Quick Tip for Shoulder Rehabilitation

People possess different learning styles when it comes to learning exercises.  Some are adept at putting verbal instructions into proper use.  Others are visual learners and are good at mimicking what is demonstrated to them.  Still others require manual cuing in order to learn how to perform certain movements.

The above learning styles are auditory, visual and tactile, respectively.

One particular area of motor learning where I find that folks require tactile cuing is scapular mobility and stability training.

What are the scapulae?  They are the shoulder blades that articulate with the back of your thorax (rib cage).  I like to describe the scapulothoracic joint as the "core" of the shoulder.  In a healthy shoulder, it ought to be able to move in multiple planes and directions.  It also needs to be stable through it's given ranges.  Training the movements of the scapulothoracic joint is an integral part of shoulder rehabilitation.  What I find with most folks though is that they have a very difficult time learning how to isolate and control these movements.

Here is a quick video in which I demonstrate how to use a common rehabilitative device, a foam roller, to help manually cue one of the important movements of the scapula, which is retraction.

Give this a try yourself, or if you're a rehabilitation specialist, use it with your client who has a difficult time with this movement.  I have found it to be a very helpful first step towards improving scapular movement and control.

It's YOUR Choice

Yesterday I emailed a number of patients whom I haven't seen in a while to check on how they are feeling and to wish them a happy and healthy holiday season.

One of my patients responded that he was feeling great from his original foot injury, but that he had injured his shoulder a while ago in the gym.  Regarding the doctor who evaluatied him, he wrote the following:  "Unfortunately, I ended up getting sucked into their insurance and health care system and could not easily go outside for PT, even though I'd have preferred to come to you."

I am certainly not writing this to pat myself on the back because he wanted to come back to work with me.  Rather, I want to remind you that it is YOUR choice when it comes to picking a health care provider!  I have heard this same story many times in the past, and I find it very frustrating.  I fully recognize that insurance companies play a big role in steering you towards in-network providers.  But your doctor ought to provide you with referrals without leaving you thinking you have no other choice.   Ideally, you have a good enough relationship with your primary care doctor that you trust his/her recommendations.  

If you ever find yourself in a position where you feel corned to go see a specific referral, please ask questions.  Let your doctor know that you know better, and that it's ultimately up to YOU to decide from whom you seek care.

Swing Safely

The kettlebell swing is a great exercise for jacking up your heart rate and for strengthening your gluteals and hamstrings.  However, I see it performed with poor technique all the time, making it a high-reward, high risk-exercise.  Here is a brief tutorial on how to safely swing a kettlebell and get maximum benefit from this move.

Again, this a wonderful exercise to add to your routine.  Just be sure that you are performing it properly.  Swing in good health!

Ladies Who Lift

On the first day of the year I walked into the gym, which was predictably empty (New Year's Day is one of my favorite days because of the quiet on the streets).  The next day I showed up to a full parking lot.  As I walked through the door, I saw all the "cardio" equipment being used to near full capacity.  But when I went downstairs to the weights, it was a different story.  There was not a soul to be found.

I am not one to put down any particular form of exercise.  I think a lot of the internet bashing of certain exercise modalities is completely unwarranted.  You love Crossfit?  Great!  Enjoy running?  Awesome!  Like to dance to break a sweat?  Keep shaking those hips.  Whatever gets you moving is okay in my book, as long as you're being smart and safe about it.  The best exercise is one that you enjoy enough to actually DO!

This post isn't about some "bad" exercise I'm seeing.  It's about a GREAT form of exercise that I'm afraid I'm not seeing performed enough by women.  And that exercise modality is strength training.

This morning I witnessed two women working out with their trainer.  They were performing a series of cable column exercises under his watchful eye, who was there to ensure proper form and to progress, coach and encourage them.  It was great to see.  I just wish the ratio of men and women was 50:50 in the weight room.

What's the biggest reason more women don't strength train?  Probably due to the unwarranted fear that they will get big and bulky like their male counterparts.  Sure, muscles will adapt to the stress of lifting heavy things repeatedly.  But women should not fear that they will turn into Schwarzenegger.  Their genetic makeups ensure that it will be much tougher to do so.

I would guess that the majority of people who exercise regularly do so at least in part for the aesthetic effect, as much as for the health benefits.  And that's okay.  If people want to look good in their clothes (or out of them), then good for them.  If they put the effort in to look good, then they will reap the numerous health effects as well, which is fantastic.  I personally don't care what your motivation is, because I know that regular exercise will benefit you in many ways.

I am not suggesting that women give up their ellipticals, treadmills, spinning, or Zumba classes.  They each add value in their own way.  I'm simply recommending that you consider adding some strength training.  The benefits are myriad, including but not limited to the following:

-Improved heart health
-Improved bone density
-Increased strength
-Increased metabolic rate (the ability to burn more calories at rest)
-Leaner body mass
-Increased insulin sensitivity
-Better fitting clothes

I added that last one because as I mentioned earlier, this is what really matters to many folks.  That's perfectly fine.  Don't rely on a scale to tell you the full picture.  Muscle is more dense than adipose (fat) tissue, so it's entirely possible to be heavier on the scale, but to have your clothes fit better and to be healthier.

