BY Dylan Chisholm, PT, DPT, cert. DN, cert. VRS

Many people will attain medical professionals, including physical therapists, for spinal manipulations for their acute or chronic lower back, neck or mid back pain in hopes of alleviating their ongoing pain or related dysfunction. These manipulations, or “adjustments”, often produce loud, cracking noises that allow for the body’s natural receptors to reset, giving better alignment and thus assisting in reducing overall pain in the spine. However, many are unaware that physical therapists are also capable of manipulating, or “cracking”, various other joints of the body, including the hips, wrists, elbows, knees and ankles. This is known as extremity manipulations with the goal of reducing pain and allowing you to get back to doing the activities you love. The purpose of this blog is to educate you on various diagnosis and pain patterns that extremity manipulations can assist with along with various other physical therapy interventions.

One of the most common diagnoses that physical therapists see daily is osteoarthritis (OA), often in the hip, knee and ankle. Osteoarthritis is generally a degenerative process of the joint which can be very debilitating and painful for many patients. Hip OA will often clinically show as pain that can be along the front of the hip as well as into the groin. This pain is commonly seen due to extra compression into the hip that produces a “bone on bone” effect over time. The hip manipulation is a technique used to quickly decompress the joint and allow for fluids inside of the hip to better flow in and out of the joint, which provides nutrients and healing properties that can alleviate pain and make your walking tolerance better.

Knee OA can present as having increased stiffness and achiness into your knee especially with walking long distances, stairs and getting out of the car. The cartilage and menisci of your knee that provide a “cushion” for the knee bones over time will break down, causing the dreaded “bone on bone” and thus leading to increased pain and difficulty performing daily activities. Performing a quick knee manipulation can allow for the receptors of your knee to reset, which can assist in reducing pain and improve Range of Motion (ROM) and balance at the joint.

Many patients will at some point sprain their ankle, which can cause significant instability, swelling and pain at the ankle and can be a long-term problem if ankle sprains occur frequently over time. Due to progressive ankle OA, our calf muscles will also become tighter, which reduces the ability for us to pull our foot off the ground and clear the toes when we are walking, which can cause trips and falls. A manipulation of the ankle can help to reduce pain and improve the ability for the joints to move, which can help with walking and most daily activities.

Extremity manipulations are an important aspect of physical therapy treatment that is often overlooked but can be a game changer when it comes to reducing pain and improving function. This technique along with various other interventions that physical therapists perform, including soft tissue mobility, functional strengthening, dry needling, joint mobilizations and balance training can improve your quality of life and get you back to doing the things you love.

If you experience daily pain into your hips, knees and ankles and wish to get back to walking more with less pain, give Rye Physical Therapy a call and schedule with one of our highly skilled and trained physical therapists today!

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We are getting close to that time of the year where the nights get colder, the leaves start changing color and pumpkin is everywhere! Right around this time of year, a lot of us also decide to lace up our dusty hiking boots and head to the White Mountains as well. Whether you are a novice hiker or an experienced regular, it seems that everyone has hiking the 4000 footers in New Hampshire on their bucket list. It’s definitely on my list! But, with checking off these bucket list hikes, it is also very common to experience knee pain during or afterwards.

Below are my top tips for preparing for your next hike and battling with any existing or future knee pain you might have!

Stretching

When it comes to hiking and knee pain, I think stretching is essential. However, this is almost always the first thing I hear my patients skip – whether it’s an afternoon pickleball game or a morning walk – no one likes to stretch. As you start on your next White Mountain adventure, walk for about 5-10 minutes on your trail or around the parking lot. If you need to you can grab your phone, watch or friend to hold each other accountable that you’ve got your body moving before you start to stretch. This allows your heart rate to elevate, blood to pump to your muscles and a more comfortable and effective stretch than if you just rolled out of bed or the car. After 5-10 minutes, step off to the side and give your muscles some TLC before you ask them to carry you up and down a mountain.

Goal: Hold each stretch for ~30 seconds on each side and repeat 2-3 times.

