Patellofemoral Knee Pain

Patellofemoral pain syndrome (PFPS) refers to pain at the front of the knee, in and around the kneecap (patella). PFPS is one of the most common types of knee pain experienced in the United States, particularly among athletes, active teenagers, older adults, and people who perform physical labor. Patellofemoral pain affects more women than men and accounts for 20% to 25% of all reported knee pain. Physical therapists design exercise and treatment programs for people experiencing PFPS to help them reduce their pain, restore normal movement, and avoid future injury.

Current research indicates that PFPS is an "overuse syndrome," which means that it may result from repetitive or excessive use of the knee. Other contributing factors may include:

  • Weakness, tightness, or stiffness in the muscles around the knee and hip

  • An abnormality in the way the lower leg lines up with the hip, knee, and foot

  • Improper tracking of the kneecap

These conditions can interfere with the ability of the kneecap to glide smoothly on the femur (the bone that connects the knee to the thigh) in the femoral groove (situated along the thigh bone) during movement. The friction between the undersurface of the kneecap and the femur causes the pain and irritation commonly seen in PFPS. The kneecap also may fail to track properly in the femoral groove when the quadriceps muscle on the inside front of the thigh is weak, and the hip muscles on the outside of the thigh are tight. The kneecap gets pulled in the direction of the tight hip muscles and can track or tilt to the side, which irritates the tissues around the kneecap.

PFPS often occurs in people who are physically active or who have suddenly increased their level of activity, especially when that activity involves repeated knee motion, such as running, stair climbing, squatting, or repeated carrying of heavy loads. Older adults may experience age-related changes that cause the cartilage on the undersurface of the kneecap to wear out, resulting in pain and difficulty completing daily tasks without pain.

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How Does it Feel?

People with PFPS may experience:

  • Pain when walking up or down stairs or hills

  • Pain when walking on uneven surfaces

  • Pain that increases with activity and improves with rest

  • Pain that develops after sitting for long periods of time with the knee bent

  • A "crack" or "pop" when bending or straightening the knee

How Is It Diagnosed?

Your physical therapist will review your health history, perform a thorough examination, and conduct a series of tests to evaluate the knee. Your therapist may observe the alignment of your feet, analyze your walking and running patterns, and test the strength of your hip and thigh muscles to find out whether there is a weakness or imbalance that might be contributing to your pain. Your physical therapist also will check the flexibility of the muscles in your leg, paying close attention to those that attach at the knee.

Generally, X-rays are not needed to diagnose PFPS. Your physical therapist may consult with an orthopedic physician who may order an X-ray to rule out other conditions.

How Can a Physical Therapist Help?

After a comprehensive evaluation, your physical therapist will analyze the findings and, if PFPS is present, your therapist will prescribe an exercise and rehabilitation program just for you. Your program may include:

Strengthening exercises. Your physical therapist will teach you exercises targeted at the hip (specifically, the muscles of the buttock and thigh), the knee (specifically, the quadriceps muscle located on the front of your thigh that straightens your knee), and the ankle. Strengthening these muscles will help relieve pressure on the knee, as you perform your daily activities.

Stretching exercises. Your physical therapist also will choose exercises to gently stretch the muscles of the hip, knee, and ankle. Increasing the flexibility of these muscles will help reduce any abnormal forces on the knee and kneecap.

Positional training. Based on your activity level, your physical therapist may teach you proper form and positioning when performing activities, such as rising from a chair to a standing position, stair climbing, squatting, or lunging, to minimize excessive forces on the kneecap. This type of training is particularly effective for athletes.

Cross-training guidance. PFPS is often caused by overuse and repetitive activities. Athletes and active individuals can benefit from a physical therapist’s guidance about proper cross-training techniques to minimize stress on the knees.

Taping or bracing. Your physical therapist may choose to tape the kneecap to reduce your pain and retrain your muscles to work efficiently. There are many forms of knee taping, including some types of tape that help align the kneecap and some that just provide mild support to irritated tissues around it. In some cases, a brace may be required to hold the knee in the best position to ensure proper healing.

Electrical stimulation. Your physical therapist may prescribe treatments with gentle electrical stimulation to reduce pain and support the healing process.

Activity-based exercises. If you are having difficulty performing specific daily activities, or are an athlete who wants to return to a specific sport, your physical therapist will design individualized exercises to rebuild your strength and performance levels.

Fitting for an orthosis. If the alignment and position of your foot and arch appear to be contributing to your knee pain, your physical therapist may fit you with a special shoe insert called an orthosis. The orthosis can decrease the stress to your knee caused by low or high arches.

Can this Injury or Condition be Prevented?

PFPS is much easier to treat if it is caught early. Timely treatment by a physical therapist may help stop any underlying problems before they become worse. If you are experiencing knee pain, contact a physical therapist immediately. 

Your physical therapist can show you how to adjust your daily activities to safeguard your knees, and teach you exercises to do at home to strengthen your muscles and bones—and help prevent PFPS.

Physical therapists can assess athletic footwear and recommend proper choices for runners and daily walkers alike. Wearing the correct type of shoes for your activity and changing them when they are no longer supportive is essential to injury prevention.

Real Life Experiences

Amelia is a 25-year-old office assistant who loves to start her day with a 5-mile run. Over the past 6 months, she has been training for her first marathon. She began by training on very flat ground and has just moved to a hilly area.

Last week, Amelia began feeling pain in the front of her left knee when running downhill. Today, she had to stop running after 3 miles because of her knee pain. She called her physical therapist.

Amelia's physical therapist completes a comprehensive evaluation, including a screening for other possible conditions that might be causing her pain. He uses special tests to measure her strength and finds that she has weak hip muscles and tenderness around the kneecap. He determines that she has developed PFPS. Amelia is shocked to learn that she also has flat feet, and she’s not wearing the right supportive running shoes.

To begin her treatments, Amelia’s physical therapist applies special tape to the front of her knee to help reduce her pain, and instructs her in the use of ice to decrease her symptoms. He performs gentle movements of her kneecap and the surrounding tissues to help increase mobility and decrease pain. He teaches her special exercises to gently strengthen the weak muscles that support the knee.

He also designs a specific home-exercise program for Amelia to perform between sessions. He provides information about proper shoe choices for her foot and body type, and advises her to purchase shoes that will give her feet the right type of support. He also recommends that she try deep-water running or swimming for a week instead of her regular running program, until her condition improves.

After her first week of physical therapy, Amelia notices a decrease in her pain and an increased ability to walk up and down stairs without pain. Her physical therapist approves her new footwear, and adds more challenging exercises to her session and her home program. He gives her the go-ahead to race-walk. She applies ice only when she has pain.

After 2 weeks, Amelia reports she is feeling even less pain. Her physical therapist continues to increase the intensity of her exercises, and she starts to run again—but only on flat surfaces and short distances combined with longer walk intervals.

After a few more weeks of therapy, Amelia occasionally feels only slight twinges of pain and gradually resumes her prior level of training. Her physical therapist recommends continuation of her stretching and strengthening exercises, and discharges her from physical therapy.

A few months later, Amelia completes her first marathon pain free. She is thrilled to learn that her time was a personal best!

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 a variety of conditions or injuries. 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 has completed a residency or fellowship in orthopedic physical therapy and 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 patellofemoral pain syndrome.

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 patellofemoral pain syndrome. 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.

Tevhen DS, Robertson J. Knee pain: strengthen my hips? But it's my knees that hurt! J Orthop Sports Phys Ther. 2011-41-571. Article Summary on PubMed.

