Spinal Manipulation Treatment for Cervical Radiculopathy


Randomized Clinical Trials show Thoracic Spinal Manipulation to be an effective treatment for Cervical Radiculopathy

If you have symptoms of pain/tingling/numbness in your shoulder/arm or hand, it is likely a result of a problem stemming from your neck commonly known as cervical radiculopathy, and it is most commonly associated with a cervical disc derangement or other space-occupying lesions, resulting in nerve root inflammation or impingement. As a result of the nerve being compressed, it can send these symptoms down the arm and into the hand. Generally speaking, the further down the arm the signs travel the worse off it is. This is called peripheralization. When pressure is relieved in the neck and upper extremity, hand symptoms may disappear or move toward the area that is producing them- the point of origin (the neck). This concept is called centralization and is a good thing. This means that you are closer to recovering from your condition.

So does something as simple as cracking your neck help?

This is a question that people have wondered for years is does cracking your neck help to relieve the pain? Recent evidence supports that it does! The use of high velocity, low-amplitude (HVLA) thrust manipulation of the thoracic spine- or upper to the mid-back area- is evidenced to increase ROM and decrease pain more than the non-thrust mobilization of the same joints. In a study published in the Journal of Orthopaedic & Sports Physical Therapy, one session of thoracic manipulation resulted in improvements in pain, a disability rating, cervical ROM, and deep neck flexor endurance in patients with cervical radiculopathy. Immediately after treatment and around the 48-to-72-hour window following the procedure, the manipulation group had at least moderate improvements in symptoms compared to the sham manipulation group. The manipulation group also had moderate to substantial changes over time.

But is it safe? Could it worsen the symptoms?

In the same study, adverse reactions were also recorded and indicated that this should not be a concern. No increases in the neck, arm, or hand symptoms were reported immediately after the treatment or at the 48-to-72-hour follow-up. Additionally, no soreness lasting more than 3 hours was reported.

The findings of this study support clinician decision to use spinal manipulation for both immediate and short-term benefits for patients with cervical radiculopathy and support that thoracic manipulation specifically, in patients with cervical radiculopathy, is an effective early treatment option.

What are the sounds you hear with “popping or cracking” joints and where are they coming from?

This has also been a hypothesized subject for quite some time. The “popping sound” phenomenology is still not fully understood. Traditionally it has been accepted that the “popping sound” is a result of gas bubble collapse, but it is unclear whether or not this is true.

When there is a “pop”- formally known as a “cavitation,” it has also been unclear exactly where the sound is coming from until now. The popping sound, or high-frequency vibration, should be expected as the desired effect of HVLA thrust manipulation provided from an external force that creates motion at the joint level. The sound is one of the main features that define an HVLA thrust manipulation.

According to a recent study titled “Unilateral and Multiple Cavitation Sounds During Lumbosacral Spinal Manipulation” practitioners performing spinal manipulation at the low back-pelvis area, or lumbosacral region (specifically L5-S1), should expect multiple popping sounds that most often occur on the upside or the downside facet articulations, but not typically both. There is, however, still question as to whether the multiple “popping sounds” found in this study emanated from the same joint or adjacent ipsilateral or contralateral facet joints. Therefore, it cannot be determined whether or not it is possible to isolate a single spinal segment during HVLA nor whether the relief felt by the patient is due to “correcting” a single-targeted joint dysfunction or multiple at once. The methods also may not necessarily be able to explain all of the audible sounds during HVLA thrust manipulation.

The study WAS able to determine that the “popping sounds” were no more likely to occur on the upside [176 ipsilateral pops] or the downside [144 contralateral] pops) during [60] HVLA thrust manipulations, but they were almost always unilateral with only 2% of cases resulting in “popping sounds” occurring on both sides. Further research is needed to investigate the remaining unknowns.

Who can perform this treatment for me?

At Fox Physical Therapy, all of our clinicians can perform the thoracic manipulation treatment described above. Additionally, Dr. Fox, Dr. ‘O’Rourke, Dr. Alexander, and Dr. Espinosa are all SMT-1 certified having completed additional continuing education specifically in Spinal Manipulation Therapy. Let us help you today!