Quadriceps

Hamstrings

Gastroc/Soleus (Calves)

Strengthening

Regular hiking builds up strength in the sagittal plane and involves significant power and endurance of your quadriceps, hamstrings, gastroc/soleus, anterior tibialis and more. The strength you build while hiking helps you continue to hike, but what about injury prevention for your knees? Are they already starting to bother you? Do you notice that you are better trained for the power of climbing up the mountain? Or maybe you have great control on the way down, but climbing 1000 rock stairs gets your legs shaking uncontrollably. We all have areas we can work on – that is where cross training comes in. No matter what your “sport” of choice is, cross training is always important. Below are three exercises to try at home

Gluteus Medius Hip Abduction Leg Raise

Single Leg Dead Lift

Single Leg Sit to Stands/Squats

Preparation Hikes

One of the most important recommendations I can make is to pick a hike that you and your knees are ready for. Do you plan on completing a 5-mile hike in November? If so, it’s important that you’ve completed a few 2-3 or 3-4 mile hikes in preparation to give your knees and muscles time to adapt to the new stress you are putting on them. Moreover, take a look at the parking ahead of time! Last year I planned to hike Franconia Ridge and thought I was prepared for the distance. The morning of my hike, I got there and saw that the parking lot was full so I just kept driving down the road. I finally found parking about 1 mile away from the trailhead. I thought to myself, that’s not too bad, but what was supposed to be a 6-7 mile hike then turned into an 8-9 mile hike because I had to walk an extra 2 miles to my car. If you’ve regularly been hiking 1-2 mile adventures, you don’t want to jump to 8 miles for your next one – you want to give your knees the appropriate mileage to adapt to the stress you’re putting on them AND you never know how far away you’ll be parking!

Taking off some of the load

If you’ve gone on at least 1 hike, you’ve likely seen some hikers out there using trekking poles. And if you think like me, you’ve likely also wondered if those poles help, hurt or just get in the way? One literature article looked at 15 males who individually completed 60 hikes under different conditions. These conditions included hiking poles or no poles as well as carrying no backpack, a small pack or a large pack. The results showed that there was a reduction in force, moments and power around the ankles, knees and hips. The takeaway here is that if you’re currently having knee pain, but hiking is your passion, give trekking poles a try to reduce some of the load you are putting on your knees. Also, try carrying a lighter pack and sharing your snacks with a friend.  Give us a call if your knees have pain, Rye Physical Therapy can help!

Sources:
https://pubmed.ncbi.nlm.nih.gov/17218900/

http://eds.b.ebscohost.com/eds/detail/detail?vid=0&sid=d417422f-6b15-4ba0-a41b-5013f9121361%40pdc-v-sessmgr02&bdata=JnNpdGU9ZWRzLWxpdmU%3d#AN=125728050&db=asx

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by KRISTIN KEAFER DPT, Rye Physical Therapy

Osteoarthritis is a degenerative process over time where the cartilage at the ends of your bones starts to “wear and tear”. Many different joints throughout your body may be affected with age related changes and the knee joint is commonly a symptomatic area. This involves the break down of cartilage at the end of the femur (thigh bone) and the end of the tibia (shin bone). Typically, an x-ray and a severe decline of your daily function will determine if you are in need of a joint replacement surgery. In the United States alone, 4.7 million individuals (3.0 million women and 1.7 million men) were with a total knee replacement in 2010.² Signs that you may be ready for a knee replacement are significant swelling around the knee, tenderness, stiffness, pain with inability to straighten knee, deformities such as knock- knee or bow legged, and severe functional limitations. Physical therapy is the first line of defense to address pain and function, however if conservative methods are not working, it may be time for a joint replacement. All non-surgical treatments will be exhausted before moving forward with a surgical intervention. This can be discussed with both your physical therapist and your doctor.

What is a knee replacement?

The worn cartilage at the ends of the bones are surgically removed and replaced with a combination of metal and plastic implants. Typically, a knee replacement will last up to 20 years, however this can vary based on wear and tear of the components placed. In some cases, the doctor will only replace one side of the joint called a uni-compartmental replacement because the other side of the joint is still healthy. In these cases, the surgery is quicker, hospital stay is shorter, and rehabilitation process is faster.