Davis IS, Powers CM. Patellofemoral pain syndrome: proximal, distal and local factors, an international retreat, April 30-May 2, 2009, Fells Point, Baltimore, MD. J Orthop Sports Phys Ther. 2010;40:A1–A16. Article Summary on PubMed.

Fukuda TY, Rossetto FM, Magalhaes E, et al. Short-term effects of hip abductors and lateral rotators strengthening in females with patellofemoral pain syndrome: a randomized controlled clinical trial. J Orthop Sports Phys Ther. 2010;40:736–742. Article Summary on PubMed.

Dixit S, DiFiori JP, Burton M, Mines B. Management of patellofemoral pain syndrome. Am Fam Physician. 2007;75:194–202. Free Article.

Powers CM, Ward SR, Chan LD, et al. The effect of bracing on patella alignment and patellofemoral joint contact area. Med Sci Sports Exerc. 2004;36:1226-1232. Article Summary on PubMed.

Bizzini M, Childs JD, Piva SR, Delitto A. Systematic review of the quality of randomized controlled trials for patellofemoral pain syndrome. J Ortho Sports Phys Ther. 2003;33:4–20. Article Summary on PubMed.

Crossley K, Bennell K, Green S, et al. Physical therapy for patellofemoral pain: a randomized, double-blinded, placebo-controlled trial. Am J Sports Med. 2002;30:857–865. 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 Christopher Bise, PT, MS, DPT. Revised by Julie Mulcahy, PT. Reviewed by the MoveForwardPT.com editorial board.

 

Ulnar Collateral Ligament Injury

Ulnar collateral ligament (UCL) injuries generally occur when repetitive stress damages the inside of the elbow, compromising stability. UCL injuries are most common in athletes who play "overhead" sports, such as volleyball and baseball, which require using the arms in an overhead position. These injuries are occurring in greater frequency with the rise of sport specialization. They are often referred to as "Tommy John" injuries, named after the famous baseball pitcher who underwent the first surgery for a UCL injury in 1974. A physical therapist can help improve your arm's strength and range of motion, and your body's overall stability and balance following a UCL injury.

What Are Ulnar Collateral Ligament Injuries?

The ulnar collateral ligament is a band of tissue that connects the inside of your upper arm (humerus) to the inside of your forearm (ulna). This ligament helps to support and stabilize your arm when you perform a motion, such as throwing a ball. A UCL injury may at first cause pain and tightness in the area. However, over time and with repetitive stress or trauma, the UCL can become stretched and even tear. Surgery is not always necessary to heal a UCL injury, but it may be performed if pain persists or the elbow feels unstable upon a return to sport or other activities.

Signs and Symptoms

With a UCL injury, you may experience:

  • Soreness or tightness along the inside of your elbow

  • Minor swelling and possible bruising along the inside of your arm

  • Possible numbness and tingling in your arm

  • Instability at your elbow joint (a feeling like your elbow might “give out” when you move it through certain motions)

  • Pain when using your arm in an overhead position (eg, throwing/pitching a ball, swinging a racquet)

  • Difficulty warming up for a sport, or needing a longer time to warm up

  • Poorer performance (eg, a decrease in pitching speed)

How Is It Diagnosed?

Your physical therapist will conduct a thorough evaluation that includes taking your health and activity history. Your physical therapist may ask you questions including:

  • When and how did this injury occur? (Sudden or gradual?)

  • How long have you had pain?

  • Have you had any numbness and tingling in your arm?

  • Did you feel a "pop" near your elbow when throwing or performing an overhead activity?

  • Have you experienced any instability (eg, a feeling of your arm “giving out”) when performing an overhead activity?

  • Have you experienced a decrease in job or sport performance?

  • What other sports or activities do you participate in?

  • Have you had to stop playing your sport, or performing your job, because of the injury to your elbow?

Your physical therapist may gently touch the area around your elbow joint to locate the specific area of pain. Your physical therapist may slightly bend your arm while applying pressure along the outside of your elbow joint, or ask you to mimic a throwing motion as the therapist resists against it.

To provide a definitive diagnosis, your physical therapist may collaborate with an orthopedic surgeon. The surgeon may order further tests, such as magnetic resonance imaging (MRI) or magnetic resonance arthrogram (MRA), to confirm the diagnosis and to rule out other possible damage.

How Can a Physical Therapist Help?

Your physical therapist can help improve your arm's strength and range of motion following a UCL injury, and help restore your shoulder and core stability, coordination, and balance. Your therapist also will work with you before and after any necessary surgery, and can help identify other issues that may have contributed to your injury, such as range of motion and strength deficits, or improper throwing mechanics. Your physical therapist will help you:

Boost your healing process. Decreasing stress across the injured area is the best way to promote healing of a UCL injury. Your physical therapist will likely tell you to take some time off from your sport or other activity. Your therapist may educate you on the RICE (rest, ice, compression, elevation) principle and may implement "cross-friction massage" to help the body supply nutrients to the injured ligament.

Strengthen your muscles. After your injury your arm may feel weaker. Strengthening the muscles of your shoulder, upper back, and shoulder blades in addition to those of the forearm will help decrease the stress at the elbow joint. Addressing lower-body balance or any weakness through your hips and trunk also may help decrease stress across your elbow.

Improve your range of motion. After your injury you may notice more difficulty straightening or bending your arm. Your physical therapist will work with you to improve your arm's range of motion, including possibly stretching your shoulder to help decrease stress on your elbow when performing overhead movements.

Correct your movements. While every sport requires different arm positions, certain positions may put an athlete at greater risk for injury to the elbow. Examining and modifying the movements you perform may help you safely return to your sport. Your physical therapist will help design a specific program to allow a gradual full return to activity.

Prepare to return to sport. An important component of preparing for a return to sports after an UCL injury is preparing the arm to properly withstand the stress placed on it during throwing or other overhead motions. Your physical therapist will work with you to establish and implement a progressive program to prepare you for a return to practice and competition.

If Surgery Is Required

If surgery is necessary, your physical therapist may measure your arm strength and range of motion prior to surgery to define a baseline goal to achieve following the procedure.

Immediately following surgery, your arm will likely be placed in a splint, brace, or sling to protect your elbow. Physical therapy will begin within the first week to 10 days following surgery. Your physical therapist will:

  • Provide appropriate guidance. You will receive an individualized treatment program of gradual rehabilitation that will ensure you heal in the safest and most effective way possible. 

  • Protect the graft/repair site in the early postoperative period. You will be provided a brace that will likely need to be worn for 5 to 6 weeks, depending on your surgeon’s preference. Your physical therapist will show you how to ensure you don’t bend your arm too much or rotate your shoulder too far during this time.

  • Improve how far you can move your shoulder and elbow. When you are ready, your physical therapist will help you gently bend and straighten your arm through different exercises and stretching techniques. Your therapist also will gently stretch your shoulder to help decrease stress across the elbow.

  • Improve the strength of your arm. Through a series of exercises, your physical therapist will work with you to improve your arm strength. Your hand grip and forearm strength will likely be the first things you will work on following surgery. As you progress, the exercises will begin to focus more on your shoulder blade and upper back muscles.

  • Improve muscle strength and coordination. As you begin to heal and progress, your exercises will become more specific to your sport or other activity.

Resuming sport-specific activities. An athlete who has experienced a UCL injury can begin to return to throwing at approximately 6 months after surgery. The return is based on the surgeon and physical therapist providing clearance to do so.

Returning to full competition. An athlete generally can be cleared to return to game competition approximately 12 to 14 months after surgery.

Can this Injury or Condition be Prevented?