Why You Should See a Doctor of Physical Therapy When You First Get Injured 

doctor of physical therapy

Why You Should See a Doctor of Physical Therapy When You First Get Injured

Studies show that seeking treatment from a physical therapist can speed up healing time, reduce medical expenses, and lessen the need for pain medication

A Doctor of Physical Therapy is trained to evaluate and treat a variety of conditions ranging anywhere from chronic lower back pain to stroke. But why see a physical therapist before another provider? According to a study of 150,000 insurance claims, patients with low-back pain are actually better off seeing a physical therapist first in regards to alleviating their pain. The study, published in Health Services Research, found that those who saw a physical therapist at the first point of care had an 89 percent lower probability of receiving an opioid prescription (therefore avoiding the risk of addiction), a 28 percent lower probability of having advanced imaging services performed (saving the patient money), and a 15 percent lower probability of an emergency department visit. It did, however, show a 19 percent higher probability of hospitalization- but why is this a good thing?
This higher rate of hospitalization indicates proper referrals by PTs to specialized care when pain does not resolve by addressing potential musculoskeletal causes first and, instead, may indicate a more serious issue such as an underlying systemic condition-heart condition, renal failure, cancer etc. Not only can physical therapy make you feel better, but it can reduce the cost of unnecessary imaging, reduce potential dependence on pain medication and “catch” potential underlying conditions early leading to better treatment options and outcomes for such conditions.

Why seek care from a Doctor of Physical Therapy versus a traditional Physical Therapist?

The ability to recognize and properly refer patients who present with conditions that do not appear to be musculoskeletal in nature is one reason why seeing a Doctor of Physical Therapy (DPT), would be advisable versus seeing a traditional Physical Therapist Assistant or Technician. This ability to screen patients for various non-musculoskeletal conditions is one reason why the doctorate level degree was developed in the first place. These DPTs have had additional coursework focused on recognizing yellow and red flags for general medical conditions that may not be treatable with physical therapy. They have also had more education on the nature of such comorbidities leading to a more holistic approach to therapy.

Did you know that a physical therapist can specialize in certain injury types and sections of the body?

Although 42% of patients know that physical therapy can only be performed by a licensed physical therapist, 37% still believe other health care professionals can also administer physical therapy. What they may also not know is that additionally, many Doctor’s of Physical Therapy choose to pursue board certification by the American Board of Physical Therapy Specialties (ABPTS) in specific areas such as neurology, orthopedics, sports, pediatrics, geriatrics, electrophysiology, cardiovascular & pulmonary and/or women’s health. This means that if you are seeking treatment from a DPT with these credentials, you have the opportunity to obtain more specialized care.

Specialty Physical Therapy Credential Designations:

In order to become specialized PTs must: 1) have current licensure to practice physical therapy in the United States, Puerto Rico, or the Virgin Islands; and 2) have at least 2,000 hours of direct patient care in the specialty area (25% of which must have occurred within the last 3 years). Additional specific requirements are required by each specialty area. PTs must pass the specialist certification examination and be recognized by the American Board of Physical Therapy Specialties to use the above designations.
• CCS (Cardiovascular and Pulmonary Certified Specialist)
• ECS (Clinical Electrophysiologic Certified Specialist)
• GCS (Geriatric Certified Specialist)
• NCS (Neurologic Certified Specialist)
• OCS (Orthopaedic Certified Specialist)
• PCS (Pediatric Certified Specialist)
• SCS (Sports Certified Specialist)
• WCS (Women’s Health Certified Specialist)

What is the difference between a Doctor of Physical Therapy and Physical Therapy Assistant or Physical Therapy Technician?

Physical Therapist (PT): Physical therapists are licensed professionals who have completed an accredited physical therapist program (degrees have evolved from 4-year bachelor degrees to 7-year clinical doctoral degrees) and have passed a licensure examination.
Physical Therapist Assistants (PTA): are educated at the associate degree level. Depending on state law, they may be licensed, certified, registered, or unregulated depending on the state. PTAs may only provide physical therapy services under the direction and supervision of a physical therapist (PT). They may not perform evaluations, re-evaluations, discharges or alter the plan of care. They may only execute the plan of care established by the PT.
Physical Therapy Technician: have no regulatory designator. Physical therapy aides and technicians are on-the-job-trained workers in the physical therapy clinic who assist the PT/PTA with tasks related to physical therapy services. They are not eligible for license, certification, or registration.