Pre-Operative Treatment

Usually, your surgeon will refer you to physical therapy for pre-operative treatment prior to your knee replacement. Research indicates that it can improve early post-operative pain and function.¹ A physical therapist will evaluate your range of motion at your knee, your strength, and your overall function with daily activities. This will further justify need for the surgery to your insurance company and will allow the therapist to work with you to increase strength and range of motion as much as possible to improve your post-operative outcome.

Pre-operative treatment is unique in the fact that you can meet with your therapist prior to undergoing your surgery to ask any additional questions and learn more about the rehabilitation part of this journey. Many of the range of motion and strength exercises that are prescribed to you before surgery will be similar to those after surgery. This always helps to make you feel more comfortable with what to expect.

Post- Operative Treatment

After surgery, typically you will spend 1-2 days in the hospital. You will work with a physical therapist in the hospital who will help you out of bed and start moving. They will show you how to use a walker or crutches and they will give you some exercises to work on while you are in bed. It is important to move after surgery to avoid a DVT (blood clot). Your plan for discharge depends on how functionally limited you are and what your home situation is like. Sometimes you will be discharged directly to home, and other times you may go to a skilled nursing facility if you need more help after surgery. Once at home, a physical therapist will come to your home to help you. As soon as you are able to safely leave your home, you will transition to outpatient physical therapy for continued rehab.

Outpatient rehab… this is where Hampton Physical Therapists’ are essential in this process!

You should expect your therapist to be working hands on to reduce swelling and pain in the early stages. We also help to properly transition you off of a walker, crutches, and/or a cane to return you to normal walking mechanics. Manual stretching is implemented to improve your range of motion into flexion (bending the knee) and extension (straightening the knee). You will be given exercises to work on in the clinic and at home. It is imperative that you work as a team with your therapist to reach the best outcome. Gradually the focus will transition from range of motion exercises to strengthening exercises to improve all of your functional activities.

Below are guidelines for reaching functional goals post operatively to get you back to living a normal life!

Reaching Your Goals!

Day 1- 2 weeks
0 degrees of extension and 65-90 degrees of knee flexion. You will be able to stand, walk, go up and down stairs with assistance. Decrease swelling and keep pain under control!

2- 6 weeks
0 degrees of extension and greater than 90 degrees of flexion. You will be able to walk without an assistive device, sit and stand more comfortably, and do stairs with minimal support.

6-12 weeks
0 degrees of extension and 115 degrees of flexion or better. You should be able to move around normally, bend down to pick things up, sit comfortably, stand for longer periods, and tie your shoe laces.

12+ weeks
0 degrees of extension and 115-135 degrees of flexion. The first 90 days are definitive in your recovery. You should have little pain and be able to do most daily activities with ease. You will be working towards walking longer distances and getting back to normal life.

Range of Motion Milestones

0 degrees of extension to walk normal without a limp
65 degrees of flexion to walk on even surfaces
70 degrees of flexion to lift an object from the floor
85 degrees of flexion to climb stairs
95 degrees of flexion to sit comfortably and to stand up from being seated
105 degrees of flexion to tie shoe laces comfortably
115 degrees of flexion to squat or sit cross legged comfortably
135 degrees of flexion to get into and out of a bath tub without limitation

Rye Physical Therapy is here to help with your journey before and after joint replacement surgery! Please contact us at either our Hampton or Seabrook office with any additional questions or to schedule a FREE discovery visit!

Resources

• • Li Wang, et al. Does preoperative rehabilitation for patients planning to undergo joint replacement surgery improve outcomes? A systematic review and meta-analysis of randomised controlled trials. BMJ Open. 2016; 6(2): e009857. Published online 2016 Feb 2. doi: 1136/bmjopen-2015-009857
  • Maradit Kremers H, et al. Prevalence of Total Hip and Knee Replacement in the United States. J Bone Joint Surg Am.2015 Sep 2;97(17):1386-97. doi: 10.2106/JBJS.N.01141.
  • Rowe PJ, et al. Knee joint kinematics in gait and other functional activities measured using flexible electrogoniometry: how much knee motion is sufficient for normal daily life? Gait Posture.2000 Oct;12(2):143-55.