Certain factors may increase a person’s chances of injuring the UCL. For example, shoulder and elbow range of motion imbalances may play a role in creating too much stress at the elbow. Balance and coordination deficits also can lead to improper movement during sporting or other activities. Your physical therapist will design an individualized treatment program to address and correct these deficits.

Current evidence suggests the biggest factors for athletes developing this injury are pitch velocity, and the overall volume of throwing and other overhead activities performed in a specific sport. Throwing with high velocity (>83 mph), pitching too many pitches, pitching on short rest, pitching while fatigued, and introducing new pitches in excess are all factors related to exposing the UCL to force that it may not be able to withstand. Other factors such as age, type of sport, and position played also may affect overall arm fitness and health. It is important to keep up with regular arm care and exercises in order to reduce the likelihood of injury. 

Real Life Experiences

Jason is an 18-year-old college baseball player who is also on the Dean’s List at school. Last week, he “pulled an all-nighter” studying for an important test, and pitched an important game on exam day.

Jason pitched a great first inning, but noticed his right elbow began to feel tight in the second inning; he lost some control over his pitches in the third. By the fourth inning, he was pushing through pain and tightness because he didn’t want to let his team down. When throwing a fast ball to the second batter in the fifth inning, he felt a “pop” and a sharp pain in his right elbow. He then felt numbness and tingling on the inside of his right forearm and was unable to continue pitching.

The school’s athletic trainer examined Jason, applied ice to the arm, and put it in a sling. He referred Jason to an orthopedic surgeon who specialized in baseball injuries. The surgeon diagnosed a severe UCL injury. After talking with the surgeon and his family, Jason decided to have surgery to reconstruct the UCL on his right elbow.

Immediately after surgery, Jason was placed in a custom splint that held his elbow at a 90° angle with a sling around his shoulder to support his arm. He began his physical therapy 10 days after his surgery.

Jason’s physical therapist gently removed his splint and helped him begin to move his right elbow and shoulder. He gave Jason a series of exercises to perform at home, to work on his posture, shoulder blade strength, and the overall range of motion of his elbow and shoulder.

Over the next few weeks, Jason teamed with his physical therapist to work on his shoulder and elbow range of motion, single-leg balance exercises, core strengthening, and posture and shoulder-blade exercises. As he regained strength and motion, Jason learned new exercises to strengthen the muscles of his shoulder. His physical therapist measured his range of motion to ensure he was on track, and introduced more intense exercises at the shoulder and elbow.

Jason then began a throwing program that gradually increased the stresses across his elbow as he moved from shorter- to longer-distance throws. His physical therapist and pitching coach instructed him to focus on his mechanics and be aware of the position of his arm, trunk, and legs when he threw.

When the new baseball season began, Jason was able to return to the starting lineup! With careful attention to the instructions of his physical therapist on adequate warm ups, safe throwing motions, maintaining shoulder and arm strength and overall balance, and not throwing too much, he was able to pitch a complete season.

Jason called his physical therapist after his last postseason game, proud to report that he had set a personal record for number of wins and earned run average!

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?

Although all physical therapists are prepared through education and experience to treat UCL injuries, you may want to consider:

  • A physical therapist who is experienced in treating people with UCL injuries. Some physical therapists have a specialized practice with a focus on sports and orthopedics, and more specifically, the upper extremity.

  • A physical therapist who is a board-certified clinical specialist or who has completed a residency or fellowship in sports or orthopaedic 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 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:

  • 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 UCL injuries.

  • 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 a visit with their health care provider.

The following articles provide some of the best scientific evidence related to physical therapy treatment of UCL injuries. 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.

Whiteside D, Martini DN, Lepley AS, Zernicke RF, Goulet GC. Predictors of ulnar collateral ligament reconstruction in Major League Baseball pitchers. Am J Sports Med. 2016;44(9):2202–2209. Article Summary in PubMed.

Bruce JR, Andrews JR. Ulnar collateral ligament injuries in the throwing athlete. J Am Acad Orthop Surg. 2014;22(5):315–325. Article Summary in PubMed.

Garrison JC, Cole MA, Conway JE, et al. Shoulder range of motion deficits in baseball players with an ulnar collateral ligament tear. Am J Sports Med. 2012;40(11):2597–2603. Article Summary on PubMed.

Shanley E, Rauh MJ, Michener LA, et al. Shoulder range of motion measures as risk factors for shoulder and elbow injuries in high school softball and baseball players. Am J Sports Med. 2011;39(9):1997–2006. Article Summary on PubMed.

Wilk KE, Macrina LC, Fleisig GS, et al. Correlation of glenohumeral internal rotation deficit and total rotational motion to shoulder injuries in professional baseball pitchers. Am J Sports Med. 2011;39(2):329–335. Article Summary on PubMed.

Fleisig GS, Andrews JR, Cutter GR, et al. Risk of serious injury for young baseball pitchers: a 10-year prospective study. Am J Sports Med. 2011;39(2):253–257. Article Summary on PubMed.

Hariri S, Safran MR. Ulnar collateral ligament injury in the overhead athlete. Clin Sports Med. 2010;29(4):619–644. Article Summary on PubMed.

Lin YC, Thompson A, Kung JT, et al. Functional isokinetic strength ratios in baseball players with injured elbows. J Sport Rehabil. 2010;19(1):21–29. Article Summary on PubMed.

Dines JS, Frank JB, Akerman M, Yocum LA. Glenohumeral internal rotation deficits in baseball players with ulnar collateral ligament insufficiency. Am J Sports Med. 2009;37(3):566–570. Article Summary on PubMed.

Reinold MM, Wilk KE, Macrina LC, et al. Changes in shoulder and elbow passive range of motion after pitching in professional baseball players. Am J Sports Med. 2008;36(3):523–527. Article Summary on PubMed.

Kibler WB, Sciascia AD, Uhl TL, et al. Electromyographic analysis of specific exercises for scapular control in early phases of shoulder rehabilitation. Am J Sports Med. 2008;36(9):1789–1798. Article Summary on PubMed.

Petty DH, Andrews JR, Fleisig GS, Cain EL. Ulnar collateral ligament reconstruction in high school baseball players. Am J Sports Med. 2004;32(5):1158–1164. 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.

Revised by David Colvin, PT. Authored by Craig Garrison, PT, PhD, ATC, and Joseph Hannon, PT, DPT. Reviewed by the MoveForwardPT.com editorial board.

 


Tarsal Tunnel Syndrome

Tarsal tunnel syndrome (TTS) is a condition that develops when a nerve within the tarsal tunnel of the inner ankle is compressed. TTS can lead to alterations in sensation and movement of the foot, ankle, and lower leg, and/or pain. It is often associated with conditions causing increased compression or swelling in the lower leg. Physical therapists help people experiencing TTS to relieve their pain and restore their normal function.

What is Tarsal Tunnel Syndrome?

Often described as the carpal tunnel syndrome of the lower extremity, tarsal tunnel syndrome is a condition that results from the compression of the posterior tibial nerve as it runs through the tarsal tunnel (a structure made up of bone and tissue (retinaculum) on the inside of the ankle). As it passes through the tarsal tunnel, the tibial nerve divides into 3 branches that provide sensation for the heel and bottom of the foot, and aid in the foot's function. When this structure becomes compressed, symptoms, such as pain, numbness, and/or tingling may occur and radiate into the lower leg, foot, and toes. Individuals may also experience muscle weakness in the area.

How Does it Feel?

The most common symptoms of TTS result from irritation of the tibial nerve and its branches. People with TTS may experience:

  • Pain, numbness, or tingling in the foot or ankle, which may radiate into the lower leg, foot, and toes

  • Weakness in the muscles of the lower leg and foot

  • Weakness of the big toe

  • Foot swelling

  • Symptoms that increase with prolonged standing or walking

  • Symptoms that decrease with rest

  • Altered temperatures of the foot and ankle

  • Pain that disrupts sleep

How Is It Diagnosed?