Admittedly, exercising regularly runs the risk of becoming monotonous.  Combat that by trying different things.  You might find that you really enjoy something that you previously wrote off.  As for resistance training, it should hardly be reserved for men only.  Ladies, don't be afraid to venture into the weight room to complement your aerobic exercise. You will undoubtedly love the physical results.

***A WARNING ABOUT STARTING A NEW EXERCISE PROGRAM.  STRENGTH TRAINING DOESN'T COME WITHOUT RISKS, SO BE SMART ABOUT IT.  SEEK GUIDANCE TO ENSURE PROPER FORM AND TECHNIQUE.  AS A RULE OF THUMB, IF YOU CAN'T PEFORM A MOVEMENT WITH PROPER POSTURE, GOOD FORM, AND PAIN-FREE, YOU SHOULD NOT BE ADDING LOAD TO THAT MOVEMENT.*****

A Texting P.S.A.

Virtually every single patient I see in the clinic is there because they are in pain.  I do my best to educate, treat and assist them out of their painful experience and back to full healthy function.  But I also believe in prevention, and that's what today's post is about.

One of the things that I don't do is fear-monger.  I don't believe in saying to people, "If you do action x, it will lead to outcome y".  I'll certainly teach ways to move and function that may be more optimal for the patient, but I draw the line at making declarative statements.  As I've said many times in the past, the human body is just too variable to make definitive assertions about the future.

Last year, there was a study that was published and heavily circulated on social media about "text neck", or "tech neck".  The author drew a correlation between the pressure exerted on the cervical spine with forward flexion and neck pain.  He concluded that the constant head-down position we find ourselves in due to our omnipresent device usage will lead to pain, damage, and maybe even surgery.  Pretty scary words, in my opinion.  You mean to tell me that if I text too much, I'm destined for the O.R.?  If that's the case, we'll all one day be unified by our common neck scars.  Texting is not going away.

While I'll stop way short of declaring that over-texting will lead to surgery, I certainly think that we'd all be better off lifting our heads more often, pulling our shoulders back, breathing in more deeply, and taking in the world immediately surrounding us.  I see the opposite behavior every day on my walk to and from Penn Station.  People connected via their phones to places unknown, while completely oblivious to their immediate vicinities.  I suppose they assume that everyone else will get out of their way as they tend to whatever important task lies at the tips of their thumbs.  That would be fine, until the day we all decide just to walk by leading with the crowns of our heads.  While the ambulatory texters are mildly annoying, at least they aren't a real threat.  Last week I looked over at a girl who was driving (not simply waiting at a light) on Old Country Road (a busy multi-lane road on Nassau County) in rush our, head down, both thumbs texting away.  Do what you want on your own open road, but as long as you have a 2-ton weapon surrounding you, it is all of our business.

Why the preachy message?  I know I'm not telling you anything you don't already know.  I also am not sitting on a high horse, as I too have checked my phone at a red light.  The reason I'm writing about this today is because of something I observed earlier while driving, and something one of my patients told me a couple of weeks ago.

A few hours ago, I was waiting to make a right hand turn at a red light.  I was focusing my attention on the traffic coming from my left.  As I edged up to make the turn, I caught sight of a woman stepping off the curb to my right to cross in front of me.  She was texting away, and didn't once glance up as she made it across.  It would have been my fault had I hit her, and fortunately nothing happened.  But at this same time, I was wondering how someone could be so oblivious while walking amid traffic?  I know when I'm out for a run, and I'm the pedestrian in that exact same scenario, I always make sure I get eye contact with the driver first before proceeding.  I know it doesn't seem like much of a big deal, but the startled looks of the drivers reminds me that they are rarely looking right to make that turn.  Drivers (myself included) tend to focus exclusively on the auto traffic, and forget entirely about pedestrians.

One of my patients is seeing me following a second hip operation.  She is only 31 years old, but has undergone two hip operations and a knee operation stemming from being hit by a car as a pedestrian 2007.  She's a great person, and works diligently to get herself back to full functional capacity.  But her frustrations often boil over, and I'm always there to lend a sympathetic ear.  I have full faith that she will be okay in the long run, but it's a tough road for her.  She said the following to me two weeks ago:

"You know, if there is one message I could give to people it would be to tell them that it's not worth it.  Even if I was in a situation where I won some big monetary award for my troubles, it's simply not worth it.  I wouldn't wish this on anyone, and if people just paid a little more attention, then perhaps they will avoid being in my shoes one day."

An ounce of prevention is a wonderful thing.  I'm always encouraging folks to invest in their health now so that their body will give back to them in the future.  In this case, the preventative step that we're talking about is simply slipping your phone into your pocket as you walk or drive.  It can't be any easier than that.  There is nothing on that little screen that is more important than your and your neighbor's health.  It can wait.

Tools in the Toolbox and K.I.S.S.

This past week, I was reminded of a couple of simple but important concepts when it comes to giving and receiving rehabilitative health care.