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by Jessica Leberman, DPT – Hampton NH Clinic

• Young athletes may have had an increase in complaints of knee pain this past winter after playing on harder indoor courts. Adolescent athletes are among those most frequently plagued by knee injuries. Knee pain and clicking not precipitated by a traumatic injury is a common complaint heard from young athletes. One of the most common diagnoses for adolescents with knee pain is Patellofemoral Pain Syndrome (PFPS)(1).
• 
  The knee joint is comprised of the articulation of 3 bones; the femur, the tibia and the patella (knee cap). The patella rests in a groove commonly referred to as the “patellar groove”. As a person bends and straightens the knee the patella glides within the groove(1).

• What is Patellofemoral Pain Syndrome?

• PFPS is an umbrella term used to describe pain and/or clicking or crunching in and around the knee joint associated abnormal gliding of the patella in the patellar groove. Often the symptoms occur on the front side of the knee and underneath the patella.
• Common signs and symptoms of PFPS include;
  • pain with repetitive activities such as running, jumping, or squatting
  • pain with climbing/descending stairs
  • pain after sitting with your knees bent for a long period of time such as in school at a desk, at the movie theater or on an airplane
  • Popping or crackling sounds (known as crepitus) in your knee when bending the knee or squatting down(1)

What Causes Patellofemoral Pain Syndrome?

Common causes of PFPS include a change in activity level, a change in activity surface, or a change in footwear. Adolescents that participate in activities on more firm surfaces such as basketball, indoor track and dance are more prone to PFPS. PFPS can be due to abnormal alignment of the patella within the patellar groove, muscle imbalances, biomechanical abnormalities of the hip, knee and/or feet, and walking/running/jumping mechanical faults1. Genu valgum (knock knees) is a biomechanical abnormality commonly associated with PFPS. PFPS occurs more commonly in females (55%) than males (45%) as females are more prone to genu valgum(2).

How can Physical Therapy help?

A physical therapist will perform a full assessment to determine the underlying source of your pain and establish a comprehensive individualized plan based on your presentation. Your individualized plan can include any combination of the following;
• Taping treatments to address mal-tracking of the patella(3)
• Guided strengthening activities of the core, pelvic, hip, knee and ankle stabilizing muscles(4)
• Myofascial treatments such as stretching, Instrument Assisted Soft Tissue Mobilization and Dry Needling.(5)
• Assessment for orthotic prescription to address abnormal biomechanics of the feet. Those who over pronate (more commonly referred to as having flat feet) are more prone to PFPS and can benefit from arch support in shoes.(6)
• Assessment of your walking, running, and/or jumping mechanics and training to optimize mechanics and dynamic balance to decrease abnormal stresses through the knee joint.(4,6)

Although adolescent athletes are those that frequently experience PFPS people of any age and activity level can experience symptoms related to PFPS. If you start to notice knee pain or crepitus within your knee Rye Physical Therapy can help you. If you have any questions regarding this condition feel free to call or stop into one of our two locations in either Hampton or Seabrook to speak to one of our physical therapists.