There are several tests that can help a clinician determine if TTS is present. Your physical therapist and/or physician will first take a comprehensive health history, and inquire about your current symptoms. Then your physical therapist may conduct tests, such as:

  • Gently tapping over the posterior tibial nerve in an attempt to reproduce your symptoms.

  • Tensing of the posterior tibial nerve, a maneuver that looks and feels like a "stretch," in an attempt to reproduce your symptoms.

  • Conducting a nerve condition study—a diagnostic test to determine the speed at which a nerve conducts information.

  • Ruling out other conditions, such as plantarfasciitis (inflammation of the tissue that runs along the bottom of the foot).

How Can a Physical Therapist Help?

Physical therapists play a vital role in helping people experiencing TTS to improve and maintain their daily function and activities. Your physical therapist will work with you to develop a treatment plan to help address your specific needs and goals.  

Because the signs and symptoms of TTS can vary, the approach to care will also vary. Your physical therapist may provide the following recommendations and care:

Nerve Gliding Activities. Gentle exercises that move and "glide" the nerves may help reduce symptoms and improve function.

Muscle Strengthening Exercises. Strengthening activities for any muscles affected by TTS, such as the tibialis posterior muscle in the back of your lower leg.

Balance and Coordination Activities. Work to improve your balance and coordination, which are often affected by TTS.

Orthotics/Taping/Bracing. Apply ankle taping, a custom orthotic, or bracing to position the foot to decrease stress on the posterior tibial nerve.

As with many conditions, education is key. Understanding the underlying mechanisms of TTS, and learning to recognize early signs and symptoms of stress may help you better manage the condition.

Can this Injury or Condition be Prevented?

Although there are no proven strategies for preventing TTS, there are ways to minimize stress to the foot and ankle, such as choosing appropriate footwear, wearing custom orthotics, minimizing the amount of time spent standing on hard surfaces, and improving and maintaining strength in the muscles of your legs, ankles, and feet. These strategies can be discussed further with your physical therapist.

In addition, early detection of the signs and symptoms of TTS will help you and your medical providers begin appropriate management of the condition, which may enhance your long-term well-being.

Real Life Experiences

Kim is a 46-year-old woman who works on an automobile assembly line. Her job involves standing on hard surfaces for prolonged periods of time. Kim recently noticed an onset of pain in her inner ankle after working a few hours, as well as an occasional shooting pain in her big toe. Now, her pain gets progressively worse throughout the day, and often interrupts her sleep. She is afraid of losing her job if she mentions her symptoms to her boss, and really can't afford to miss work. Kim decides to call her physical therapist.

Kim's physical therapist asks about her medical history, and learns that Kim has been diagnosed with high blood pressure and high cholesterol. They discuss Kim’s current symptoms.

He examines Kim’s ankle motion and strength, and gently performs procedures to provoke her symptoms. He also observes how she walks, and assesses her balance. Based on these signs and symptoms, he diagnoses tarsal tunnel syndrome.

Over the next several weeks, Kim works with her physical therapist to reduce her pain and improve her function. Her treatments include:

  • Application of a custom orthotic to better support her foot/ankle.

  • Nerve-gliding activities to improve the mobility of the posterior tibial nerve.

  • Balance exercises.

  • Manual therapy to ease her pain and improve her ankle mobility.

  • Strengthening exercises for her affected muscles.

  • Education about modifying her work positioning and activities.

After 4 weeks of physical therapy, Kim reports a significant reduction in her symptoms. She says she no longer fears going to work, and believes that she has taken control of her current situation. She continues to perform the home-based exercises her physical therapist taught her, and is amazed at how comfortable her feet feel throughout the workday—in her new shoes with custom orthotic inserts.

This story highlights an individualized experience of TTS. 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 experience to treat conditions, such as TTS. However, when seeking a provider, you may want to consider:

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

  • A physical therapist who is well-versed in the treatment of TTS or other neuropathic disorders.

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 painful conditions

  • 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 way of approaching care.

 

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 for the treatment of Tarsal Tunnel Syndrome. 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.

Alshama AM, Souvlis T, Coppieters MW. A review of plantar heel pain of neural origin: differential diagnosis and management. Man Ther. 2008;13(2):103–111. Article Summary on PubMed.

Kavlak Y, Uygur F. Effects of nerve mobilization exercise as an adjunct to the conservative treatment for patients with tarsal tunnel syndrome. J Manipulative Physiol Ther. 2011;34(7):441–448. 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.

Acknowledgements: Joseph Brence, PT, DPT, FAAOMPT, COMT, DAC. 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.

 

Total Knee Replacement (Arthroplasty)

The knee is the most commonly replaced joint in the body. The decision to have knee replacement surgery is one that you should make in consultation with your orthopedic surgeon and your physical therapist. Usually, total knee replacement surgery is performed when people have:

  • Knee joint damage due to osteoarthritisrheumatoid arthritis, other bone diseases, or fracture that has not responded to more conservative treatment options

  • Knee pain or alignment problems in the leg that cause difficulty with walking or performing daily activities, which have not responded to more conservative treatment options

What is a Total Knee Replacement (TKR)?

A total knee replacement (TKR), also known as total knee arthroplasty, involves removing the arthritic parts of the bones at the knee joint (the tibia, sometimes called the shin bone; the femur, or thigh bone; and the patella, or kneecap) and replacing them with artificial parts. These parts consist of a metal cap at the end of the femur and a cemented piece of metal in the tibia with a plastic cap on it to allow the surfaces to move smoothly. When appropriate, the back part of the kneecap also may be replaced with a smooth plastic surface.

KneeReplacement-SM.jpg

How Can a Physical Therapist Help?

The physical therapist is an integral part of the team of health care professionals who help people receiving a total knee replacement regain movement and function, and return to daily activities. Your physical therapist can help you prepare for and recover from surgery, and develop an individualized treatment program to get you moving again in the safest and most effective way possible.

Before Surgery

The better physical shape you are in before TKR surgery, the better your results will be (especially in the short term). A recent study has shown that even 1 visit with a physical therapist prior to surgery can help reduce the need for short-term care after surgery, such as a short stay at a skilled nursing facility, or a home health physical therapy program.

Before surgery, your physical therapist may:

  • Teach you exercises to improve the strength and flexibility of the knee joint and surrounding muscles.

  • Demonstrate how you will walk with assistance after your operation, and prepare you for the use of an assistive device, such as a walker.

  • Discuss precautions and home adaptations with you, such as removing loose accent rugs that could cause you to “catch” your leg on them when maneuvering with an assistive device, or strategically placing a chair so that you can sit instead of squatting to get something out of a low cabinet. It is always easier to make these modifications before you have TKR surgery.

Longer-term adjustments that are recommended prior to surgery include:

  • Stopping smoking. Seek assistance or advice from your physician on stopping smoking, as you schedule and plan for your surgery. Being tobacco-free will improve your healing process following surgery.

  • Losing weight. Losing excess body weight may help you recover more quickly, and help improve your function and overall results following surgery.

Immediately Following Surgery

You may stay in the hospital for a few days following surgery, or you may even go home on the same day, depending on your condition. If you have other medical conditions, such as diabetes or heart disease, you might need to stay in the hospital or go to a skilled nursing facility for a few days before returning home. While you are in the hospital, a physical therapist will:

  • Educate you on applying ice, elevating your leg, and using compression wraps or stockings to control swelling in the knee area and help the incision heal.

