What is Blood Flow Restriction Training?


What Is Blood Flow Restriction Training?

Can Blood Flow Restriction Training help improve patient recovery time following an injury? Read our post below as we discuss everything you need to know.

Blood Flow Restriction (BFR) Training is a strategy involving the brief and intermittent occlusion of arterial and venous blood flow that occurs with use of a tourniquet placed around the proximal limb of the upper or lower extremity. When performing BFR for resistance training purposes, relatively light loads of around 20-30% of 1 RM allow a person to increase strength without the stress/strain of heavy loads.

blood flow restriction tourniquet

Resistance training with BFR has also been shown to increase post-exercise muscle protein synthesis and elevate growth hormone levels. It can be used to improve muscle strength, size and functional aerobic capacity in shorter amounts of time with less stress on the body than typical resistance training. Blood flow restriction training (BFRT) essentially tricks the brain-body into thinki

ng one is performing high-intensity exercise when, in fact, the loads are much lower. BFR can also be used to reduce muscle atrophy through passive applications and by creating cellular swelling.

Who can benefit from BFR?

BFR can be useful for rehabilitation, fitness, performance training or recovery and is ideal for populations who have limitations to high mechanical loads such as those who are bedridden, casted/braced, pre/postoperative and/ or elderly. In addition to these more fragile populations, BFRT can also be used on the athletic community for performance training.

How is it used? What does a treatment session with BFR look like?

BFR can be used in different ways depending on the goals and limitations of the individual. In all circumstances, the cuff is first applied as proximal on the limb as it can be placed. Next, the loss of pulse (LOP) is calculated using an ultrasound unit to determine at what pressure a person’s pulse in that limb can no longer be detected. Lastly, a pressure in the cuff is set depending on the type of BFR to be performed.

In Passive BFR (no exercise) used to reduce muscle atrophy and stimulate capillary growth, the cuff pressure is set to 100% LOP and a patient sits with the cuff on for 5-minute increments with 5 minutes of rest in between. In Cellular Swelling and Strengthening protocols, the cuff pressure is set between 40-50% for the upper extremity and 60-80% for the lower extremity. When strengthening, the intensity should be 15-30% of a person’s 1 rep max, and 4 sets should be performed (30 reps; 15 reps; 15 reps; 15 reps) with 30 seconds of rest between each set. A total of 5-6 exercises should be performed during the treatment session with 60 seconds of rest between each new exercise while the cuff is deflated.

If the goal is not strengthening, but cellular swelling, which reduces disuse atrophy and recruits muscle fibers (perhaps someone with ROM or WB restrictions), a person should perform 5 sets of 5 minutes with a 3-minute rest in between. This can be achieved with no exercise or while performing isometrics. These are but a few of the ways BFR can be implemented into a person’s rehabilitation or strength training program.

For more information on BFR, contact us today, click here. 

What is Eccentric Strengthening?

Eccentric Strengthening Miami and Boca Raton

What is Eccentric Strengthening?

Eccentric contraction exercises are an important and often overlooked component of strength training.

By: Dr. Ashley O’Rourke PT, DPT, ATC, LAT

Eccentric strength refers to tension being applied to a muscle as it lengthens. This is also when the muscle’s force-producing capacity is most optimal. Studies show that eccentric exercise results in less oxygen consumption, greater force production, and less energy expenditure than concentric strengthening- or the active shortening of the muscle. The force produced by a concentric contraction is always less than the muscles maximum force. During a voluntary muscle contraction, the speed of the contraction and the ability to exert tension are inversely related. Therefore, the faster a muscle contract concentrically, the lower the tension it is able to generate. An example of concentric strengthening would be a classic bicep curl, whereas the eccentric component would occur as a person lowers the arm into a straightened position (as the bicep muscle lengthens).

