Hip Impingement (Femoroacetabular Impingement)

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

What is Hip Impingement?

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

Pincer-Type Impingement

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

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

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

 

Cam-Type Impingement

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

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

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

HipImpingement-SM.jpg

Signs and Symptoms

Hip impingement may cause you to experience:

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

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

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

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

  • Pain that increases with prolonged sitting or forward leaning.

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

How Is It Diagnosed?

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

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

How Can a Physical Therapist Help?

Without Surgery

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

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

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

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

 

Following Surgery

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

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

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

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

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

Can this Injury or Condition be Prevented?

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

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

Real Life Experiences

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

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

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

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

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

What Kind of Physical Therapist Do I Need?

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

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

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

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

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

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

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

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

Further Reading

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

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

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

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

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

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

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

Guide to Osgood-Schlatter Disease

What is Osgood-Schlatter Disease?

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

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

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

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

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

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

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How Does it Feel?

With Osgood-Schlatter, you may experience:

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

  • Pain that worsens with exercise.

  • Swelling and tenderness at the top of the shin.

  • A boney growth at the top of the shin.

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

  • Increased tightness in the quadriceps muscle.

  • Loss of knee motion.

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

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How Is It Diagnosed?

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

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

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

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How Can a Physical Therapist Help?

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

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

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

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

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

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

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

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Can this Injury or Condition be Prevented?

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

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

  • Educating athletes on the risks of playing through pain.

  • Scheduling adequate rest time to recover between athletic events.

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

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

  • Encouraging consultation with a physical therapist whenever symptoms appear.

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Real Life Experiences

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

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

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

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

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

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

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

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

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

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

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What Kind of Physical Therapist Do I Need?

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

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

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

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

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

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

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

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

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Further Reading

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

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

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

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

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

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

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


Achilles Tendinopathy

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

Achilles Tendinopathy

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

Achilles tendinopathy is linked to several different factors, including:

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

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

AchilleTendonInjury-SM.jpg

How Does it Feel?

With Achilles tendinopathy, you may experience:

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

How Is It Diagnosed?

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

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

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

How Can a Physical Therapist Help?

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

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

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

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

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

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

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

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

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

Can this Injury or Condition be Prevented?

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

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

What Kind of Physical Therapist Do I Need?

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

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

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

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

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

Further Reading

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

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

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

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

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

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

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

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

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

What is Pitcher's Elbow?

