fellowship in orthopedic or sports physical therapy. This physical therapist has advanced knowledge, experience, and skills that may apply to your condition.

You can find physical therapists who have these and other credentials by using Find a PT, the online tool built by the American Physical Therapy Association to help you search for physical therapists with specific clinical expertise in your geographic area.

General tips when you're looking for a physical therapist (or any other health care provider):

  • Get recommendations from family and friends or from other health care providers.
  • When you contact a physical therapy clinic for an appointment, ask about the physical therapists' experience in helping people who have Achilles tendinopathy.
  • During your first visit with the physical therapist, be prepared to describe your symptoms in as much detail as possible, and say what makes your symptoms worse.

Further Reading

The American Physical Therapy Association (APTA) believes that consumers should have access to information that could help them make health care decisions and also prepare them for their visit with their health care provider.

The following articles provide some of the best scientific evidence related to physical therapy treatment of Achilles tendinopathy. The articles report recent research and give an overview of the standards of practice both in the United States and internationally. The article titles are linked either to a PubMed* abstract of the article or to free full text, so that you can read it or print out a copy to bring with you to your health care provider.

Martin RL, Chimenti R, Cuddeford T, et al. Achilles pain, stiffness, and muscle power deficits: midportion Achilles tendinopathy revision 2018. J Orthop Sports Phys Ther. 2018;48:A1–A38. Free Article.

Maffulli N, Longo UG, Loppini M, Denaro V. Current treatment options for tendinopathy. Expert Opin Pharmacother. 2010;11:2177–2186. Article Summary on PubMed.

Jonsson P, Alfredson H, Sunding K, Fahistrom M, Cook J. New regimen for eccentric calf-muscle training in patients with chronic insertional Achilles tendinopathy: results of a pilot study. Br J Sports Med. 2008;42:746–749. Article Summary on PubMed.

Alfredson H, Cook J. A treatment algorithm for managing Achilles tendinopathy: new treatment options. Br J Sports Med. 2007;41:211–216. Free Article.

Maffulli N, Wong J, Almekinders LC. Types and epidemiology of tendinopathy. Clin Sports Med. 2003;22:675–692. Article Summary on PubMed.

*PubMed is a free online resource developed by the National Center for Biotechnology Information (NCBI). PubMed contains millions of citations to biomedical literature, including citations in the National Library of Medicine’s MEDLINE database.

Reviewed by Ruth Chimenti, PT, DPT, PhD. Authored by Allison Mumbleau, PT, DPT. Dr Mumbleau is a board-certified sports clinical specialist. Reviewed by the MoveForwardPT.com editorial board.