A common phrase in the rehabilitation world regarding skill sets is "tools in the toolbox".  This analogy refers to both manual and diagnostic skills that therapists acquire in school and through continuing education courses.  I am all for expanding my skills and knowledge in order to better serve my patients.  But once I realized that there is no one "magic bullet" treatment that will help everybody, I gained a lot more confidence as a physical therapist.  While the possibilities for acquiring knowledge are limitless, I no longer feel that I am missing the one thing.   

Several years ago, I asked the instructor of a class I was taking about a specific manual technique. She detoured from her agenda to give us her perspective as a 35-year veteran therapist.  

"Look," she said, "I have been doing this for a long time now.  Many of these latest and greatest techniques and interventions are things that have been around for decades.  Don't forget that there is a lot of savvy marketing behind a lot of this.  Don't think that you have to spend a lot of money to become certified in this or that special technique.  I'm not saying that they can't be helpful.  I'm just saying that there's not one technique that necessarily better than another."

Those remarks have resonated with me ever since as I consider which courses I am going to pursue in an effort to make myself a better clinician.  And her advice doesn't just pertain to therapeutic techniques.  It also applies to rehabilitative devices that therapists often prescribe to their patients for home use, such as the following example.

The other day, while instructing a patient on how to perform a soft tissue technique for her homework, she asked me if a particular brand of ball (which I will not mention) is "better" than the lacrosse ball I had her using.  Her question relates to the concept that simple is very often effective. It's a ball.  It doesn't need a fancy name attached to it.  My personal feeling is that I want patients to be able to use tools and techniques that are inexpensive yet effective.  If someone is trying to convince you that their magic ball with a thousand dimples on it, or their special foam roller with spikes protruding from it will get you better faster, be leery.  I'm not saying they won't work for you.  I'm simply advising you to save you money and keep it simple.

Fancy bells and whistles often grab people's attention.  The more equipment in a gym or rehabilitation center the better, right?  The more letters credentialing a practitioner's academic achievement the better, right?  Perhaps, but don't be blinded those alone.  All the tools in the world are meaningless unless they are properly and effectively applied to your specific needs.  

Yesterday, I was at my local car dealership to have my car inspected.  I saw a woman ambulating past me with a cane in her right hand.  Her shoulder was jacked up by her ear, indicating that her cane might not be fitted quite right for her.  So I stopped her, and after identifying myself as a physical therapist, asked if anyone had ever properly sized her cane.

"No," she replied.

After explaining the rationale for how to fit a cane, and asking her permission, she allowed me to resize it.  After shortening it about 3 inches and handing it back to her, she said the following:

"That feels much better.  My shoulder doesn't hurt anymore.  I have been going to physical therapy three times a week for several months now, and nobody said anything.  God is good!"

My entire interaction with her lasted less than 2 minutes.  I did not lay a hand on her to perform any special technique.  Just a simple adjustment of her cane had her feeling better immediately.  This is not rocket science.  It was just Keeping It Simple by observing, explaining and offering to help.

I'll continue to pursue continuing education because it constantly keeps me focused and helps my patients.  But I have come to understand that the most important tools therapists have in their toolboxes are their observation and listening skills, their ability to effectively educate folks, and their kindness in wanting to help people feel and function better.

Lower Extremity Foam Rolling

There are many quick and effective ways to help maintain your body's tissues as you endure the rigors of your workouts and the wear and tear of daily living.  Foam rolling is one of these popular modalities.  I find myself teaching this to people every day in the clinic.

Why use a foam roller?  The easy answer is that it will make you feel better.  Grab one and give it a try the next time you're at the gym, and see for yourself how it can help reduce your post-workout soreness and leave you feeling more flexible.  This answer falls into the anecdotal, non evidence-based bucket.  But since we are always looking to validate our interventions with research, here is an excellent summation of the current literature on foam rolling, done by strength and conditioning researcher Chris Beardsley:

http://www.strengthandconditioningresearch.com/foam-rolling-self-myofascial-release/#3

Because I'm always demonstrating how to use a foam roller, I made a brief video to readily share with my patients.  It focuses on how to roll out your lower extremities, and here it is:

I am always cognizant of keeping people's home programs simple and inexpensive, and foam rolling fits that bill.  The one I'm using in the clip above is a high density, 36" x 6" diameter roller.  They also come in smaller sizes, and in lower densities (softer).  They can be picked up at your local sports store, but your best bet is to go to Amazon where you can purchase one for nearly have the price at about $22.

A little self-maintenance will serve your body well.  Foam rolling is a nice place to start, so give it a try and experience the benefits for yourself.

The Hills of Ithaca

This past weekend my wife and I went up to Ithaca, NY to attend my college reunion.  The weather was as beautiful as I've ever seen it in Western New York, and we took advantage with a good walking tour of the campus.

Kristen noted several times that Cornell is so hilly.  It reminded me of the toll those slopes took on me when I first arrived on campus as freshman all those years ago.

During that first semester I developed a nasty case of shin splints.  I had no idea at the time what was going on, nor did I do anything to address it.  Eventually, the condition improved and ultimately disappeared.  A few years later, I spent the spring semester of my junior year in Washington, D.C. as part of a Cornell in Washington program.  Later that fall, after returning to the hills of Ithaca, so too returned the shin splints.