Pitcher's elbow, also known as  medial epicondyle apophysitis , is a common injury that occurs among young baseball players. Caused by "overuse" and "repetitive motion," pitcher's elbow causes pain and swelling inside of the elbow, can limit one's range of motion, and will limit or prevent the ability to throw a ball.  Causes  The forceful and repetitive nature of overhand throwing for baseball players (pitchers in particular) can cause inflammation of the growth plate inside the throwing elbow, resulting in pitcher's elbow. Adolescent baseball players are most likely to experience this injury because their elbow structure (ie, bones, growth plates, and ligaments) is not fully mature or developed.  The following risk factors contribute to pitcher's elbow:   Age.  Young baseball players (particularly those between the ages of 9 and 14 years) are at greater risk because their elbow joints are not fully developed. Less mature bones, looseness of the ligaments, open growth plates, and undeveloped musculature are common in youth pitchers and predispose them to overuse injuries.    Pitching too many games.  The number of games pitched should be carefully monitored and the  league's pitch count rules  followed. Research has proven that overuse in baseball contributes to injuries such as pitcher's elbow. Specifically, there is evidence it can occur over the course of a game (pitching more than than 75 pitches per game), per season (pitching more than 1,000 pitches per season), or per year (pitching more than 3,000 pitches per year. Also, it is advised that pitching not occur for greater than 8 months of the year. If pain occurs before the pitch count limit is reached, the player should stop immediately. Additionally, pitching should be halted if fatigue is experienced during the game. Rotating pitchers within games is a good idea to ensure each pitcher gets adequate rest.   Curveballs and breaking pitches.  Likely due to poor pitch mechanics, both of these types of pitches appear to put more stress on the growth plate than other pitches. These should be limited, especially in players between the ages of 9 and 14 years.   Improper mechanics.  Improper throwing mechanics can put undue force on the elbow joint. Proper throwing mechanics can help a young player avoid unnecessary injury and develop proper technique that improves their game. Your coach or other qualified instructors can be used as a resource to ensure you have learned proper mechanics.  More about pitch count   No multiple pitching appearances in a single game.  Your child should not make more than 1 pitching appearance in 1 game (ie, pitch, change positions, then pitch again).   No circumventing pitch count rules by pitching in multiple leagues.  Most youths now play in multiple leagues and the number of pitches can only be tracked for each individual league. It is important to avoid violating the pitch count restrictions by pitching in multiple leagues.   No pitching at home after having pitched in a game.  To limit the number and amount of overall pitches thrown, players are advised not to pitch at home after having pitched in a game.   Get appropriate rest between pitching performances .  See recommended pitch count rules .  How a Physical Therapist Can Help  Physical therapists are experts in restoring and improving mobility and motion in people's lives, and eliminating pain. For young baseball players, this means a physical therapist will work with you to help prevent pitcher's elbow, and recover safely if it does occur.  In addition to following the guidelines for pitch counts and recommendations for rest, a physical therapist will help baseball players prevent the occurrence of pitcher's elbow by teaching them stretching and strengthening exercises that are individualized to their specific needs. Everybody is different, which means pitcher's elbow may occur for different reasons for each person. A physical therapist will help a player recover by designing an individualized treatment plan to regain range of motion, flexibility, and strength.  Bibliography  MomsTeam.com. Protecting Young Pitching Arms.  The Little League pitch count regulation guide for parents, coaches, and league officials . Updated February 27, 2017. Accessed March 7, 2018.  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.  Free Article .  Nissen CW, Westwell M, Ounpuu S, Patel M, Solomito M, Tate J. A biomechanical comparison of the fastball and curveball in adolescent baseball pitchers.  Am J Sports Med . 2009;37(8):1492–1498.  Free Article .  Dun S, Loftice J. Fleisig GS, Kingsley D, and Andrews JR. A biomechanical comparison of youth baseball pitches: is the curveball potentially harmful? Am J Sports Med. 2008;36(4):686–692.  Free Article .  Olsen SJ Jr, Fleisig GS, Dun S, Loftice J, Andrews JR. Risk factors for shoulder and elbow injuries in adolescent baseball pitchers. Am J Sports Med. 2006;34(6):905–912.  Free Article .  USA Baseball Medical & Safety Advisory Committee.  Position statement on youth baseball injuries . Updated May 2006. Accessed March 7, 2018.  Lyman S, Fleisig GS, Andrews JR, Osinski ED. Effect of pitch type, pitch count, and pitching mechanics on risk of elbow and shoulder pain in youth baseball pitchers. Am J Sports Med. 2002;30(4):463 –468.  Free Article .  Lyman S, Fleisig GS, Waterbor JW, et al. Longitudinal study of elbow and shoulder pain in youth baseball pitchers. Med Sci Sports Exerc. 2001;33(11):1803–1810.  Free Article .  Andrews JR, Fleisig GS. Preventing throwing injuries [editorial]. J Orthop Sports Phys Ther. 1998;27(3):187–188.  Free Article .  Ireland ML, Hutchinson MR. Upper extremity injuries in young athletes. Clin Sports Med. 1995;14(3):533–569.  Article Summary in PubMed .

Pitcher's elbow, also known as medial epicondyle apophysitis, is a common injury that occurs among young baseball players. Caused by "overuse" and "repetitive motion," pitcher's elbow causes pain and swelling inside of the elbow, can limit one's range of motion, and will limit or prevent the ability to throw a ball.

Causes

The forceful and repetitive nature of overhand throwing for baseball players (pitchers in particular) can cause inflammation of the growth plate inside the throwing elbow, resulting in pitcher's elbow. Adolescent baseball players are most likely to experience this injury because their elbow structure (ie, bones, growth plates, and ligaments) is not fully mature or developed.

The following risk factors contribute to pitcher's elbow:

Age. Young baseball players (particularly those between the ages of 9 and 14 years) are at greater risk because their elbow joints are not fully developed. Less mature bones, looseness of the ligaments, open growth plates, and undeveloped musculature are common in youth pitchers and predispose them to overuse injuries. 