  • Teach you breathing exercises to help you relax, and show you how to safely get in and out of bed and a chair.

  • Show you how to walk with a walker or crutches, and get in and out of a car.

  • Help you continue to do the flexibility and strengthening exercises that you learned before your surgery.

As You Begin to Recover

The goal of the first 2 weeks of recovery is to manage pain, decrease swelling, heal the incision, restore normal walking, and initiate exercise. Following those 2 weeks, your physical therapist will tailor your range-of-motion exercises, progressive muscle-strengthening exercises, body awareness and balance training, functional training, and activity-specific training to address your specific goals and get you back to the activities you love!

Range-of-motion exercises. Swelling and pain can make you move your knee less. Your physical therapist can teach you safe and effective exercises to restore movement (range of motion) to your knee, so that you can perform your daily activities.

Strengthening exercises. Weakness of the muscles of the thigh and lower leg could make you need to still use a cane when walking, even after you no longer need a walker or crutches. Your physical therapist can determine which strengthening exercises are right for you.

Body awareness and balance training. Specialized training exercises help your muscles "learn" to respond to changes in your world, such as uneven sidewalks or rocky ground. When you are able to put your full weight on your knee without pain, your physical therapist may add agility exercises (such as turning and changing direction when walking, or making quick stops and starts) and activities using a balance board that challenge your balance and knee control. Your program will be based on the physical therapist’s examination of your knee, on your goals, and on your activity level and general health.

Functional training. When you can walk freely without pain, your physical therapist may begin to add activities that you were doing before your knee pain started to limit you. These might include community-based actions, such as crossing a busy street or getting on and off an escalator. Your program will be based on the physical therapist's examination of your knee, on your goals, and on your activity level and general health.

The timeline for returning to leisure or sports activities varies from person-to-person; your physical therapist will be able to estimate your unique timeline based on your specific condition.

Activity-specific training. Depending on the requirements of your job or the type of sports you play, you might need additional rehabilitation that is tailored to your job activities (such as climbing a ladder) or sport activities (such as swinging a golf club) and the demands that they place on your knee. Your physical therapist can develop an individualized rehabilitation program for you that takes all of these demands into account.

Can this Injury or Condition be Prevented?

If you have knee pain, you may be able to delay the need for surgery by working with a physical therapist to improve the strength and flexibility of the muscles that support and move the knee. This training could even help you avoid surgery altogether. Participating in an exercise program designed by a physical therapist can be one of your best protections against knee injury. And staying physically active in moderately intense physical activities and controlling your weight through proper diet might help reduce the risk of osteoarthritis of the knee getting worse.

Real Life Experiences

Carmella is a 67-year-old grandmother of 3 who has had osteoarthritis in her right knee for a few years. She used to take care of her grandchildren after school each day before her daughter got home from work. Then Carmella's knee became so painful that she could no longer walk up and down stairs or stand for long periods of time. She also had a lot of difficulty getting up from a chair. She had to tell her daughter that she couldn't take care of her grandchildren anymore. She decided to see a physical therapist.

Carmella’s physical therapist began her first session by asking detailed questions about her knee, such as what other treatments Carmella had tried and the outcomes of those treatments. Carmella said she had seen an orthopedic surgeon who had suggested injections, which helped reduce her pain for a period of time. Her physical therapist then asked her how her current knee pain affected her ability to do the things she wanted to do. Carmella said it made her unable to care for her grandchildren, participate in a regular walking program for fitness, or do the things she enjoyed for recreation.

Her physical therapist then took some measurements of her knee range of motion and strength and conducted tests to get a better idea of what was generating her pain. He suggested that she consult with an orthopedic surgeon. After carefully reviewing her condition and learning about her previous treatments and current activity limitations, the surgeon suggested it was time for a total knee replacement. Carmella agreed. The surgeon scheduled the procedure for 1 month later.

To prepare for surgery, Carmella’s physical therapist taught her strengthening and stretching exercises, showed her how to use crutches following surgery, and advised her on preparing her home environment to make it safe post surgery.

The first day after her surgery, a hospital-based physical therapist came to Carmella's room to begin a gentle recovery program. She showed Carmella how to bend and straighten her knee and how to tense and then relax and release her knee, calf, and hip muscles to strengthen them. She then helped Carmella practice sitting at the edge of her hospital bed and standing up using crutches.

The second day after surgery, Carmella started walking with crutches with the physical therapist’s assistance, putting a little weight on her right leg. The physical therapist also instructed her in some gentle leg-strengthening exercises.

On the third day after surgery, Carmella was able to walk using her crutches, monitored by the physical therapist but without her help, in the hospital hallways and up and down a few stairs. Her physical therapist designed an at-home exercise program just for her, and taught it to her. Carmella was discharged home with a pair of crutches.

Once Carmella returned home, a home-care physical therapist regularly visited her at her house to continue her rehabilitation. As she improved, he prescribed more challenging exercises for her that added weights for strengthening. Carmella also began to practice walking with a cane instead of her crutches.

Two weeks after her surgery, Carmella began going to outpatient physical therapy. Her pain progressively decreased and she had noticeable improvements in her knee range of motion and the strength of her lower body. She and her physical therapist developed a plan that would help allow her to get back to her recreational activities as well as allow her to care for her grandchildren.

A few weeks laterCarmella felt hardly any pain in her knee. She could walk without using a cane, but still needed to use a handrail when going up or down stairs. At times, her knee felt "shaky." She told her physical therapist she was still not comfortable taking care of her grandchildren because of these remaining challenges.

Carmella's physical therapist instructed her in more aggressive strengthening and movement exercises for her hips, knees, and ankles. She also worked with her on improving her stair climbing, balance, and agility. Carmella began to feel more confident walking up and down stairs, getting in and out of her car and driving, and performing other daily activities. She felt that her new knee was much more stable.

A few weeks later, Carmella was able to take care of her grandchildren again! She also joined a health club that offered exercise programs for older adults, so she could maintain the benefits she had gained from her physical therapy.

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?

Although all physical therapists are prepared through education and experience to treat people who have a TKR, 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 has completed a residency or fellowship in orthopedic physical therapy, giving the physical therapist 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 TKR.

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 therapist treatment of TKR. 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 (summary) of the article or to free access of the entire article, so that you can read it or print out a copy to bring with you when you see your health care provider.

Harmelink KE, Zeegers AV, Hullegie W, et al. Are there prognostic factors for one-year outcome after total knee arthroplasty: a systematic review. J Arthroplasty. 2017 August 1 [Epub ahead of print]. doi: 10.1016/j.arth.2017.07.011. Article Summary in PubMed.

Pua YH, Seah FJ, Poon CL, et al. Age- and sex-based recovery curves to track functional outcomes in older adults with total knee arthroplasty. Age Ageing. 2017 August 30 [Epub ahead of print]. doi: 10.1093/ageing/afx148. Article Summary in PubMed.

Sobh AH, Siljander MP, Mells AJ, et al. Cost analysis, complications, and discharge disposition associated with simultaneous vs staged bilateral total knee arthroplasty. J Arthroplasty. 2017 September 13 [Epub ahead of print]. doi: 10.1016/j.arth.2017.09.004. Article Summary in PubMed.

Bistolfi A, Zanovello J, Ferracini R, et al. Evaluation of the effectiveness of neuromuscular electrical stimulation after total knee arthroplasty: a meta-analysis. Am J Phys Med Rehabil. 2017 October 7 [Epub ahead of print]. Article Summary in PubMed.

Otero-López A, Beaton-Comulada D. Clinical considerations for the use lower extremity arthroplasty in the elderly. Phys Med Rehabil Clin N Am. 2017;28(4):795–810. Article Summary in PubMed.