As an 18-22 year old, I had no idea that I would end up in a career as a physical therapist.  I was too preoccupied with all the other things going on in college to really analyze what happened with my shins, and why it happened when it did.  But after this weekend's reminder, it's very evident to me why I developed pain in my legs from simply walking.

It was a matter of tissue overload.

Many of our musculoskeletal issues are caused when the demands on our tissues exceed our body's ability to adapt to them.  That's exactly what happened to my shins when hills became a part of my regular routine during my freshman and senior years.  Prior to that, I had lived in an environment with virtually no exposure to gradient changes.

The good news is that we have the capacity to fortify ourselves against these higher imposed demands.  It's called the S.A.I.D Principle, which stands for Specific Adaptation to Imposed Demand.  If you want your body to be better prepared for unexpected changes in forces imposed on it, you can train for it.

Last night, I took a misstep going down some stairs in the dark.  My rear left foot struck the edge of a step and I lunged forward.  I felt a strong pull in my quad tendon, just above my patella (knee cap).  Thankfully, I walked it off and awoke this morning without any signs of injury.  I've seen this mechanism of injury land folks in my clinic with surgically repaired ruptured quad tendons.  I feel partly lucky that nothing happened, but mainly grateful that I've spent time doing things like squats and lunges in order to keep my muscles and tendons prepared for such moments.

All your tissues can be maintained.  Weight training will make your muscles and tendons more resilient.  Cardio training will make your cardiopulmonary system more resilient.  Even your brain can be trained.  The next time you try to remember the name of a person, place or thing, see if you can use your powers of recall to exercise your neurons rather than going immediately for your phone for a Google search.  I just run through the alphabet, and am amazed at how often the first letter alone will elicit the answer.  Studies show that those who stay mentally engaged in activities such as crossword puzzles demonstrate lower incidences of dementia-related symptoms as they age.  There is no reason to allow ourselves to become dumber as our phones get smarter.

There are no foolproof safeguards against injury.  Unfortunately, they can and will happen no matter how many preventative measures we take.  But risk can be mitigated through a little effort.  It's never a waste of time, as not only will it reduce injury risk, it will improve your overall function.

With your body and mind, as with most things in life, expect to get back what you put in.

How Long Will This Take?

People always want to be given time frames for their recovery from injuries and painful episodes.  They want to know how long they'll be on the sidelines from their usual sports and activities.  They also want to compare themselves to others to be sure they're "on track".

I completely understand why I'm asked all the time: "How long will it take before I'm better?"

The reality is that I (nor anyone for that matter) don't really know for sure.  Yes, there are general time frames that we can go by regarding particular conditions or post-surgical protocols.  But there are just too many variables to account for to make definitive assertions about recovery from injuries and painful movement dysfunctions.

Here's a quick example.  On April 28, 2012, Derrick Rose of the Chicago Bulls tore his left anterior cruciate ligament (ACL) in a game against the Philadelphia 76ers.  A few hours later, Iman Shumpert of the New York Knicks tore his left ACL in a game against the Miami Heat.  While both of these world-class athletes had the best rehabilitation teams at their disposal, it took Rose significantly more time to get back on the court compared to Shumpert.  While their injuries were diagnostically the same, their recoveries took varied routes.  This speaks to the multiple variables involved in recovery, which include some of the following:

1) Age
2) Pre-injury condition (co-morbidities)
3) Nutrition
4) Access to care
5) Quality of care
6) Home support
7) Social/emotional components
8) Fear
9) MOTIVATION

These are just a few factors that help dictate one's recovery.  No two of us are the same, so we shouldn't expect our rehabilitation to be exactly the same as others.

I don't mind when folks ask me how long their therapy will take.  After all, it's important to establish goals that follow time frames.  I also respect the fact that many people are simply naturally competitive and want to know how they stack up against others who have been in similar situations.  But please recognize your individuality and realize that there's only one person who matters in the equation, and that's YOU.  If you respect the body's capacity to heal, seek out the best care possible, and allow time to do its thing, you'll ultimately achieve your goals.

A little bit of perspective and patience in the short term will help lead you to long-term meaningful gains.

Flip Flop Feet

With last week's plunge in temperatures in the Northeast, it seems hard to believe that beach season kicks off in a month from now.  With that comes a return to less restrictive footwear, which for many of us means flip flops.

There are people in the world of rehabilitation and movement who think that flip flops are the root of all evil.  I'm not one of them.  In fact, I just returned from running some errands in my flops for the first time this spring.  I am not one to speak in absolutes when it comes to injuries and prevention.  Our bodies and movement strategies are just too variable to make declarations that something is "all bad" or "all good", including wearing flip flops.  After all, if flip flops are so bad, then wouldn't everyone who dons a pair end up with plantar fasciitis, shin splints, posterior tibialis tendonitis, low back pain, or some other malady?

