Archive for the ‘Physical Therapy’ Category

“Stressing Out Over Stress Fractures”

Monday, July 21st, 2008

This is a good title.  Dr. Suzanne Hecht (UCLA>>>now University of Minnesota) and I wrote this article originally for USECA.  I may have used parts of it before in lectures or after in other articles/lectures; but, here it goes again:

GETTING STRESSED OUT ABOUT STRESS FRACTURES?

So what is a stress fracture?  Dr. Hecht writes –

A stress fracture is an overuse injury to the bone that occurs when the bone cannot keep up with the demand that is placed on it leading to microfractures (mini breaks in the bone) and swelling of the bone marrow.

Dr. Hecht continues by describing typical symptoms of a tibial stress fracture include the following: 

·        Pain develops gradually

·        Shin pain occurring during or after workouts

·        Pain improves with rest

·        A sudden increase in training time or intensity

·        The shin may be sore to touchX-rays are often negative early on in the course of a stress fracture. 

Remember…just because the x-rays are negative doesn’t mean your gymnast doesn’t have a stress fracture.  The physician may recommend further testing to confirm the suspected diagnosis or may suggest treatment options and repeat the x-rays in 2-4 weeks to see if the stress fracture can be seen.  A bone scan is a common test used to look for stress fractures if the x-rays are negative.  Other physicians might order a MRI scan.

Dr. Hecht emphasizes that stress fractures of the front portion of the tibia (anterior) are very concerning.  These fractures can show up as a dark black line on the x-rays and physicians commonly refer to this finding as “the dreaded black line”.  This stress fracture worries physicians since the bone in this area is on tension and doesn’t like to heal.  The anterior tibial stress fractures should be taken very seriously and treated with extensive rest of the leg or placement of a rod into the tibia to help facilitate healing.  Stress fractures of the inside, back portion of the tibia (posteromedial) heal better and can be treated more liberally.  

A note from “The Posture Lady” regarding

BIOMECHANICS OF THE LOWER BODY

Poor biomechanics of the lower extremities and pelvic area often lead to conditions such as tibial stress fractures.  Be sure to check for muscle imbalances.  Finally, emphasizing correct standing posture cannot go unnoticed and should be an important part of the training process.

Comments from “The Posture Lady” 07/21/2008:  I have seen preschool kids, as young as two or three years old, stand in severe knee hyperextension.  My 3 and 1/2 year old son stands with “loosey goosey” looking knees, in complete knee hyperextension, every day and I remind him EVERY DAY that he needs to stand with his knees “soft.”  I believe we need to go this far back and start educating parents and kids about correct standing posture.

There are many elite gymnasts that stand in knee hyperextension.  This can be seen especially when at the chalk box or awaiting a turn on vault or beam.  It’s a horrible stance.  This is not to say that the gymnast’s legs should not look straight and gorgeous once airborne, but just to say we are NOT meant to stand in knee hyperextension.  I will soon learn how to post a picture from my mentor (RIP) Florence Kendall, PT.  She gave me permission to use the very picture that best shows the problem and consequences of knee hyperextension.  From the book, “MUSCLES Testing and Function” 5th edition, page 84, ISBN 0-7817-4780-5  (I’m in the book too – pages 395,396,397, if you want to see some crazy-short hip flexors and ITBs as a former elite gymnast.  What a mess.)

Back to the problem with this picture.  A gymnast that stands in knee hyperextension risks the possiblity of ending up with a posterior (backward) bow in the tibia and fibula.  I wonder if this helps lead to stress fractures or bones that “just pop and crack.”  My gut says, yes.  It saddens me that an elite gymnast may get to this point from something that might be prevented with education as early as the preschool years.  Let’s work to help fix the issue.

The gymnast should stand with good posture at all times.  The femurs (thighbones) should be in neutral rotation with the patellae (kneecaps) facing straight ahead.  The feet should be in good alignment; turned out only 7 to 10 degrees and arches maintained. 

If a gymnast has difficulty holding the arches up, the following suggestions may help:

-Reinforce the idea of contracting the side buttock muscles to help align the legs and lift the arches.