Loyd BJ, Jennings JM, Judd DL, et al. Influence of hip abductor strength on functional outcomes before and after total knee arthroplasty: post hoc analysis of a randomized controlled trial. Phys Ther. 2017;97(9):896–903. Article Summary in PubMed.

Piva SR, Teixeira PE, Almeida GJ, et al. Contribution of hip abductor strength to physical function in patients with total knee arthroplasty. Phys Ther. 2011;91:225–233. Free Article.

Dowsey MM, Liew D, Choong PF. The economic burden of obesity in primary total knee arthroplasty. Arthritis Care Res(Hoboken). 2011;63(10):1375–1381. Article Summary on PubMed.

Piva SR, Gil AB, Almeida GJ, et al. A balance exercise program appears to improve function for patients with total knee arthroplasty: a randomized clinical trial. Phys Ther. 2010;90:880–894. Free Article.

Bade MJ, Kohrt WM, Stevens-Lapsley JE. Outcomes before and after total knee arthroplasty compared to healthy adults. J Ortho Sports Phys Ther. 2010;40:559–567. Free Article.

Walls RJ, McHugh G, O’Gorman DJ, et al. Effects of preoperative neuromuscular electrical stimulation on quadriceps strength and functional recovery in total knee arthroplasty: a pilot study. BMC Musculoskelet Disord. 2010;11:119. Free Article.

Topp R, Swank AM, Quesada PM, et al. The effect of prehabilitation exercise on strength and functioning after total knee arthroplasty. PM R. 2009;1:729–735. Article Summary on PubMed.

Kirkley A, Birmingham TB, Litchfield RB, et al. A randomized trial of arthroscopic surgery for osteoarthritis of the knee [published correction appears in: N Engl J Med. 2009;361:2004]. N Engl J Med. 2008;359:1097–1107. Free Article.

Minns Lowe CJ, Barker KL, Dewey M, Sackley CM. Effectiveness of physiotherapy exercise after knee arthroplasty for osteoarthritis: systematic review and meta-analysis of randomised controlled trials. BMJ. 2007;335:812. Free Article.

Moffet H, Collet JP, Shapiro SH, et al. Effectiveness of intensive rehabilitation on functional ability and quality of life after first total knee arthroplasty: a single-blind randomized controlled trial. Arch Phys Med Rehabil. 2004;85:546–556. Free Article.

Deyle GD, Henderson NE, Matekel RL, et al. Effectiveness of manual physical therapy and exercise in osteoarthritis of the knee: a randomized, controlled trial. Ann Intern Med. 2000;132:173–181. 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 Anne Reicherter, PT, DPT, PhDThe author is a board-certified clinical specialist in orthopaedic physical therapyReviewed 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.



3 Ways a Physical Therapist Can Help Manage Headaches

Headaches affect 47% of the global population and are described by the type and location of pain in the head. Many headaches are harmless and resolve gradually. However, more frequent moderate to severe headaches can impact your ability to do daily activities and quality of life. 

Different types of headaches include:

  • Tension

  • Cervicogenic or neck muscle-related

  • Migraine

  • Secondary headaches from an underlying condition, such as fever, infectious disease, sinus disorder, or in rare cases, a tumor or more serious illness

  • Unspecified headaches

A physical therapist will perform a clinical examination to diagnose the type of headache and develop an effective treatment plan. Physical therapy has been proven to:

  • Decrease or resolve the intensity, frequency, and duration of headache

  • Decrease medication use

  • Improve function and mobility

  • Improve ease of motion in neck

  • Improve quality of life

A physical therapist treatment plan may include:

  1. Manual therapy: Proven hands-on techniques are designed to alleviate joint and muscle stiffness, increase mobility of the head and neck, decrease muscle tension and spasms, and improve muscle performance.

  1. Exercise: Research has shown that various types of specific exercises will decrease pain, improve endurance, decrease inflammation, and promote overall healing. In addition to individualized prescribed exercises, customized home-exercise programs are an essential part of the treatment plan.

  1. Education: Educational strategies have been found helpful at lessening severity and/or frequency of headaches. These strategies include identifying highly individualized triggers (ie, dietary, sleep, movement/postural habits, stressors, hydration). Effective strategies to alleviate symptoms also include a wide variety of relaxation techniques.

 

Resources

Blanpied PR, Gross AR, Elliott JM, et al. Neck pain: revision 2017. J Orthop Sports Phys Ther. 2017;47(7):A1–A83. Free Article.

Ferracini G, Florencio LL, Dach F, et al. Myofascial trigger points and migraine-related disability in women with episodic and chronic migraine. Clin J Pain. 2017;33(2):109–115. Article Summary in PubMed.

Bevilaqua-Grossi D, Goncalves MC, Carvalho GF, et al. Additional effects of a physical therapy protocol on headache frequency, pressure pain threshold, and improvement perception in patients with migraine and associated neck pain: a randomized clinical trial. Arch Phys Med Rehabil. 2016;97(6):866–874. Free Article.

Fernandez-de-las-Penas C, Cuadrado ML Physical therapy for headaches. Cephalalgia. 2016;36(12):1134–1142. Article Summary in PubMed.

Irby MB, Bond DS, Lipton RB, Nicklas B, Houle TT, Penzien DB. Aerobic exercise for reducing migraine burden: mechanisms, markers, and models of change processes. Headache. 2016;56(2):357–369. Free Article.

Louw A, Puentedura EJ, Zimney K, Schmidt S. Know pain, know gain? A perspective on pain neuroscience education in physical therapy. J Orthop Sports Phys Ther. 2016;46(3):131–134. Free Article.

Fernandez-de-las-Penas C, Courtney CA. Clinical reasoning for manual therapy management of tension type and cervicogenic headache. J Man Manip Ther. 2014;22(1):45–50. Free Article.

Page P. Cervicgogenic headaches: an evidence-led approach to clinical management. Int J Sports Phys Ther. 2011;6(3):254–266. Free Article.

Zito G, Jull G, Story I. Clinical tests of musculoskeletal dysfunction in the diagnosis of cervicogenic headache. Man Ther. 2006;11(12):118–129. Article Summary in PubMed.

Jull G, Trott P, Potter H, et al. A randomized controlled trial of exercise and manipulative therapy for cervicogenic headaches. Spine (Phila Pa 1976). 2002;27(17):1835-1843. Article Summary in PubMed. 


Authored by Denise Schneider, PT.

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.



Tennis Elbow (Lateral Epicondylitis)

Most people who get tennis elbow don't play tennis! In fact, less than 5% of all cases of tennis elbow occur in people who play tennis. Tennis elbow can happen to anyone who repeatedly uses their elbow, wrist, and hand for their job, sport, or hobby.

Tennis elbow is a painful condition caused by overuse of the "extensor" muscles in your arm and forearm, particularly where the tendons attach to rounded projections of bone (epicondyles) on the outside or lateral aspect of the elbow. The muscles you use to grip, twist, and carry objects with your hand all attach to the "lateral epicondyle" at the elbow. That's why a movement of the wrist or hand can actually cause pain in the elbow.

Prolonged use of the wrist and hand, such as when using a computer or operating machinery —and, of course, playing tennis with an improper grip or technique—can lead to tennis elbow. It can happen to athletes, non-athletes, children, and adults. It occurs more often in men than women, and most commonly affects people between the ages of 30 and 50.

TennisElbow_SM.jpg

Signs and Symptoms

Symptoms of tennis elbow can occur suddenly as a result of excessive use of the wrist and hand for activities that require force, such as lifting, twisting, or pulling. Forceful activities—like pulling strongly on a lawn mower starter cord—can injure the extensor muscle fibers and lead to a sudden onset of tennis elbow.