That being said, I do think that some simple mindfulness makes sense when it comes from transitioning from cold to warm weather footwear.  As with many overuse injuries, it's a simple case of the demand being placed on your tissues overwhelming your ability to adapt to those forces.  Another way to put it is that overload (too much, too quickly) may lead to injury.  But the good news is that you can do something to diminish the risk of that happening.

I'm fortunate in that I spend the majority of my day without shoes on.  This is a reflection of the nature of my daily work, which involves a lot of demonstration on gym matts.  Oddly, nobody ever questions why I'm only wearing socks, but perhaps it's because I generally have them barefooted through their entire session too.  However, I recognize that many of you don't have the luxury of walking around your offices without shoes.

Why does this matter?  Many "dress" shoes are very restrictive.  Toe boxes are too narrow.  Soles are too rigid.  Heels are too high.  This prevents your foot and its intricate system of bones, ligaments, muscles and tendons from doing what they are intended to do.  Then, when you put your feet into something like a flip flop, your body and brain are left wondering what the heck you want your them to do.

One of the criticisms of flip flops is that they place too much demand on your toe flexors.  Every time you stride, your toes have to grip to keep the flop from flying off.  The flexor hallucis longus and brevis (big toe flexors) and the flexor digitorum (2nd-5th toe flexors) muscles are responsible for gripping.  To feel these muscles in action, try this quick experiment.  Take your shoes off.  Now gently begin to lean forward.  As your center of mass displaces forward, your calf muscles will begin to kick in.  Continue forward and you'll feel and see your toes attempt to "grip" to floor.  These are the muscles that help keep those flops on. Overuse of your toe flexors could lead to pain in your foot and/or lower leg.

So, what do do about it, you might ask?  Your goal is to train these muscles so that they don't ever feel that they're being "overused" in the first place.  If you're a flip flop wearer, don't slip them on for the first time of the season and head out for a full day.  Rather, I suggest you start to train your toe flexors by beginning to wear them around the house first.  Gradually start getting them ready for the increased demand you're about to place on them for the next several months.  This will allow your tissues to keep pace with the increased demand, rather than becoming overwhelmed by it.

As bipedal beings, ground reaction force attenuation begins at the feet.  Keep them prepped and ready for all seasons so that you can enjoy them all without any pain.

A Lesson From My Father

Today is my father’s 72^nd birthday.  According to statistics, he’s fortunate to be here.

In 2008, my mother and father were just back from a trip to visit my younger brother in Australia, where he spent 5 months studying.  Their awareness of the dangers of skin cancer was heightened as Australia is noted to have a big depletion in the ozone layer.  One morning, there was a news segment centering on the importance of getting your skin checked regularly.  My father turned to my mom and asked, "Do you think this is something to worry about?" as he leaned forward to reveal something on the crown of his head.

As it turned out, it was.  Melanoma was the diagnosis.

Melanoma is a nasty cancer, with pretty grim statistics.  However, statistics are just numbers that reveal patterns.  When it comes to fighting a disease like cancer, the only sample size that really matters is n=1.

Over the past 7 years, my father has lived with this disease courageously and with dignity.  It has spread, popping up in various places.  Some have necessitated surgery, while others have not.  My father has been blessed with finding two excellent doctors close to home on Long Island whom he trusts.  Along the way, he has measured and considered all his treatment options, mostly choosing to try something rather than nothing.  Some have left him knocked out and feeling worse than the cancer itself.  I haven’t heard him complain once.

Anyone who knows my father knows that he is very active.  Whether it’s golf (his favorite passion/obsession), tennis, or platform tennis, he’s always outside playing.  While he never spent time in a gym lifting weights in his younger years (I don’t think many people did) he’s now a committed gym goer, dedicated to his fitness.  At his age, he moves better than many of my contemporaries, despite having 30 years on us.

I don’t remember my father spending Sunday afternoons watching football, or some other sport, on television.  He’s definitely a sports fan, but I recall him telling me once, “I’d much rather be doing something than watching something.”  It’s a lesson that has really resonated with me.  Life is too short to spend it on a couch.

During one particular treatment period, my dad was feeling pretty run down.  But on a 95-degree, oppressively humid day, he and my brother Brad played Bethpage Black.  This is a grueling, long, hilly golf course, one that does not allow golf carts.  So they walked, carrying their own bags for 18 holes.  It would have been understandable had he chosen to skip playing that day, in light of the physical demands and the way he was feeling.  But he has been completely committed to keeping on moving and participating in life throughout his ordeal.  It has been good for his body, and even better for his mind.

When given a diagnosis with associated statistics, I imagine it’s extraordinarily difficult not to harp on the potential negative outcomes.  Illness can be a mortality check, but the reality is, nobody is guaranteed tomorrow.  I have greatly admired the courage and example that my dad has shown over these years (along with my mother, who has been by his side throughout and is herself a tough 20-year cancer survivor). 

I know how cliché it is to talk about not taking one’s health for granted.  But I see it every day, people desperate to get back to the state of not having to think about their pain or illness.  It’s just so darn easy to take for granted feeling well and being without illness.  Take a moment to reflect on your good fortune should you be in good health.  It’s a blessing.  And if you’re not, get busy doing something about it.