 Eccentric Strengthening in Post-Op Knee Rehab:

Eccentric quadricep and gastrocnemius (calf) strength, in particular, are important following knee surgeries such as ACL reconstruction because of their importance in absorbing the weight of your body as they lengthen in order to control your descent- this includes going downstairs, sitting down in a chair or decelerating from a sprint. Without sufficient eccentric control, it would be difficult and, in some cases, unsafe to perform these activities. In regards to running, the primary muscles involved in acceleration and deceleration are quadriceps and gastrocnemius. However, acceleration involves the concentric contraction of these muscles, while deceleration involves the eccentric use of these muscles. Therefore, eccentric strength is important to safely slow down following a sprint or before initiating a rapid change of direction. Research suggests that eccentric strengthening on the non-involved lower extremity is also beneficial for improving both the quadriceps muscle strength and the quadriceps accelerated reaction time in the surgical lower extremity.

Concerns with Eccentric Strengthening in Post-Op ACL:

Though the idea of early post-operative eccentric resistance exercise to the surgical limb has traditionally been contraindicated, due to the potential for injury to the graft, articular cartilage, or surrounding soft tissue structure, recent evidence has shown that the application of early eccentrics to the ACL limb can be used to safely increase quadriceps muscle volume and strength. While eccentric quadriceps strength is important to regain following ACL reconstruction, it does not come without caveats. As with any eccentric training program, careful progression of training volume and intensity in the post ACL reconstruction patient is a necessity and should be performed under the direction of a licensed physical therapist as too much eccentric quadriceps strength could increase the chances of anterior tibial translation if not accompanied by sufficient hamstring strength. Therefore, a comprehensive approach, including both concentric and eccentric training to both the anterior and posterior chains surrounding the knee joint should be considered.

Take-Home Message:

Eccentric exercise has the ability to be an effective means to manage many common orthopedic conditions such as tendinopathies, post-op recovery, and muscle strain prevention. This potential is based on muscle/tendon physiology as it relates to performance. Eccentric exercise, or when the muscle is lengthened and an external force exceeds the force produced by the muscle, has been shown to be more effective than traditional concentric strengthening at minimizing muscle atrophy and improving muscle force production. It results in less oxygen consumption, greater force production, and less energy expenditure and should be incorporated into both a preventative strength training program, as well as, an effective post-op rehabilitation protocol.

Schedule Your Appointment

To learn more about our eccentric strengthening program and to schedule a consultation call 305-735-8901 or click here. 

The Benefits of Functional Range Conditioning

The Benefits of Functional Range Conditioning

Learn to increase mobility, build strength and prevent injury using Functional Range Conditioning

Functional Range Conditioning MiamiFunctional Range Conditioning is a system of training which applies scientific methods to the acquisition and maintenance of functional mobility, articular resilience, and articular health and longevity. It was created by Dr. Andreo Spina and is quickly growing in popularity due to its effectiveness in training mobility of the human body. Mobility refers to the amount of active, usable motion that a person possesses. The more mobile a person is, the more they can maximize their movement potential safely and effectively. It is the difference between being flexible and able to stretch to specific passive ranges versus having actual control into those end ranges of motion. By training mobility one can capture what was once only passive ranges of motion and make them active and therefore usable. This, in turn, enhances the load bearing capacity of a joint and its ability to withstand the forces of everyday activity and sport.

Not only does FRC help to improve the mobility of the human body and develop improved load capacity in the joints, but it also improves body control. Body control is one of the critical factors in reducing the occurrence of injury and painful conditions that frequent training and sport.

To achieve the improvements in mobility, joint strength, and body control FRC implements two critical principles into the system. They are the principle of progressive adaptation and the principle of specificity. The principle of progressive adaptation states that incremental loads applied to the tissue results in adaptation of said tissue in such a way that the load absorption capacity will improve. This also makes FRC an inherently safe system to use. The loads applied to the tissues early on are scaled only to what that person can tolerate. As their tolerance improves so to will the articular strength of the joint. The principle of specificity states that the adaptation of the tissue is specific to the demand. This means by frequently incorporating end range mobility training into the maintenance and training of the human body, one is effectively injury-proofing themselves. The vast array of musculoskeletal injuries occur when tissue is loaded past what it can tolerate or the new demands on the tissue exceed what was previously the norm. By moving the joints of the body through all available ranges of motion and training into these ranges there will rarely be a situation the body is not already prepared for.