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 thinking 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?

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.

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.

Cervicogenic Headaches

Do You Suffer From Nauseating Headaches?

If you experience strong headaches in the morning or after work you could be experiencing Cervicogenic Headaches

Are you experiencing headaches in the morning or after a long day of work? Do you notice pain localized to the back of the head where the junction with the neck begins, the front of the head, or behind one or both eyes? This and many other symptoms can be a sign you are experiencing what is called Cervicogenic Headaches. These headaches consistently get misdiagnosed as migraines. Part of the reason is many of the symptoms are similar including nausea, dizziness, and sensitivity to light and sound. These headaches are often stemming from an issue with the joints, muscles or nerves of your neck (cervical spine).

Common symptoms may include:

  • Reduced neck range of motion
  • Upper neck pain in conjunction with a headache
  • One-sided headache pain that presents in a “rams horn” pattern
  • Nausea
  • Blurred vision
  • Dizziness
  • Light/sound sensitivity.

How to Treat Cervicogenic Headaches

These headaches can quickly be diagnosed by a trip to your Orthopedic Physical Therapist. Through a biomechanical analysis and mechanical special testing designed to pinpoint the structures at fault, your physical therapist will be able to identify the true cause of your pain.

Treatment options include spinal manipulation, mobilizations of the spine, myofascial release, correction of faulty posture mechanics, contract/relax stretch, strengthening of the deep neck muscles, and education on self-treatments. We focus on correcting the mechanical generator of your pain, not simply offering quick fixes or temporary relief.

Schedule Your Consultation Today

If you have been experiencing any of the above symptoms do not hesitate to give us a call. There is no reason to suffer through another day of work with a nauseating headache. The board certified therapists at Fox Physical Therapy specialize in identifying disorders of the head and neck. We take pride in using only the latest in evidence-based treatments to fix the root cause of your problems.

Click here to schedule an appointment.

Learn How to Remedy Plantar Fasciitis

planters fasciitis physical therapy miami boca raton

Do You Have Plantar Fasciitis?

Learn how these 4 simple at-home exercises can help you remedy the pain caused by Plantar Fasciitis.

By: Stephanie Beckel, DPT and Eric Alexander, DPT, OCS, Cert. MDT

If pain occurs with your first steps in the morning, chances are you may have plantar fasciitis. In fact, plantar fasciitis is the single most common foot condition treated by healthcare practitioners, affecting about 2 million Americans each year. This type of injury is especially prevalent in runners, as studies have found that over 30% of runners struggle with this condition. The good news is that greater than 95% of cases will heal non-surgically with the correct application of skilled physical therapy by a state licensed doctor (DPT).

So what exactly is the plantar fascia?

The plantar fascia consists of three bands of dense connective tissue that run along the bottom of the foot. All three bands originate from the calcaneus (heel bone) and then spread out as they run forward to connect to the base of each phalynx (toes). This fascia is responsible for tightening during the push-off phase of walking to elevate and support the medial arch, so that the foot may become a rigid lever propelling the body forward.

Plantar Fasciitis describes a condition that is often associated with overuse, resulting in a chronic degenerative process. The condition begins with repetitive strain, which leads to microtears ultimately inducing an inflammatory response. Over time, this leads to degeneration of the plantar fascia, primarily at its attachment site to the heel. When looked at under a microscope, there is evident thickening and fibrosis as well as damaged collagen and calcification of the fascia.

Plantar Fasciitis Symptoms:

Symptoms include pain in the medial heel, usually most noticeable with first steps out of bed in the morning, standing after a period of inactivity, and also after prolonged weight-bearing. Pain is also present with deep palpation of the heel at the insertion of the plantar fascia.

While 80% of heel pain stems from the plantar fascia, several other conditions can mimic this pain and may need to be ruled out. In one retrospective study of 250 individuals with plantar heel pain, the majority were diagnosed with plantar fasciitis. The next most common diagnosis was fat pad atrophy (approximately 15%). Those with fat pad atrophy were more likely to have pain primarily after long periods of standing, pain at night, and lacked the characteristic first-step pain in the morning. Les common conditions include Ankylosing spondylitis, Reiter’s syndrome, and osteoarthritis. If symptoms are in both heels, rheumatoid arthritis becomes a likely culprit in women, while ankylosing spondylitis or Reiter’s is more common in men. For patients with a history of diabetes, an abscess in soft tissue must be ruled out. Rarely the condition may be caused by entrapment of nerves (usually the first branch of the lateral plantar nerve or the medial calcaneal nerve), proximal plantar fibroma, lumbar herniation causing S1 radiculopathy, or a hidden fracture. These conditions can be ruled out during the evaluation process with your physical therapist.