My father’s approach and attitude remind me of a quote from my favorite movie of all time, “The Shawshank Redemption”:

“You can either get busy living, or get busy dying.”

Last week, my father was given the news that the experimental treatment he underwent last summer to target an inoperable tumor has been working.  His screens showed no sign of cancer.

Dad, thanks for choosing to keep on moving, no matter what.  It’s an invaluable lesson.  Happy birthday, and many more.

Spring Training

It's been a looooong winter! Tomorrow morning, the youth soccer program commences in my hometown.  Spring is finally here by calendar, if not by temperature. With many of us cooped up for the past six months, our bodies might not be prepared for the increased activities that spring inevitably brings.  Here are a few thoughts on ways to stay healthy and pain-free until next winter.  It's by no means an exhaustive list.  Each topic warrants its own lengthy article, but I've learned after writing these for the past few years that shorter is sweeter.  So here are just a couple of quick thoughts:

Runners:

1)  If you've been on a treadmill all winter and plan to resume outdoor running, be mindful of the change in surfaces.  Treadmills are more forgiving.  Consider easing back on the distances you've been covering once you hit the pavement.  Give your body time to adapt to the increased demand from the higher ground reaction forces imposed by pavement.

2)  If you like to run on a track, consider alternating directions so that you cover equal distances running clockwise and counterclockwise.  Going in only one direction will put asymmetrical demands on your legs as you go though the turns at either end of the track.

3)  If you run in the street, try alternating sides.  The camber (curve) of the street will place asymmetrical demands on your legs if you stick to only one side.

Overhead Athletes:

1)  Before going from your desk to your beer league softball game, check your shoulders.  Can you raise them above head without pain?  Can you reach behind your back to touch your opposite shoulder blade without pain?  Can you reach behind your head to touch the top of your opposite shoulder blade without pain?  If the answer is "no" to any or all of the above, your arm is probably not ready to throw a ball repetitively without risking rotator cuff tendinopathy, or imposing increased demand on your elbow.  These are just some quick and easy self-assessments that can alert you to the need for further care and attention.

2)  Warm up!  If you're showing up at the ball field straight from 8-10 hours of sitting at your desk, don't expect your arm to respond favorably if the first throw you make is from deep center to the infield.  Give yourself a few minutes to do a dynamic warm up routine (did you ever see the great Mariano Rivera go through the same paces each and every time he pitched?), followed by some short to progressively longer tosses.  Your arm will thank you for the extra care.

Tennis/Golf:

1)  There is a lot of lateral stress placed on the legs with tennis.  You're often running from side to side to cover the court, requiring quick, sharp cuts for directional changes.  Prep your ankles with ankle pumps, rolls and alphabets.  They're not getting this multi planar movement during your daily work grind.  In addition to keeping your ligaments and tendons pliable and strong, you want to give your joints and brain the sense that they've "been there before".

2)  Improve your lateral strength with banded abduction walks.  You can pick up a resistance band in your local sports store.  It's a rubber loop that you place around your legs above your ankles.  Simply walk back and forth across a room.  When performed correctly, you'll feel a good "burn" on the outsides of your upper legs and hips.

3)  Trunk rotation is a huge component of many sports.  We're multi-planar beings, gifted with the ability to move in the sagittal (front/back), coronal (side to side), and transverse (rotational) planes.  Unfortunately, modern life calls for a sagittal-dominant existence.  While there is movement in all three planes with every step you take, you're not challenging the increased ranges imposed by sporting activities.  So, if you plan on swinging a tennis racket, a golf club, or a bat this spring/summer, implement some rotational movements into your workout and warm-up routines.  Remember, your body is very good at sacrificing form for function.  If you lack rotation where you should have it (thoracic spine and hips), your body will seek it elsewhere, forcing mobility out of places that don't love to be mobile in the transverse plane (low back and knees).

3 Quick Bonus Self Assessments:

1)  Check your core stability by doing a plank.  Can you hold a straight and side plank for 20 seconds without compensating all over the place?  Athletic movements require mobile limbs to work off of a stable base.  If you can lock down a decent plank, it's a pretty good starting point for core competency.

2)  Can you squat deeply without assistance?  Being able to do a good body-weight squat under your own control will demonstrate adequate ankle, knee, hip and back mobility, along with the motor control to take you through the joint movements.

3)  Can you balance on each leg for 20 seconds?  If you find yourself flailing all over the place, balance and stability may be an issue for you.  Just like strength and mobility, this is trainable.

Again, this is a VERY brief list of things to consider.  I know how easy it is to think that we're still 18 years old, when we never had to put much thought into injury prevention.  Our bodies were simply more pliable and responsive.  But I KNOW that with a little extra care and attention, we're perfectly capable of enjoying all the activities we did when we were younger.  Whether the goal is to continue to compete with our peers, or to be able to participate with our kids, go for it.

Life is meant to be lived.  Have fun, and play ball!

Fitting a Cane

One of the things I often see in the streets is folks with ill-fitting canes.  Most of the time, they have them sized too tall.  This may force their shoulder to rise up too much, put unnecessary pressure on their wrist, or both.  I've occasionally stopped and asked strangers (after identifying myself as a physical therapist) if they've ever been properly fitted for their assistive device.  Every time the answer is "no".  After allowing me to adjust their cane, they all reported that it felt better.