At Fox Physical Therapy we always seek to stay on the cutting edge of evidence-based practice. Dr. Fox and Dr. Alexander became certified in FRC last fall. FRC has seamlessly blended into the daily clinical practice and has only enhanced the already great outcomes expected here at Fox. If you are feeling stiff during sports or experiencing aching joints from a sedentary desk job, we encourage you to give us a call. Once in the clinic, you will learn how to perform the necessary maintenance work necessary to keep your body healthy and operating at optimal function.

Why Choose an Orthopedic Clinical Specialist

  • Orthopedic-Clinical-Specialist-miami-boca-raton-florida

Orthopaedic Clinical Specialist

The Orthopaedic Clinical Specialist (OCS) is a board certification administered by the American Board of Physical Therapy Specialties.

This board certification identifies Physical Therapists who have gone above and beyond in their training in order to ‘specialize’ in the realm of orthopedics. In order to achieve the OCS designation, the Physical Therapist must demonstrate the required knowledge in identifying musculoskeletal dysfunction via a board examination.

The American Board of Physical Therapy Specialties identifies their mission statement as:

“The mission of the American Board of Physical Therapy Specialties is to advance the profession of physical therapy by establishing, maintaining, and promoting standards of excellence for clinical specialization, and by recognizing the advanced knowledge, skills and experience by physical therapist practitioners through specialist credentialing.”

It is important that if you are seeking care for an injury or chronic pain that you seek out a Physical Therapist that has achieved this OCS designation. This demonstrates that the Physical Therapist has taken the time to gain the required skills and experience in the realm of musculoskeletal disorders. This also, more importantly, ensures that you are receiving the best care possible.

If you thought you were experiencing an issue with your heart you would likely seek out the help of a Cardiologist, an MD who specializes the cardiovascular system, instead of a general practitioner. The same holds true for your Physical Therapist. If you have an injury to the bones, joints, or associated muscles it is in your best interest to seek out care from a Physical Therapist who is an Orthopaedic Clinical Specialist.

At Fox Physical Therapy our mission is to provide the best orthopedic evidence-based musculoskeletal care in South Florida. Our board-certified Doctors of Physical Therapy will quickly identify and resolve your pain without the need for medicine or surgery. We have two locations in Wynwood, Miami, and Boca Raton.

Contact us today schedule an appointment.

The true source of your back pain—is it really what you think?

  • the-truth-about-mri-and-backpain

The true source of your back pain—is it really what you think? n

Do you have back pain and are thinking about getting an MRI? Or maybe you got your MRI and you believe the results spell dread?

The relationship between MRI changes and low back pain may not be so clear-cut. In fact, research shows that changes on an MRI don’t necessarily correlate to pain, while many patients with pain show no abnormalities on MRI. Before jumping to any conclusions, read on for more detail on the complex relationship between what your image shows and whether is it ultimately driving the pain and symptoms you are experiencing.

First, if you’re experiencing back pain, you are not alone. Pain in the lower back is one of the most common musculoskeletal complaints. In fact, 8 out of 10 people will experience low back pain over their lifetime. About 1 out of 4 people experience chronic low back pain (lasting longer than 3 months). Any structure of the lumbar spine that is innervated by nerve endings can cause both low back pain and/or referred pain, which is felt in one or both lower extremities. Some of the more common potential structures that may be involved include muscles, ligaments, vertebrae, facet joints (joints connecting the vertebrae), dura mater ( a membrane that surrounds and protects the spinal cord), and nerve roots.

So how could my imaging be wrong?