Risk Factors:

There are several categories of risk factors, some of which can be mediated and others which are more difficult to change. Anatomic risk factors are those that are inherent characteristics that you may be born with. These include flat feet, high arches, or a shortened Achilles tendon. Limitations in hamstring flexibility and the difference in leg length have also been associated with this condition. Biomechanical risk factors are those that describe faulty movement patterns. These include an inward roll of the foot (overpronation), poor alignment of the lower extremity, limitations in ankle dorsiflexion, and weak plantar flexor and intrinsic muscles of the foot. The condition also frequently occurs after a recent increase in activity, such as a recent increase in walking mileage or training for a run, so make sure to increase activity slowly. Lastly, there are environmental risk factors, which are often the easiest to eliminate. These include poor footwear, walking barefoot, hard surfaces, unusually long weight-bearing, lack of stretching, and being deconditioned/ overweight.

How can physical therapy help?

A full biomechanical evaluation is warranted in all cases of plantar fasciitis. Often times it is not the tissue at the bottom of the foot that is faulty, but something up the chain that is driving increased or aberrant forces through the fascia on the bottom of the foot. What is often seen clinically is dysfunction in the calf musculature, weak stabilizers in the lateral hip preventing proper control of the femur, and stiffness through the thoracic and lumbar spine driving aberrant forces through the chain from a top-down fashion. These are just a few examples of biomechanical faults that may be present. Failure in addressing the cause of the biomechanical dysfunction and only treating the irritated tissue will lead to failed treatment. Addressing deficits of the entire lower extremity often result in improved biomechanics and correction of the underlying cause of dysfunction. Some of these interventions include correction of gait mechanics, joint mobilizations to improve the mobility of the first metatarsalphalangeal joint (big toe), talocalcaneal/talocrural (ankle), knee, and hip, as well as stretching to restore optimal muscle length to the calf, thigh, and hip. Important areas to strengthen in order to limit pronation and reduce impact when the foot hits the ground include the tibialis posterior and fibularis longus (directly limit midtarsal pronation via eccentric contraction), tibialis anterior (eccentrically controls ankle plantarflexion), quadriceps femoris (eccentrically limits knee flexion), gluteus medius (eccentric control of hip adduction and internal rotation). At Fox Physical Therapy all of our board certified Doctors of Physical Therapy will help to identify the true cause of your pain and teach you how to prevent it from ever coming back.

Here are a few home treatments you can start right now. Many of these techniques will treat the painful site at the heel directly. Remember that to truly rid yourself of this issue work up and down the chain is needed as well. This is where a visit to a skilled Doctor of Physical Therapy can get the help you need.

Tips for at Home Treatment

Tip #1: Calf and arch stretch with a towel. Perform 3 sets pulling back on the foot for 30 seconds before going to sleep and before first steps in the morning.

Tip #2: Stretch of the plantar fascia stretch with cross-friction massage. Stretch the big toe up and massage bottom of the foot for 1 minute, 3 times before taking first steps. This can also be done throughout the day by placing the heel on the ground and the ball of the foot on the wall and leaning forward.

Tip #3: Roll plantar fascia over a can or ball. Perform for 1 minute (3 times with 30 rest in between) before going to sleep and before first steps in the morning. You can also roll over a frozen water bottle as needed for control of pain and inflammation.

Tip 4:
Use the toes of the painful foot to pick up a dry paper towel, drop and repeat for 2 minutes. Also, scrunch a towel using only your toes.

Contact us today and let us get you back on your feet!

If you or someone you know is suffering from foot pain, the board-certified Doctors of Physical Therapy at Fox Physical Therapy can provide a complete evaluation, including biomechanical screening to identify deficits and underlying causes. No two people are the same and therefore it is essential to have a plan of care that is specific to your needs. Individualized treatment programs can help to relieve plantar fasciitis and prevent it from coming back.