I'm amazed at how often people have come into the clinic with assistive devices they've received from the hospital or from their doctor's office with NO INSTRUCTION.  I suppose that many doctors just assume that people will figure it out intuitively.  But I've learned over the years that it's a mistake to make assumptions, and that even some of the most basic interventions should not be taken for granted.

Towards that end, here's a brief clip on how to properly fit a straight cane.  With the awful weather we've been experiencing in the northeast this winter, unfortunately there will be an uptick in people in need of such assistance.  If you or someone you know ends up with an injury that requires some "off loading" of a lower extremity, please view and share this.  I hope that it will help make what's already an uncomfortable situation less so.

Check the Trunk Before the Branches

I want to share a quick patient history that perhaps will save you from wasting your time and money in the future.

This is about a forty five year-old female with complaints of acute onset right shoulder and neck pain that had developed while snow boarding in Utah.  She had already been in my care for a left ankle issue when she texted from her trip alerting me to her new intense pain.  She was intent on coming back to New York to be seen immediately by her doctor.  In short order, she convinced her doctor to order an MRI and received an injection to the shoulder.  But she was NEVER ASSESSED BY THE DOCTOR!

Three days after receiving the injection, my patient was back in my clinic in the same level of pain.

After I put her through a series of muscle tests, there was ZERO pain provocation surrounding the shoulder.  However, both palpation (touch) and cervical (neck) motions caused pain to radiate into the spots in her shoulder and arm that she had reported to her doctor.  This afternoon, her MRI report came back which revealed that absolutely nothing was unusual.

The pain was felt by my patient primarily in her shoulder and arm, but in her case it was not where the issue originated.  Yet she underwent an expensive imaging examination and misguided injection with no positive results.

What's the point?  Your pain is a symptom that does not necessarily correlate to tissue damage in that same spot.  It can be referred from somewhere else.  Here's a quote about pain that I recently ready in Tom Myer's "Anatomy Trains":

"When a crime is committed, it's the victim that cries out, not the criminal."

If you find yourself with pain in your arms or legs, check the spine first.  Then work your way down from proximal (close to trunk) to distal (away from trunk).  The nerves that emanate from your spine branch out to reach all aspects of your body, providing both sensory and motor function.  Think of it as your body's switchboard.  Going right to the point of pain to treat would be like changing the bulb in darkened room without first checking the circuit breaker.  Check the source first, or you'll wind up frustrated, in pain, and in the dark.

A basic orthopedic examination ought to be the norm when you visit your doctor in pain.  But in today's hyper kinetic health care environment, you can't assume that will happen.  Instead, you've got to be your own biggest advocate.  Demand to be thoroughly assessed by your doctor.  If they don't lay a hand on you, consider that to be a red flag.  You will save yourself a lot of time, frustration and unnecessary costs by doing so.

Avoid the FOOSH

This post might best be filed in the "Stating the Obvious" drawer, but after witnessing several falls over the past week, I thought this might serve as a friendly reminder.

A couple of Sundays ago (January 18th), I stepped outside to grab the paper.  I nearly had by legs fly out from underneath me, but fortunately caught myself.  I didn't see any obvious ice on the ground, but it certainly was present.  Later in the evening, I saw numerous images of folks and cars sliding all over the place while enduring a nasty black ice event.  I knew that I would be seeing people in my clinic over the following weeks with injuries sustained due to these hazardous conditions, and unfortunately I have been correct.

A FOOSH injury is a fall on outstretched hand.  Your arms will shoot out reflexively when you lose your balance in an attempt to protect your head.  While you may avoid catastrophic injuries by doing so, typical injuries to the upper extremity due to a FOOSH would include wrist fractures, elbow fractures, humerus (upper arm bone) fractures, dislocated and/or separated shoulders, rotator cuff tears, and labrum tears.  All of these are painful and debilitating injuries, but pale in comparison to a more tragic outcome.  For you N.Y. Giants fans, you were likely aware that Ann Mara, the matriarch of the team, passed away this week at the age of 85.  As it turns out, she had slipped and fallen on January 18th and never recovered from her injuries.

Falls can happen any time and anywhere.  But the two simplest yet effective pieces of advice I can give you to avoid them in treacherous weather are the following:

1)  Give yourself more time!  If you keep your regular schedule during bad weather without giving yourself some wiggle room, you're setting yourself up for trouble.

2)  Wear practical footwear!  The young lady I saw fall this morning was wearing fashionable boots with 5 inch heels on them.  Fortunately she got right back up, but hopefully she'll rethink her shoes tomorrow.

Let fashion take a back seat when it comes to your safety.  Carry your professional shoes with you, or keep an extra pair in the office.  And slow down.  An ounce of prevention may save you the arduous, expensive, and painful experience of having to rehabilitate an injury.  And if it's fashion that's paramount to you, I'd suggest purchasing coats and pants that will match the slings, casts, braces and boots you might find yourself needing should you take a spill.