-Strengthen the posterior Gluteus Medius muscle with the following exercises and suggestions…

KICKS (with good hip turn-out and tight abdominal muscles) / JUMPS (pay close attention to straddle jumps very early in the gymnast’s career and make sure that they turn the leg out from the hip) / SIDELYING HIP ROTATION / HEEL PUSHES / POSTERIOR TIBIALIS STRENGTH / CORRECT WALKING and CORRECT CHOREOGRAPHY

Correct landings during the development of the young gymnast will help that athlete in the future.  The gymnast should have correct ankle range of motion and correct hip turnout.(“Quick Tests” and Corrective Exercises such as knee/foot mechanics and hip turn-out exercise)

The pelvis should be in good alignment with normal back curvature – the low back should curve in only slightly.  The gymnast should have good lower abdominal muscle control during landings.  The hip flexors and quadriceps should not be overdeveloped and over-used.  The Hamstring and gluteal muscles should contract sufficiently during landings.(“Quick Tests” and Corrective Exercises such as hip flexor stretch – two- joint muscles)

AVOID PAINFUL TIBIAL STRESS FRACTURES BY REALIZING THAT THE BASICS OF GOOD POSTURE, MUSCLE BALANCE AND BIOMECHANICS ARE THE POINTS THAT NEED TO BE STRESSED!  

More details on specific exercises to come…

The Power of Positive Posture

Thursday, May 1st, 2008

The word “posture” is finally a buzz word again.  If you read Florence Kendall,’s early work called “Posture and Pain,” you can imagine “posture” was a household word.  In the 1940’s or so, Florence and her husband (Henry O. Kendall) took 5000 posture pictures of guys at West Point!  People knew what posture was.

One of my mentors, Dr. Shirley Sahrmann, reminded me that in the 1950’s teachers and parents reminded children about good posture, but then we “lost” the idea in the 60’s and 70’s with that era of slouching (and other habits!).  I’m glad the word is back and I’m glad to see it in print and to hear it.

Now-a-days you hear the word “posture” on TV shows like “Dancing With the Stars” and “America’s Next Top Model.”  You read about it in magazines and see it in USAG’s compulsory writings (thank goodness!). I would like to see the word used more by moms and dads and teachers in the schools again.

I’d like to think that we could all play a part in educating the people that we work with on the power of positive posture…

“Stand even on both legs.” “Keep your knees soft.” “Stand up tall.”  “Sit up tall.” “Pull your shoulder blades down” “Pull your abs UP and IN.” “Lift your chest up and forward.” “I give you permission to bug me about MY posture!”     

So…You’re Sitting At Your Computer…

Friday, April 18th, 2008

So…You’re Sitting At Your Computer…

Posture Alert:

SITTING POSTURE: The low back should be straight and relaxed flat against the back of the chair, with the feet flat on the floor (put something under your feet if they don’t touch the floor). The chest should be slightly up, shoulders pulled gently back and shoulder blades pulled gently down and back and in toward the spine.  Get up and move around every 15 to 30 minutes.

Lift your arms up over your head as if you are doing a wall slide exercise (sitting or standing): Place your hands up beside your head with your elbows touching the wall (or imaginary wall).  If needed, correct your feet and knees (face them straight ahead, with “soft” knees if you are standing), then tilt your pelvis to flatten your low back against the wall by pulling up and in with the lower abdominal muscles.  Keeping your arms in contact with the wall, move your arms slowly to a diagonally overhead position.  (Hold several seconds and repeat 5 to 8 times.)

Stop slouching!

“Got Posture?!?!?!?”

Using Crutches (not!)

Thursday, April 17th, 2008

I never dreamed that walking on a college campus would be hazardous to my health.

Both ankles were bad.  My left ankle was so shot.  I didn’t use crutches after I sprained as a kid (big mistake!), I did use DMSO on it and compete on it, and I sprained it at least 12 times.

When I was going to class during PT school in the mid-1980’s one day, I sprained my left ankle on the side of a curb.  In order to avoid falling flat on my face to the left, in the middle of a busy lane of cars (I used to sprain and my back pack would fly about 10 feet), I compensated and threw my body to the right.  What happened is the somewhat usual bone bruise on the inside/medial side of my ankle (from the bones hitting hard, with no ligaments on the lateral side) and the not so usual thrust of my entire body to the right in a “C”-shaped curve.