More commonly, though, symptoms of tennis elbow develop gradually over a period of weeks or months as a result of repeated or forceful use of the wrist, hand, and elbow. If you work as a grocery store cashier, you might have symptoms of tennis elbow as a result of repetitive (and often too forceful) typing—combined with continuous lifting of grocery bags.

Your symptoms may include:

  • Pain that radiates into your forearm and wrist

  • Difficulty doing common tasks, such as turning a doorknob or holding a coffee cup

  • Difficulty with gripping activities

  • Increased pain when you use your wrist and hand for lifting objects, opening a jar, or gripping something tightly, such as a knife and fork

  • Stiffness in the elbow

  • Weakness in the forearm, wrist, or hand

How Is It Diagnosed?

Tennis elbow usually occurs due to repeated movements. As a result, other muscles and joints in this region of the body may be affected as well. Your physical therapist will perform a careful examination not only of your elbow but of other areas of your body that might be affected and might be contributing to your pain. Your therapist will perform special manual tests that help diagnose the problem and help detect conditions such as muscle weakness that might have led to the problem in the first place. For instance, the therapist might ask you to gently tense or stretch the sore muscles to identify the exact location of the problem. Rarely is an x-ray required to diagnose this condition.

How Can a Physical Therapist Help?

The First 24 to 48 Hours

For the first 24 to 48 hours after acute onset of your pain, treatment includes:

  • Resting the arm by avoiding certain activities and modifying the way you do others

  • Using 10-20 minute ice treatments

  • Using elastic bandages or supports to take the pressure off of the painful muscles

Your physical therapist will decide if you should use a brace or support to protect your muscles while the area is healing. Depending on severity, your therapist may recommend that you consult with another health care provider for further testing or for consideration of additional treatment such as medication. In rare cases, treatments such as cortisone injection or surgery might be needed. Your physical therapist can help you determine whether you need a referral to another health care provider.

Your physical therapist can design a specific treatment program to speed your recovery. There will very likely be exercises and other treatments that you will be expected to do at home. Your physical therapist also might use special physical therapy treatments to help relieve pain, such as manual therapy, special exercises, and ice or heat treatments or both.

For an "acute" case of tennis elbow—one that has occurred within the past few weeks— it's important to treat as early as possible. Left untreated, tennis elbow may become chronic and last for months and sometimes even years. This is especially true if treatment is focused only on relieving pain and not on correcting the muscle weakness and bad habits that might have led to your condition in the first place.

Improve Your Ability to Move

Your physical therapist may use manual therapy to enable your joints and muscles to move more freely with less pain.

Improve Your Strength

Insufficient muscle strength can lead to tennis elbow. Sometimes the weakness is in the muscles of the wrist and forearm. In many cases, the problem stems from weakness of the supporting postural, or "core," muscles. In fact, you might find that it is necessary to improve your overall level of fitness to help manage your elbow condition. Based on the evaluation, your physical therapist can determine the type and amount of exercises that are right for you.

Physical therapists prescribe several types of exercises during recovery from tennis elbow:

  • Early in the treatment, when the pain is most intense, your therapist may recommend passive exercises in which your wrist and elbow are moved without the use of your muscles.

  • As your symptoms improve, you can move the wrist and elbow actively without assistance.

  • As the muscles become stronger and the symptoms have lessened, you will be able to begin using weights or resistance bands to further increase your strength. The amount of weight will need to be carefully monitored to make sure you continue to progress and avoid re-injuring your muscles.

 

Use Your Muscles the Right Way

Your physical therapist can help you retrain your muscles so that you use them properly. For example, when you lift a heavy grocery bag, you should contract the muscles around your shoulder blade and trunk to provide support for your arm muscles. This simple movement can be easily taught to you by a physical therapist can lessen the stress to the injured muscles and help you return to your normal activities while avoiding re-injury.

Return to Your Activities

Your physical therapist will help you remain active by teaching you how to modify your daily activities to avoid pain and further injury. Sometimes it's necessary to make changes at work, on the playing field, or in the home. Your physical therapist can help you make simple modifications to your work site, your computer set-up, your kitchen devices, your sports equipment, and even your gardening tools to lessen the strain to your hand, wrist, and forearm. Your therapist will emphasize the importance of taking stretch breaks so that your muscles get frequent rest from repetitive movements and standing or sitting in the same position.

Tennis may be a contributing factor to tennis elbow for several reasons. Sometimes the problem results from over-training. In other cases, the weight of the racquet or its grip may need to be adjusted. For others, the problem may stem from improper form, poor overall fitness, or a lack of strength in the supporting or "core" muscles of the trunk and shoulder blades. A physical therapist can help analyze the source of the problem and help find a solution.

Can this Injury or Condition be Prevented?

Yes! You can help prevent tennis elbow by staying fit, using proper technique in your sport or in your job, and using equipment that is well designed and appropriate for your body type and your level of activity. Your physical therapist can show you how. If you had tennis elbow years ago, you might be at risk for re-injury if the tendons did not have time to completely heal or if your muscle strength and joint mobility were not fully restored. Returning to sports or activities before you have fully recovered might result in an elbow that has persistent pain or is easily or frequently re-injured. A physical therapist can help determine when you are ready to return to your activities and sports and can help make sure that your elbow, forearm, and wrist are strong and ready for action.

Real Life Experiences

You work as a computer graphics engineer. Yesterday, you spent the day gardening with an electric lawn trimmer. This morning you woke up with pain and a feeling of stiffness on the outside of your elbow. The pain increases the more you move your elbow, forearm, and wrist. It also hurts to use your computer mouse or to pick up your coffee cup. You immediately schedule an appointment for an evaluation with a physical therapist. A physical therapist performs a full examination of your elbow and surrounding muscles and joints and can determine whether additional tests or referral to another health care provider is necessary. In most cases of tennis elbow, the therapist will manage your care through your full recovery.

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 a variety of conditions or injuries. You may want to consider:

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

  • A physical therapist who is a board-certified clinical specialist or who completed a residency or fellowship in orthopaedics 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 tennis elbow.

  • 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 below-knee amputation. 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.

Weber C, Thai V, Neuheuser K, et al. Efficacy of physical therapy for the treatment of lateral epicondylitis: a meta-analysis BMC Musculoskelet Disord. 2015 Aug 25;16(1):223. Pubmed Abstract.

Shiri R, Viikari-Juntura E, Varonen H, Heliövaara M. Prevalence and determinants of lateral and medial epicondylitis: a population study. Am J Epidemiol. 2006; 164:1065-74. Pubmed Abstract.

Peterson M, Butler S, Eriksson M, Svärdsudd K. A randomized controlled trial of exercise versus wait-list in chronic tennis elbow (lateral epicondylosis). Ups J Med Sci. 2011; 116:269-79. PubMed Abstract.  Publisher Full Text

*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 the MoveForwardPT.com editorial board.



Benign Paroxysmal Positional Vertigo (BPPV)

Every year, millions of people in the United States develop vertigo, a sensation that you or your surroundings are spinning.The sensation can be very disturbing and may increase the risk of falling. If you've been diagnosed with benign paroxysmal positional vertigo (BPPV), you're not alone—at least 9 out of every 100 older adults are affected, making it one of the most common types of episodic vertigo. The good news is that BPPV is treatable. Your physical therapist will use unique tests to confirm vertigo, and use special exercises and maneuvers to help.

What Is BPPV?