Pitching too many games. The number of games pitched should be carefully monitored and the league's pitch count rules followed. Research has proven that overuse in baseball contributes to injuries such as pitcher's elbow. Specifically, there is evidence it can occur over the course of a game (pitching more than than 75 pitches per game), per season (pitching more than 1,000 pitches per season), or per year (pitching more than 3,000 pitches per year. Also, it is advised that pitching not occur for greater than 8 months of the year. If pain occurs before the pitch count limit is reached, the player should stop immediately. Additionally, pitching should be halted if fatigue is experienced during the game. Rotating pitchers within games is a good idea to ensure each pitcher gets adequate rest.

Curveballs and breaking pitches. Likely due to poor pitch mechanics, both of these types of pitches appear to put more stress on the growth plate than other pitches. These should be limited, especially in players between the ages of 9 and 14 years.

Improper mechanics. Improper throwing mechanics can put undue force on the elbow joint. Proper throwing mechanics can help a young player avoid unnecessary injury and develop proper technique that improves their game. Your coach or other qualified instructors can be used as a resource to ensure you have learned proper mechanics.

More about pitch count

No multiple pitching appearances in a single game. Your child should not make more than 1 pitching appearance in 1 game (ie, pitch, change positions, then pitch again).

No circumventing pitch count rules by pitching in multiple leagues. Most youths now play in multiple leagues and the number of pitches can only be tracked for each individual league. It is important to avoid violating the pitch count restrictions by pitching in multiple leagues.

No pitching at home after having pitched in a game. To limit the number and amount of overall pitches thrown, players are advised not to pitch at home after having pitched in a game.

Get appropriate rest between pitching performancesSee recommended pitch count rules.

How a Physical Therapist Can Help

Physical therapists are experts in restoring and improving mobility and motion in people's lives, and eliminating pain. For young baseball players, this means a physical therapist will work with you to help prevent pitcher's elbow, and recover safely if it does occur.

In addition to following the guidelines for pitch counts and recommendations for rest, a physical therapist will help baseball players prevent the occurrence of pitcher's elbow by teaching them stretching and strengthening exercises that are individualized to their specific needs. Everybody is different, which means pitcher's elbow may occur for different reasons for each person. A physical therapist will help a player recover by designing an individualized treatment plan to regain range of motion, flexibility, and strength.

Bibliography

MomsTeam.com. Protecting Young Pitching Arms. The Little League pitch count regulation guide for parents, coaches, and league officials. Updated February 27, 2017. Accessed March 7, 2018.

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. Free Article.

Nissen CW, Westwell M, Ounpuu S, Patel M, Solomito M, Tate J. A biomechanical comparison of the fastball and curveball in adolescent baseball pitchers. Am J Sports Med. 2009;37(8):1492–1498. Free Article.

Dun S, Loftice J. Fleisig GS, Kingsley D, and Andrews JR. A biomechanical comparison of youth baseball pitches: is the curveball potentially harmful? Am J Sports Med. 2008;36(4):686–692. Free Article.

Olsen SJ Jr, Fleisig GS, Dun S, Loftice J, Andrews JR. Risk factors for shoulder and elbow injuries in adolescent baseball pitchers. Am J Sports Med. 2006;34(6):905–912. Free Article.

USA Baseball Medical & Safety Advisory Committee. Position statement on youth baseball injuries. Updated May 2006. Accessed March 7, 2018.

Lyman S, Fleisig GS, Andrews JR, Osinski ED. Effect of pitch type, pitch count, and pitching mechanics on risk of elbow and shoulder pain in youth baseball pitchers. Am J Sports Med. 2002;30(4):463 –468. Free Article.

Lyman S, Fleisig GS, Waterbor JW, et al. Longitudinal study of elbow and shoulder pain in youth baseball pitchers. Med Sci Sports Exerc. 2001;33(11):1803–1810. Free Article.

Andrews JR, Fleisig GS. Preventing throwing injuries [editorial]. J Orthop Sports Phys Ther. 1998;27(3):187–188. Free Article.

Ireland ML, Hutchinson MR. Upper extremity injuries in young athletes. Clin Sports Med. 1995;14(3):533–569. Article Summary in PubMed.

Physical Therapist's Guide to Iliotibial Band Syndrome (ITBS or "IT Band Syndrome")

IliotibialBand_Small.jpg

Iliotibial band syndrome (ITBS) is one of the most common causes of knee pain, particularly in individuals involved in endurance sports. It accounts for up to 12% of running injuries and up to 24% of cycling injuries. ITBS is typically managed conservatively through physical therapy and temporary activity modification.