Imaging is useful in detecting fractures, abnormal tissue growth (i.e. cancer), inflammation/ bleeding, as well as serious compression of the spinal cord or nerves, which can help direct appropriate treatment. However, 99% of people with low back pain will not have any of these serious conditions. A large percentage will, however, have incidental findings on imaging which are normal anatomical variants, as well as normal age-related changes. In these cases, imaging is much less helpful in identifying the true cause and directing treatment. In fact, several studies have found that pain in the lower back is more strongly associated with factors such as life dissatisfaction, neuroticism, hostility, extroversion, and poor sleep quality than it is with findings on imaging. Thus, obtaining an imaging report can sometimes cause more harm than good. Research shows that patients who undergo lumbar MRI generally have worse outcomes than similar patients who do not have to image. Much of this is attributed to psychological factors, misinformation, and negative emotional responses. One common example is the finding of “dark” T2 signals within the disc on MRI. This is most often a pain-free and benign condition. However, it is labeled degenerative disk disease (DDD) leading many patients to believe their spine is “deteriorating.” In turn, these inappropriate beliefs can lead to a decrease in activity, anxiety, lifestyle changes, a perception of increased pain, changes in motor patterns, and unnecessary surgeries.

So, what exactly does the evidence say?

The exact nature of the relationship between imaging and pain is unclear, largely due to abnormal imaging findings in large numbers of people without pain (false positives). This means that many of the “abnormal” findings are indeed commonly occurring and natural parts of the aging process. One of the more common findings in the lumbar spine is disc degeneration, which is a natural process beginning fairly early on in life. In fact, more than one-third of healthy, normal adults in their 20’s present with degenerative discs on imaging. In some individuals, the rate of degeneration is quicker than others due to a combination of genetic and autoimmune factors, as well as resorption and biomechanical factors. In any case, the volume of intervertebral disc tissue naturally decreases over the lifespan.

Currently, the best available evidence demonstrates the following key concepts:

  1. Changes in diagnostic imaging are seen in many individuals with NO pain or symptoms.
  • Imaging studies (MRI & CT) show herniated disc material in up to 76% of people with NO low back pain or sciatica.
  • One-third of patients without pain have some type of “abnormality” in their lumbar spine (disc degeneration, disc bulge, facet hypertrophy, or nerve root compression).
  • Several studies have shown that professional athletes (gymnasts, volleyball players, wrestlers, weightlifters, skiers, etc.) have a higher prevalence of disc degeneration and other lumbar abnormalities, but do not have a higher incidence of back pain. In fact, athletes had significantly higher rates of changes on MRI (75-82%) when compared with age-matched non-athletes (54%). However, both groups had very similar rates of reported back pain (50% vs 44%)
  1. A large percentage of people with pain do not have correlating changes on imaging.
  • Less than half of patients who have pain in the lower back also have an “abnormality” identified in their image—this means that the majority who have pain have no associated anatomical changes.
  • One study involving horseback riders demonstrated an unusually high prevalence of lower back pain, but no conclusive MRI evidence to point to disk degeneration, spondylolysis, spondylolisthesis, or pathologic changes of the paraspinal muscles of the lumbar spine—imaging offered no explanation for their symptoms.
  • In one long-term follow-up study, 80% of athletes and 40% of nonathletes reported pain at baseline. Fifteen years later, 71% of athletes and 75% of non-athletes reported pain. At both points, athletes and non-athletes had similar rates of disc degeneration and the majority of the abnormalities seen on follow-up MRI were already present at baseline. This means that despite very few changes on images, the non-athlete group almost doubled in reports of pain—once again imaging could not identify the cause.
  1. Research has shown MRI findings are not related to the intensity of pain or extent of disability, (i.e. larger herniation does not equal more pain).
  • Several studies have found that both vertebral endplate changes and large extruded disc herniation (both believed to be causative factors in low back pain) are equally distributed between healthy subjects and those with disabling back pain. This means that as many patients without pain as those with pain had these changes on MRI and the changes did not correlate with severity of sciatica.
  1. Those with both pain and identifiable changes should be cautious, as the changes may not be the direct cause of the pain.
  • Even when abnormalities are identified, it is difficult to determine whether they are the direct cause of pain, as evidence has shown that many anatomical variations on MRI are not associated with symptoms
  • Many patients undergo unnecessary surgery to correct an incidental finding on imaging and still have pain because the original cause was something other than what was identified and wasn’t addressed (poor posture, decreased core stability, muscle spasm, etc.)