Take caution.  Be safe.  Stay upright.  Summer will be here soon enough.  Falling on the sand at the beach hurts a lot less.

American Sniper

Last weekend I saw American Sniper and left the theater in silence, along with the rest of the packed house.  Powerful is an understatement.

Last night, while celebrating my mother's 70th birthday, I was chatting with my brother, aunt and uncle about the movie.  While not everyone at the table had seen the movie, we all agreed to the incredible sacrifice our military men and women make.  Chris Kyle's bravery and dedication to his country were every bit as compelling as his actions during is four tours of duty.

This past week, I've read and heard a growing chorus of negativity aimed at Chris Kyle and American Sniper.  I simply don't understand this.  While we can hopefully all agree that a world without war would be ideal, the sad truth remains that it has, and likely will remain, a fact of life.  I can understand getting angry and upset at the politicians who make decisions to engage (or not) in war.  I CANNOT understand politicizing the actual folks sacrificing life and limb for our country.  I didn't know Chris Kyle.  Nor, likely, did some of the folks now trying to portray him in a negative light.  The only thing that I do know for a fact is that this man gave so much of himself for a cause he believed in.  For that, he and all the other people in the military have my utmost respect.

My brother Billy said something that really hit home during the conversation.  

"It's easy to say 'Thank You' to a veteran, and I'm sure they appreciate it.  But I think it would be better if we could actually DO something to express our gratitude."

What Bill said got me thinking.  As a physical therapist, I don't have the means to write meaningful checks to veterans' causes.  What I do have is my time, knowledge and caring.  Towards that end, I decided to offer men and women of the military free hour long consultations in an effort to say "THANK YOU" for all they have done.  

If you know of anybody who has served our country and is in need of physical therapy care, whether due to pain or impairment, please share with them my offer.  It is my small way of giving back to those who have given us exponentially so much more.  My contact information is below:

JAMES HORN

CHELSEA PHYSICAL THERAPY

& REHABILITATION

119 W. 23RD STREET

SUITE 1002

NEW YORK, NY 10011

(212) 675-3447

Don't Fear Lifting

My seven year-old daughter, Katie, asked me recently if she could be in one of my blogs.  This recent snow day, she got her chance.

I was working through a quick 9 minute kettle bell routine (exercise doesn't have to take long!) with Katie in the room.  Anytime she sees me doing some sort of exercise she usually joins in, which I love.  Afterwards, I gave her a quick lesson on how to lift safely via a dead lift.  Check her out:

I can't tell you how many times people express fear of lifting something from the floor.  I've had people ask me to write them a letter vouching for the fact that they "can't" lift things at work.  Perhaps some are simply looking for an excuse to avoid the full job responsibilities.  Others may genuinely be afraid because lifting is how they injured themselves in the first place.  Or they have been told by another health care provider to "avoid lifting heavy things".

What is heavy, anyway?  I've had folks freeze when asked to pick up 10 pounds!  This really ought to be an insignificant weight for almost everybody.  We are designed way too sturdily to go around life fearful of lifting a measly 10 pounds from the floor.

Katie's dead lift above was 20 kg (44.1 lbs).

Granted, my daughter has never had a pain seed planted in her brain due to a lifting mishap, so she has no fear.  But if a 7 year-old girl can safely pick up something nearly matching her body weight, it ought to make one question a fear of lifting significantly less.

If you ever find yourself unwilling or unable to perform a routine task like picking something up, get to work figuring out why.  Then, develop a safe strategy for relearning the task so that you no longer live with fear avoidance.  Life's too short for that.

Pain Free? Don't Take it For Granted!

This is the mug that I use at work:

I try to be an optimistic person.  I kind of have to be, because nearly every one of the clients I work with every day is in some level of pain (with the exception of the older adult with a gait or balance impairment).  It's really the only reason that they land in my clinic.  Pain or injury brought them in, and I want to do my best to show them the way out of it.

It's often said that we take our health for granted, and it's probably true.  We're too busy to stop to reflect on what it means to be fully functional, disease and pain-free.  So, tomorrow morning when you get out of bed to start your day, take a moment to reflect on some of the following things:

Can you to sleep soundly without pain?

Can you get dressed without pain?

Can you climb stairs without pain?

Can you sit without pain?

Can you walk without pain, and without fatiguing easily?

Can you get down to and up from the floor with relative ease, and without discomfort?

Can you take a deep breath without pain?

Can you bend down to touch your toes or put on your socks and shoes without pain?

Can you get out of bed without pain?

Can you reach up overhead to get things from cabinets without pain?

Can you lift, pull, push, and carry things without pain?

Can you enjoy your recreational activities without pain?

Can you perform your job without pain?

These are just a few of the things that folks report having difficulty doing due to pain and/or weakness.  If you can do all of these things without any issues, take a moment to appreciate how fortunate you are.

Pain is a good thing.  It helps keep us alive and acts as a warning when something may be wrong.  While we all want to avoid pain, don't fear it.  Just find out what to do about it when it comes along and impacts your daily life.

Most importantly, be grateful for the days when all your systems are in working order.  It's truly a blessing that should not be taken for granted.