What is Iliotibial Band Syndrome (ITBS)?

Iliotibial band syndrome (ITBS) occurs when excessive irritation causes pain at the outside (or lateral) part of the knee. The iliotibial band (ITB), often referred to as the "IT band" is a type of soft tissue that runs along the side of the thigh from the pelvis to the knee. As it approaches the knee, its shape thickens as it crosses a prominent area of the thigh (femur) bone, called the lateral femoral condyle. Near the pelvis, it attaches to 2 important hip muscles, the tensor fascia latae (TFL) and the gluteus maximus.

Irritation and inflammation arise from friction between the ITB and underlying structures when an individual moves through repetitive straightening (extension) and bending (flexion) of the knee. Typically, ITBS pain occurs with overuse during activities such as running and cycling.

ITBS involves many lower extremity structures, including muscles, bones, and other soft tissues. Usually discomfort arises from:

  • Abnormal contact between the ITB and thigh (femur) bone
  • Poor alignment and/or muscular control of the lower body
  • Prolonged pinching (compression) or rubbing (shearing) forces during repetitive activities

The common structures involved in ITBS are:

  • Iliotibial band
  • Bursa (fluid-filled sack that sits between bones and soft tissues to limit friction)
  • Hip muscles

ITBS can occur in:

  • Athletes performing repetitive activities, such as squatting, and endurance sports such as running and cycling
  • Individuals who spend long periods of time in prolonged positions, such as sitting or standing for a long workday, climbing or squatting, or kneeling
  • Individuals who quickly start a new exercise regimen without proper warm-up or preparation

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Signs and Symptoms

With ITBS, you may experience:

  • Stabbing or stinging pain along the outside of the knee
  • A feeling of the ITB “snapping” over the knee as it bends and straightens
  • Swelling near the outside of your knee
  • Occasionally, tightness and pain at the outside of the hip
  • Continuous pain following activity, particularly with walking, climbing, or descending stairs, or moving from a sitting to standing position

Pain is usually most intense when the knee is in a slightly bent position, either right before or right after the foot strikes the ground. This is the point where the ITB rubs the most over the femur.

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How Is It Diagnosed?

Your physical therapist will ask you questions about your medical history and activity regimen. A physical examination will be performed so that your physical therapist can collect movement (range of motion), strength, and flexibility measurements at the hip, knee, and ankle.

When dealing with ITBS, it is also common for a physical therapist to use special tests and complete a movement analysis, which will provide information on the way that you move and how it might contribute to your injury. This could include assessment of walking/running mechanics, foot structure, and balance. Your therapist may have you repeat the activity that causes your pain to see firsthand how your body moves when you feel pain. If you are an athlete, your therapist might also ask you about your chosen sport, shoes, training routes, and exercise routine.

Typically, medical imaging tests, such as x-ray and MRI, are not needed to diagnosis ITBS.

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How Can a Physical Therapist Help?

Your physical therapist will use treatment strategies to focus on:

Range of motion

Often, abnormal motion of the hip and knee and foot joint can cause ITBS because of how the band attaches to hip muscles. Your therapist will assess the motion of your injury leg compared with expected normal motion and the motion of the hip on your uninvolved leg.

Muscle strength

Hip and core weakness can contribute to ITBS. The "core" refers to the muscles of the abdomen, low back, and pelvis. Core strength is important, as a strong midsection will allow greater stability through the body as the arms and legs go through various motions. For athletes performing endurance sports, it is important to have a strong core to stabilize the hip and knee joints during repetitive leg motions. Your physical therapist will be able to determine which muscles are weak and provide specific exercises to target these areas.

Manual therapy

Many physical therapists are trained in manual therapy, which means they use their hands to move and manipulate muscles and joints to improve motion and strength. These techniques can target areas that are difficult to treat on your own.

Functional training

Even when an individual has normal motion and strength, it is important to teach the body how to perform controlled and coordinated movements so there is no longer excessive stress at the previously injured structures. Your physical therapist will develop a functional training program specific to your desired activity. This means creating exercises that will replicate your activities and challenge your body to learn the correct way to move.

Your physical therapist will also work with you to develop an individualized treatment program specific to your personal goals. He or she will offer tips to help you prevent your injury from reoccurring.

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Can this Injury or Condition be Prevented?