As one can see the current research on medical imaging does not support the notion that what is seen on the image correlates strongly with what the patient is experiencing. In fact, it has been shown that a thorough physical examination leading to a mechanical diagnosis can be just a sensitive and specific in identifying the cause of your symptoms. An evaluation by a qualified Doctor of Physical Therapy can help reveal the underlying biomechanical deficits that may have contributed to your condition and prevent it from recurring in the future. Some of the benefits of physical therapy include pain relief, increasing mobility, strengthening of the core and lumbar stabilizers, and increasing balance and functional movement.

At Fox Physical Therapy, our board-certified therapists specialize in treating and relieving low back pain. Contact us today to find out how we can help you feel better.

McKenzie Method of Mechanical Diagnosis and Therapy

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McKenzie Method of Mechanical Diagnosis and Therapy

Learn how Mechanical Diagnosis and Therapy® (MDT) can effectively treat low back and neck pain.

The McKenzie Method of Mechanical Diagnosis and Therapy (MDT) is a unique method of treating spine and extremity pain. The method has been in development for over 60 years, originally created by Robin McKenzie. It is an in-depth assessment, diagnosis, and treatment process that has been well researched throughout the years. Its validity as a treatment method for musculoskeletal pain is consistently supported in the literature. It requires no surgery, medication, needles, or expensive equipment.

The research has shown the MDT assessment to be extremely reliable in identifying pain of a mechanical origin. Mechanical pain originates from a biomechanical dysfunction in the way the bones, joints, or associated muscles are moving. The vast majority of musculoskeletal pain, including neck and low back pain, falls into this category.

Per the McKenzie Institute’s website: “The treatment principles of the McKenzie Method promote the body’s potential to repair itself and do not involve the use of medication, heat, cold, ultrasound, needles, or surgery. McKenzie allows patients to learn the principles and empowers them to be in control of their own symptom management, which can reduce dependency on medical intervention.”

Here at Fox Physical Therapy, we use the MDT assessment as one of our primary methods to effectively treat low back and neck pain. During the assessment, one of our Doctors of Physical Therapy will help to determine the exact cause of your symptoms as well as implement a treatment plan to quickly resolve your symptoms. The best part of the MDT method is that it allows you, the patient, to gain control over your symptoms and keep them under control even when outside of the clinic setting.

If you have been experiencing pain or issues with your body and its performance contact us today. You may be experiencing an underlying biomechanical that needs to be addressed by one of our doctors.

Hamstring Strain Rehabilitation Tips

Hamstring Strain Rehabilitation Tips

Don’t let a hamstring strain turn into a recurring injury!

Dr. Braulio Espinosa

Chances are if you play a sport that requires repetitive kicking then you are familiar with the term hamstring strain or “pulling a hamstring”. Hamstring strains account for 12–16% of all injuries in athletes with a re-injury rate reported as high as 22–34%. Hamstring strains are a very common and nagging injury typical seen in athletes who perform high speed sprinting, repetitive kicking and explosive movements associated with acceleration and change of direction. This injury accounts for 38% and 28% of the lower extremity injuries seen in high school and college football respectively and makes up the highest percentage of total injuries in rugby. The high incidence of injury in this muscle group may be partly due to the fact that the hamstrings cross over two joints (the hip and the knee) and are therefore subject to much greater reaction forces at multiple points along the lower extremity chain. The hamstrings are a colloquial term used to describe three distinct muscles, two on the medial side (semimebranosus, semitendinosis) and one on the lateral side (biceps femoris). All three muscles are responsible for bending the knee and extending back the hip, two actions that are crucial for sprinting, jumping, and kicking. These muscles originate from the hip and turn into tendons that with two attaching to the inside of your leg bone and one attaching to the outside, crossing the knee joint. A muscle strain is a term used to describe damage or a tear to the muscle/ tendon. Like most injuries, a strain can range from a simple overstretch injury all the way to a complete tear of the muscle.