I had my typical after-pain with the bone bruise being the problem.  There was no longer any swelling on the outside of the ankle when I did this and I could immediately grab my backpack and walk.  Usually a couple of college students would laugh at me, but this time was different.  When I got to class, one of my professors informed me that she was actually driving by and saw me save my own life by throwing my body the way I did.  Thank God that I was choreographically sound.

Anyway, she announced that I would need to have my ankle reconstructed before I could do an internship at a hospital.  Chances were too great that I would wipe out while I was walking a little old lady post-op fractured hip and pull her down with me and fracture her other hip!

So I had it reconstructed.  Chrisman-Snook style.  http://radiographics.rsnajnls.org/cgi/content/full/24/4/999?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&fulltext=tendon&andorexactfulltext=and&searchid=1&FIRSTINDEX=0&sortspec=relevance&resourcetype=HWCIT

My PT classmate Donna was there to watch (we had to watch two surgeries sometime before graduation).  I had a spinal because mono still showed up in my system after 10 months!  But, the spinal went to high up (to my eye level instead of around my belly button or so).  I could no longer feel like I was breathing right and I was slurring my speech.  They took the radio headsets off of my ears and put and oxygen mask on, thus the new sound of drills and hammers.  I heard everything!  Donna asked where my lateral ligaments were and the doc said, “Why Donna, she has no trace of any of the three ligaments on the lateral side.”  The bony was shiny.  No remaining shreds of anything.  That’s why the joint opened up 33 degrees (both ankles did that) and I would sprain to the point of clunking the medial side bones together.

Well, the reconstruction went fine on the left.  It was tight.  Far too tight until I went running and stepped in a pothole and ripped some things loose a bit.  It felt and sounded like a green stick trying to break.

It wasn’t until I was pregnant with my first child (Dani- born 6/29/92) that I knew I would have to have my right ankle reconstructed.  During the pregnancy, my right ankle would wipe out and I would quickly throw my right shoulder, like a left twist, and fall flat on my back, in order to land straight down on her.  After that 9 months of cute tricks, watching her toddle around, continued sprains, another pregnancy, delivery of my second kid (Mason- born 6/29/94, yes, the same birthday, two years apart!), waiting for the day he walked, I had my right ankle reconstructed over a Christmas break.  New doc, outcome good, not quite as stiff and tight, and another five inch scar and lots of staples/screws.

There is seriously a grocery store door bell that I “turned on” with all my hardware (knee included) in Columbia, Missouri.  I’m not sure it is still there, but if it is, I’ll find it and once again feel like the Bionic Woman!

Lots of morals of this story.  Take with you the idea of using crutches.

Crutches should be measured for a good fit as follows (because those height markings on those ole’ silver crutches are not always right):

Place one crutch under armpit.  Set crutch tip six inches diagonally out from little toe.  You should be able to fit three to four of your (crutch walker) own finger widths between the crutch and your armpit.  Lose the washrags taped around the top of the crutch.  Avoid leaning forward and slouching over your crutches with your armpits taking all of the pressure.  Had a young guy patient once who got wrist drop (a nerve palsy that eventually went away) from leaning on his crutches.  Pretty bad to have your wrist failing you when you have to walk on crutches.  Finally, make sure that the hand grasp pieces of the crutches are raised or lowered to insure that the elbow bends 30 degrees.  Secure both crutches at these measurements tightly, and you’re on your way.

RULE:  use crutches until you no longer have a visible limp.

PROGRESSION:  two crutches (usually non-weight bearing), then two crutches (partial progressing to full weight bearing), then one crutch on the OPPOSITE side of the injury.  Continue use of two crutches in crowded places (i.e. malls and airports) or in situations where you have to book it (fast).  The one crutch discipline takes time, but it segues beautifully into a non-limping gait.

Angry About Ankle Sprains? (USECA article from Dr. Suzanne Hecht with The Posture Lady) back in 2004 or so.