References:
1. Patellofemoral Pain Syndrome-OrthoInfo–AAOS. https://orthoinfo.aaos.org/topic.cfm?topic=A00680
2. Glaviano NR Kew M Hart JM Saliba S. Demographic and epidemiological trends in patellofemoral pain. Int J Sports Phys Ther. 2015;10(3):281-290
3. Kurt EE, Büyükturan Ö, Erdem HR, Tuncay F, Sezgin H. Short-term effects of kinesio tape on joint position sense, isokinetic measurements, and clinical parameters in patellofemoral pain syndrome. J Phys Ther Sci. 2016 Jul;28(7):2034-40
4. Chevidikunnan MF, Al Saif A, Gaowgzeh RA, Mamdouh KA. Effectiveness of core muscle strengthening for improving pain and dynamic balance among female patients with patellofemoral pain syndrome. J Phys Ther Sci. 2016 May;28(5):1518-23.
5. Telles G, Cristovão DR, Belache FA, Santos MR, Almeida RS, Nogueira LA. The effect of adding myofascial treatments to an exercise programme for patients with anterior knee pain. J Bodyw Mov Ther. 2016 Oct;20(4):844-850
6. Powers CM. The influence of altered lower-extremity kinematics on patellofemoral joint dysfunction: a theoretical perspective. J Orthop Sports Phys Ther. 2003 Nov;33(11):639-46.

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As the fall approaches, many of you may be signing up for a 5k, 10k, or you may be an everyday runner. As many of you know, with running may come aches and pains. The most common overuse injury in runners is Iliotibial Band Syndrome.

What is Iliotibial Band Syndrome?

ITBS accounts for 12-14% of all overuse injuries in runners. The IT band consists of a thick, tight band of fascia located on the lateral aspect of the thigh. The IT band spans from the outside of the pelvis, runs over the lateral hip, and inserts into the lateral femoral condyle located just below the lateral knee. The continuous rubbing of the band over the boney prominences on the femur, combined with repetitive flexion and extension of the knee is believed to be the cause of ITBS. The good news? It is very treatable!

Signs and Symptoms of ITBS:

• Stinging or sharp pain just above the knee joint on the lateral side of the knee

Swelling or thickness of the tissue just above the lateral aspect of the knee

Increased pain with activity: walking, running (downhill specifically)

Pain with bending and/or straightening of the knee, which can be made worse by pressing on the tissue on the lateral aspect of the knee

Causes of ITBS:

• Poor footwear
• Improper training: increase in mileage; change in type of training, change in training intensity
• Running on cambered road surface
• Running on an indoor track with tight turns
• Muscle weakness: glute med, glute max, quads
• Muscle tightness: IT band, quads, hamstrings

What can I do to treat my ITBS?

• Ice – 15 minutes at a time, 1-2 times a day

IT band Stretch

1. Use a rope or belt to wrap around your foot of the affected leg
2. Cross the affected leg over the other and pull your foot up and out until a comfortable stretch is felt along your IT band.
3. Hold for 10 seconds and return to starting position
4. Repeat 10-15 times, 1-2 times a day

Foam Roll- massage

1. Lay on foam roller on the affected side
2. Start with the foam roller just above your knee and roll up to your hip. Repeat for 3-5 mins
3. Can perform 1-2 times a day

• Strengthen:

Hip Abduction Exercise

1. Lay on your non-affected side with your bottom knee bent
2. Keep top leg straight and raise leg up towards ceiling
3. Return to starting position
4. Perform 3 sets of 10 reps

Clamshell

1. Lay on your non-affected side with both knees bent over one another
2. Keep heels touching while opening and closing your knees
3. Perform 3 sets of 10 reps

Bridges

1. Lay on our back with both knees bent up, feet on the floor
2. Raise hips off the ground and return to starting position
3. Perform 3 sets of 10 reps

Physical therapy is another option that can provide a wide variety of treatment treatments for this condition. Our team of physical therapists at Rye Physical Therapy can provide strengthening exercises, stretches, Graston technique for soft tissue mobilization, Kinesiotaping, modalities and much more to provide you with a great outcome for your symptoms. Feel free to call our office or visit https://www.HamptonPT.com for more information.

• Grau et al. The influence of matching populations on kinematic and kinetic variables in runners with Iliotibial band syndrome. Research Quarterly for Exercise and Sport. 2008; 79 (4): 450-457.
• Shamus J, Shamus E. Case report: the management of iliotibial band syndrome with multifaceted approach: a double case report. International Journal of Sports Physical Therapy. 2015; 10 (3): 378-390.
• Van Der Worp et al. Iliotibial band syndrome in runners, a systematic review. Sports Med. 2012; 42 (11): 969-992.

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