How do they happen?

What most of the literature agrees upon is that hamstring strains are typically caused by a non-contact injury secondary to forceful stretching. Building off this point; when analyzing running technique it has been shown that peak stress on the muscle occurred during a terminal swing phase of the sprint (see image), suggesting that this period may pose the greatest risk for injury. It is during this phase that the hamstrings are working to decelerate the leg while also controlling the degree to which your knee straightens. What this essentially means is that the type of contraction the hamstrings have to perform must switch extremely rapidly from slowing down the leg while it is straightening (the point of peak stress and stretch to the muscle) to then actually driving your hip back to propel you forward. Several research studies support that this rapid change from deceleration to acceleration by the hamstrings is when the muscle is most vulnerable to injury.

Severity of Strains

The severity of muscle strain injuries is generally categorized as Grade I: very mild tear of the muscle with minor strength loss, Grade II: partial tear of the muscle with mild bruising and significant strength loss that limits functional performance, and Grade III: complete tear of the muscle/tendon and severe disability with day to day activities. Complete tears like a grade III are rare, constituting about 1% of all hamstring strains. What is commonly observed with grade I and II strains is that in the middle of sprint, hurdle, jump, or kick the athlete will feel a tightness or pulling type pain in his posterior thigh that will cause him to stop physical activity.

Do not let this become a chronic issue!

The scary thing about hamstring strains is that the rate of re-injuring the muscle is very high, meaning that it can easily transition to a chronic problem if not correctly addressed. Across the board, the absolute biggest risk factor for having a hamstring strain is…. a previous hamstring strain. In fact, a study done on 500 amateur soccer players showed that a previous hamstring strain has been shown to increase the risk of a recurrence up to six times as much. The logical question is why does this happen? Since the symptoms of a grade I and grade II hamstring can be uncomfortable /annoying but tolerable during activities of daily living, the athlete often prematurely returns to activity after rest. This may lead to repeatedly unsuccessful efforts to return to sports without letting the muscle heal adequately. Thus, the muscle is not strong enough to tolerate the usual demands of sport which leads to another strain, or worse, a complete tear.

How can physical therapy help?

Risk factors shown to correlate with an initial hamstring strain are decreased hamstring flexibility, poor muscular strength/ endurance, poor core stability, lack of proper warm-up, inability to disassociate the trunk from the lower extremities, and poor lumbar posture. Our board-certified Doctors of Physical Therapy at Fox Physical Therapy will be able to identify any of these aforementioned deficits during the biomechanical evaluation. From there a plan of care will be implemented to correct the impairments quickly and efficiently. Remember the biggest risk to recurring hamstring strains is having that first hamstring strain, so even if you are not injured we can help to identify possible risk factors ensuring you stay at peak performance levels. Don’t wait until you break down to seek treatment. That’s the equivalent of letting your car break down on the side of the road before finally getting an oil change.

In the event that you do sustain a hamstring strain, physical therapy becomes of the utmost importance to guide and progress the athlete through his/her rehabilitation and prevent an acute injury from becoming chronic. Current literature supports that clinical diagnosis of a grade I/II strain by an experienced physical therapist is as reliable and valid as ultrasound and MRI, meaning that one does not necessarily have to wait to go to a doctor and then wait again to get an MRI in order to begin the rehabilitation process. In Florida, anybody can directly access their Physical Therapist without the need for referral.