Benign paroxysmal positional vertigo is a common inner-ear problem affecting the vestibular system, a system used to maintain balance. BPPV causes short periods of dizziness when your head is moved in certain positions, relative to gravity. Benign means that this disorder is not life threatening, and generally, the disorder is not progressive. Paroxysmal means that the vertigo (spinning sensation) occurs suddenly. Positional means that the vertigo is triggered by changes in head position, most commonly when lying down, turning over in bed, or looking up. This dizzy or spinning sensation is called vertigo.

A layer of calcium carbonate material is present naturally in 1 part of your inner ear (the utricle). BPPV occurs when pieces of this material break off and move to another part of the inner ear, the semicircular canals (usually the posterior canal). These tiny calcium crystals (otoconia) are sometimes called “ear rocks.”

When you move your head a certain way, the crystals move inside the canal and stimulate the nerve endings, causing you to become dizzy. The cause of BPPV is usually not known; however, the crystals may become loose due to trauma to the head, infection, conditions, such as Meniere’s disease, or aging. BPPV is more common among females, and it may be hereditary.

InnerEar_sm.jpg

How Does it Feel?

BPPV occurs most commonly following position changing, such as lying down, turning over in bed, bending over, and looking up. A short delay, often less than 15 seconds, may follow a position change before symptoms start. This dizzy sensation, called vertigo, is brief and intense and usually lasts for about 15-45 seconds. However, symptoms may last for up to 2 minutes if the crystals become stuck to part of the inner ear. The episodes of vertigo occur frequently for weeks or months at a time. During these episodes, you may feel like the room is spinning around you, and you also may feel lightheaded, off balance, and nauseous.

Signs and Symptoms

The signs and symptoms of BPPV usually last less than a minute. The signs and symptoms may come and go or may disappear for a period of time, and then recur. Movement of the head causes most of the signs and symptoms of BPPV, which may include:

  • Dizziness

  • A sense that you or your surroundings are spinning or moving (vertigo)

  • A loss of balance or unsteadiness

  • Nausea

  • Vomiting

How Is It Diagnosed?

The diagnosis of BPPV is based on whether you have a particular kind of involuntary eye movement (called "nystagmus"), and whether you have vertigo when your head is moved into certain positions. Your physical therapist will perform tests that move your head in specific ways to see whether vertigo and involuntary eye movement results. These tests will help the therapist determine the cause and type of your dizziness, and whether you should be referred to a physician for any additional testing.

The positional tests are meant to recreate BPPV symptoms. By moving your head into certain positions and watching your eyes, your physical therapist may determine the appropriate repositioning maneuver needed to reduce or eliminate your vertigo.

Many different types and causes of dizziness exist, and dizziness is difficult for people to describe, making BPPV and other causes of dizziness more challenging to diagnose. When talking to your clinician, be as specific as possible when describing your symptoms.

For example, explain if you have lightheadedness or if you see or feel the room spinning during an episode. Also, describe how long your symptoms last (seconds, minutes, hours, or days). Do your best to describe what makes your dizziness better or worse. For example, is your dizziness made worse by movement or position changes? Is your dizziness eased by stillness or rest?

Be sure to discuss any recent illnesses or injuries, problems with your immune system, changes in medications or hormones, or headaches. These clues will be very insightful for your physical therapist and can assist in establishing an accurate diagnosis, or indicate the need for a referral to another specialist.

How Can a Physical Therapist Help?

Fortunately, most people recover from BPPV with a simple but very specific head and neck maneuver performed by a physical therapist. Your physical therapist will guide you through a series of 2-4 position changes. Each position may be held for 30 seconds to 2 minutes, as prescribed by your physical therapist. These repositioning treatments are designed to move the crystals from the semicircular canal back into the appropriate area in the inner ear (the utricle). A repositioning treatment called the Epley maneuver is used for the resolution of posterior canal BPPV, the most commonly involved canal. No medication has been found to be effective with BPPV and, in some cases, medication could cause more harm.

In a very few cases, BPPV cannot be managed with treatment maneuvers, and a surgical procedure called a “posterior canal plugging” may be considered—but, surgical intervention is rare.

Can this Injury or Condition be Prevented?

No known ways exist to prevent BPPV, especially when caused by such factors as head injury or aging. Once a person has experienced BPPV, symptoms can return if new crystals break off and get into the semicircular canal, or if you dislodge loose crystals by placing your head in a certain position. Some people report that their BPPV symptoms recur predictably, perhaps seasonally, or with changes in the weather.

Within 3 years of having BPPV, about 50% of people may have a recurrence. BPPV resulting from head trauma is more likely to recur. Once a person has experienced BPPV, symptoms can return if new crystals break. Although your BPPV might return, you'll be able to recognize the symptoms and keep yourself safe until you can get help. Your physical therapist will apply the appropriate maneuver to return the crystals to their correct position in the inner ear, and also will teach you how to do exercises that can reduce or eliminate the symptoms.

Real Life Experiences

Laura B. is a 68-year-old woman with vertigo that began one morning 2 weeks ago when she got out of bed and the world started to spin. Since then, she's been having vertigo, nausea, and problems with her balance. When she visits her physical therapist, he gives her a special questionnaire to find out exactly what brings on her dizziness and balance difficulties. Turning over in bed, bending over, or looking up cause the most severe symptoms.

The physical therapist reviews Laura's medical history to make sure that no past condition may be contributing to the vertigo. He performs an examination, explains what tests he will use, and tells Laura that she should try to keep her eyes open and stay in position. The tests show that in certain positions, Laura's eyes move when they shouldn't, and she has vertigo that lasts 5 seconds. The therapist determines that she has the "canalithiasis form" of vertigo, which means that some crystals are displaced and are flowing through her semicircular ear canals, causing vertigo.

The therapist uses "canalith repositioning" to move the crystals into a proper position, using the Epley maneuver. Afterwards, he asks Laura to wait in the waiting room for a while so that he can retest her. Laura no longer has the symptoms that she had when the therapist tested her the first time, so he shows her how to do the canalith repositioning maneuver at home. She is to perform the maneuver once every day in the morning for 1 week, and then return to the clinic to make sure that she is progressing as expected.

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 dizziness and balance problems. You may want to consider:

  • A physical therapist who is experienced in treating people with neurological problems.

  • A physical therapist with specialized training and experience in vestibular rehabilitation.

  • A physical therapist who is a board-certified neurological clinical specialist, called NCS, or who completed a residency or fellowship in neurologic physical therapy, or who 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 treatment of BPPV. 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.

Hilton MP, Pinder DK. The Epley (canalith repositioning) manoeuvre for benign paroxysmal positional vertigo. Cochrane Database Syst Rev. 2014;12:CD003162. Article Summary on PubMed.

Helminski JO. Effectivess of the canalith repositioning procedure in the treatment of benign paroxysmal positional vertigo. Phys Ther. 2014:94(10):1373–1382. 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

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

Clinch CR, Kahill A, Klatt LA, Stewart D. Clinical inquiries: what is the best approach to benign paroxysmal positional vertigo in the elderly? J Fam Pract. 2010;59:295–297. Review. Article Summary on PubMed.

Fife TD, Iverson DJ, Lempert T, et al. Practice parameter: therapies for benign paroxysmal positional vertigo (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology. 2008;70:2067-2074. Free Article.

Vestibular Disorders Association. Benign paroxysmal positional vertigo (BPPV). Accessed June 20, 2015.

Authored by Susan J. Herdman, PT, PhD; Shannon L.G. Hoffman, PT, DPT; Marcia Thompson, PT, DPT; Bob Wellmon, PT, PhD, NCS; and APTA’s Section on Neurology. Reviewed by the MoveForwardPT.com editorial board.