Maintaining core and lower extremity strength and flexibility and monitoring your activity best prevents ITBS. It is important to modify your activity and contact your physical therapist soon after first feeling pain. Research indicates that when soft tissues are irritated and the offending activity is continued, the body does not have time to repair the injured area. This often leads to persistent pain, and the condition becomes more difficult to resolve.

Once you are involved in a rehabilitation program, your physical therapist will help you determine when you are ready to progress back to your previous activity level. He or she will make sure that your body is ready to handle the demands of your activities so that your injury does not return. You will also receive a program to perform at home that will help you maintain the improvements that you gained during rehabilitation.

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Real Life Experiences

Sarah is a 31-year-old mother training for her first triathlon. With a young child at home, she has to squeeze in her training sessions early in the morning. She rarely has time to cool down or stretch after riding her bike or running because she has to get home before her child wakes up.

Sarah signs up for her first race and begins to increase her cycling and running in preparation. One day during the middle of a long run, she feels a sharp pain at the outside of her knee. It starts hurting with every step, and doesn't go away, even after she stops and stretches. Far from home, she has to finish her run despite the nagging pain. When she gets home, she puts ice on it, but for the rest of the day she has trouble going up and down stairs, or squatting to pick up her son, and feels pain when standing up after driving the car. The next day, she tries to ride her bike, but the knee pain is still there and feels worse.

Wisely, Sarah stops running and cycling and contacts her physical therapist.

Sarah's physical therapist conducts a comprehensive evaluation of her hip and knee motion, strength, balance, and running mechanics. She uses special tests and measures to determine if Sarah’s pain is related to her iliotibial band or if there are other problems occurring simultaneously. She talks with Sarah about her training routine, including equipment (shoes, position on the bike, etc), the routes she runs and their surfaces, and her stretching program. The therapist diagnoses Sarah with iliotibial band syndrome. She guides Sarah through specific exercises in the clinic, including manual stretching of the hip joint by the therapist, sidelying leg raises for hip strengthening, and single leg squats to promote integrated core, hip, knee, and ankle function. Sarah will also perform these exercises at home as a part of her daily exercise routine to maximize improvement and help ensure her sustainable success.

Sarah's physical therapist helps her develop strategies for training, taking into consideration her lifestyle as a busy mother, to help her stay injury-free. Together, they outline a 6-week rehabilitation program for iliotibial band syndrome. Sarah will come to the clinic 1-2 times each week, where her therapist will assess her progress, perform manual therapy techniques, and advance her exercise program as appropriate. Sarah will also have a daily exercise routine to perform independently at home, including stretching and strengthening activities.

In 6 weeks, Sarah has met all of her physical therapy goals and completes her rehabilitation in the clinic. After building her training gradually over the next month, she is able to train and successfully crosses the finish line just as planned!

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What Kind of Physical Therapist Do I Need?

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

  • A physical therapist who is experienced in treating people with orthopedic, or musculoskeletal, injuries.
  • A physical therapist who is a board-certified specialist or who has completed a residency in orthopedic or sports physical therapy, as he or she will have advanced knowledge, experience, and skills that apply to an athletic population.

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

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

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

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Further Reading

The American Physical Therapy Association 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 ITBS. 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.

Strauss EJ, Kim S, Calcei JG, Park D. Iliotibial band syndrome: evaluation and management. J Am Acad Orthop Surg. 2011;19:726–736. Free Article.

Ellis R, Hing W, Reid D. Iliotibial band friction syndrome: a systematic review. Man Ther. 2007;12:200–208. Article Summary on PubMed.

Fredericson M, Weir A. Practical management of iliotibial band syndrome in runners. Clin J Sports Med. 2006;16:261–268. Article Summary on PubMed.

Fredericson M, Wolf C. Iliotibial band syndrome in runners: innovations in treatment. Sports Med. 2005;35:451–459. Article Summary on PubMed.

Levin J. Run down: battling IT band syndrome in long distance runners. Biomechanics. 2003;1:22–25. Article Summary Not Available.

Fredericson M, Cookingham CL, Chaudhari AM, et al. Hip abductor weakness in distance runners with iliotibial band syndrome. Clin J Sports Med. 2000;10:169–175. 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 Laura Stanley, PT, DPT, SCS. Reviewed by the MoveForwardPT.com editorial board.