New Physical Therapy Office Location Boca Raton


Fox Physical Therapy Boca Raton

Fox Physical Therapy to Open New Office in Boca Raton, Florida May 1st, 2017

Fox Physical Therapy, Miami’s premier orthopedic and sports physical therapy center, is proud to announce that we are expanding north with the opening of our newest clinic in Boca Raton Florida on May 1. Conveniently located in the Twin Lakes Professional Center at 2900 North Military Trail, Suite 220, the new Boca Raton location will offer patients a hands-on, results-based approach to addressing a wide range of work, auto, orthopedic, and sports related injuries or post-surgery therapy.

“I am excited to now offer our patients in Broward and Palm Beach County the same specialized and innovative physical therapy services our Miami patients have come to love,” said Owner and Licensed Physical Therapist Dr. Brett Fox PT, DPT, OCS, COMT. “We look forward to becoming a part of the fabric of this great community as we work together with patients to develop a holistic, cost-effective approach to managing their aches and pains.”

Fox Physical Therapy opened its flagship Miami facility in 2014. Along with an experienced team of therapists, he has grown it into one of the top physical therapy centers in South Florida. Fox Physical Therapy received the 2015 Patients’ Choice Award as one of the Top Physical Therapists in Miami.

Fox Physical Therapy Boca Raton will accept all major insurance carriers and offers those without insurance a self-pay rate. To book an appointment, please call 561-923-8292.

Must Read If Your Are Considering Spinal Surgery

Are You Considering Surgery for Sping Pain?

In continuation of our last blog post on medical imaging in regards to spine pain, we continue with a look at using medication or considering surgical interventions for controlling symptoms.

Read the original blog post, click here.

So, what about medication to help with spine pain?

Because low back pain can be excruciating, many doctors prescribe opioids for pain relief. These are narcotics and include common brand names such as OxyContin and Vicodin. In the U.S., narcotics are currently the most commonly prescribed drug, and more than half of these prescriptions are for the treatment of low back pain.

Before deciding to use these prescription drugs, it is important to understand that they alter the chemistry within the brain and have the potential to become highly addictive. Opioid addiction is responsible for more than 14,000 death per year. In as little as two weeks, the body may develop tolerance requiring increased doses and leading to withdrawal symptoms once the medication is removed. Research does show that using opioids for a short time can provide modest pain relief (up to 30%).

However, opioids provide minimal to no improvement in function. In other words, these drugs have not been shown to expedite return to work or improve functional outcomes. Moreover, long-term use has been associated with worsening disability and increased sensitivity to pain (hyperalgesia). This is because long-term use causes a reduction in the ability to tolerate pain naturally, which may mean the pain is experienced long after the original cause has healed. Other side effects include constipation, nausea, sedation, increased fall risk, fractures, depression, and sexual dysfunction. Therefore, if you decide to use these medications, current recommendations include using the lowest possible dose for the shortest amount of time.

One viable alternative to opioids includes anti-inflammatory drugs (NSAIDS), as several high-quality studies have shown they are just as effective if not superior to opioids in reducing pain and improving function with much less risk or potential harm. 

Considering surgery?

Here’s why you should explore all options and consider physical therapy before making your decision:

Surgery is almost always a last resort. The preoccupation and misconceptions associated with disc herniation found on imaging have led to many unnecessary surgeries, sometimes resulting in even worse outcomes, particularly when the herniation is not the true source of pain. Surgery carries inherent risks of complications, including infection, bleeding, and the possibility of permanent nerve damage. Significant complications occur in approximately 20% of patients. Depending on the type of procedure, the surgeon may have to cut through bone, muscle, fascia, or ligaments. Even with successful procedures, these structures take time to heal and can potentially cause scar tissue leading to pain and restricting motion. Muscles may shut down temporarily and motion may be limited for a period, which may lead to additional pain and stiffness since healthy discs require the motion for proper nutrition. The stiffness and muscle guarding may also cause other compensations in motor patterns in an effort to protect the spine. This can cause undue stress to other tissues, ultimately leading to further pain and dysfunction. Likely, physical therapy will be prescribed post-surgery and it will generally take some time to regain full function.

What can conservative care offer me?

For all these reasons, surgery is generally recommended as a last option after all other conservative treatments have failed. Research has shown that long-term outcomes after an appropriate bout of physical therapy are generally equivalent to, if not superior to outcomes after surgery. In most cases, low back pain can be addressed and relieved via physical therapy, as research shows that that therapy leads to greater pain relief and decreased drug consumption. In fact, many insurance companies require a course of physical therapy and other more conservative measures before authorizing funds for surgery. This is because the evidence shows that addressing the issue with physical therapy is successful most the time, saving both patients and their insurance companies money and eliminating potentially expensive and debilitating complications. In addition, trying therapy first is never a waste because in cases where surgery is ultimately required patients who have completed “prehab” (therapy prior to surgery) ultimately have better outcomes and faster recoveries.

We hope this small series of imaging, medication, and surgery has cleared up some preconceived myths about low back pain.

At Fox Physical Therapy, our board-certified Doctors of Physical Therapy specialize in mechanical diagnosis and treatment of spine symptoms. Contact us today to find out how we can help you feel better.

Do You Have Pain in Your Knee Cap? It Could be Patellofemoral Pain Syndrome


Patellofemoral Pain Syndrome is Causing Major Issues for Athletes Living in Miami

Read our  physical therapy tips for overcoming knee pain caused from Patellofemoral Pain Syndrome

By: Eric Alexander DPT,OCS,MDT,CSCS

If you are an active individual there is a good chance at some point in your life you have experienced knee pain. In one report, over the past 30 days, at least 1 in 5 adults in the United States have cited some form of knee pain¹. One of the more common types of knee pain is called patellofemoral pain syndrome (PFPS). This is basically an umbrella term for knee pain that occurs at and around the patella, also known as the knee cap.

The knee cap is a bone contained within a tendon that facilitates movement at the knee. The knee cap slides within a groove in the femur during flexion and extension at the knee. It is thought that pain originates when the patella begins to ‘mal-track’ through this patellar groove in the femur and causes uneven forces through the bony surfaces. The mal-tracking is commonly attributed to muscular imbalances in the hips, thigh, and lower leg. Common populations presenting with PFPS include runners, bicyclists, and young athletes. Pain can typically intensify by sports, walking, running, stair climbing, or sitting for a long time, often called the “Movie-Goers Sign.”

One research article, in particular, has demonstrated the importance of lateral hip strength in relation to knee alignment with activity². College athletes were followed over the course of an athletic season. The athletes who experienced knee and ankle injuries throughout the season all shared two things in common: a weakness of the hip abductors and external rotators of the hip. Any weakness of these muscles during activity can allow your knee to drop-in towards the midline during motion, known as genu valgum, facilitating mal-tracking of the patella and PAIN.

The muscles in question are the gluteus medius, piriformis, and smaller external rotators of the hip. There are a few key exercises that you can add to your normal exercise routine that will help strengthen these muscles in question. These exercises include:

Side-lying Leg Raises

Hip External Rotation Clamshells

Side Planks

Three sets of fifteen reps (3×15) of the side-lying leg raises and clamshells coupled with two sets of thirty to sixty-second holds (2×30-60”) in the side plank position will target these muscles and assist in strengthening. Perform these exercises three to four times a week for six to eight weeks to allow for appropriate strength gains.

If you are experiencing knee pain or know someone who does, Fox Physical Therapy board-certified therapists deliver full biomechanical screens during the evaluation process to specifically identify which structures are at fault. Schedule you consultation today at 305-735-890 or click here.


1. Centers for Disease Control and Prevention. QuickStats: Percentage of Adults Reporting Joint Pain or Stiffness, — National Health Interview Survey, United States, 2006. MMWR 2008:57(17);467.
2. Leetun, DT, et al. Core Stability Measures as Risk Factors for Lower Extremity Injury in Athletes. Medicine & Science in Sports & Exercise. Vol. 36, No. 6, pp. 926–934, 2004.