Choice – It’s yours

Choice. It’s a good thing, and we certainly enjoy that freedom. In some situations your choice is being taken away – namely your choice of physical therapy provider, is being denied to you. The scenario goes something like this – you see the doctor, maybe a specialist, and you are told you should have physical therapy to treat your particular problem. You return to the front desk, and are given a slip for your PT appointment. You are being told where you will receive physical therapy, rather than being asked where you would like to receive physical therapy. You could have made a choice, but your doctor took that away from you.

Think about it this way instead. You see the doctor, receive a prescription for medication, and then they tell you that it can only be filled at Acme Pharmacy, even though you do all your business elsewhere. A doctor cannot do that for your medicine prescription. They can however, direct you to a physical therapy provider (and some other medical providers) without offering a choice.

Is it really a big deal? Simply put, yes it is. Some physical therapists are better at treating certain problems than others, and you want the best to treat your problem. Some PT’s attend frequent continuing education courses, stay current with the research published in physical therapy journals and are treating their patients with the latest and best techniques. Some PT’s live and breathe their profession, some just collect a paycheck. You want the best, and certainly deserve the best. You want your pain to decrease, your problem to improve, and you want it to happen quickly. If you have high co-pays or a high deductible, you really want it to happen quickly.

What if you don’t know who to choose? Here are some ideas:

-Ask your friends, family members, doctor or anyone else that might help you make a good decision.  Call the physical therapy office you are onsidering and ask questions.

-Go to http://www.apta.org/ or https://www.mckenzieinstituteusa.org/ and use their physical therapist search tools to see what is available in your area.

-Stop by the office and take a look. I don’t know why any good office would have a problem.

-Ask them if they have experience treating your particular problem.

-Ask them if you will see the same therapist every time. For continuity of care, and to avoid confusion in your treatment, you should see the same therapist every time (unless your therapist is ill or on vacation – there are a couple exceptions, and only on a limited, temporary basis).

-Last, but certainly not least, ask if they participate in your particular insurance. There’s nothing worse than getting to the office, showing them your insurance card, and being told they don’t accept your insurance.

Don’t let fancy equipment or a flashy office fool you. It is the skill of the physical therapist that is going to help you recover, and you want to try to determine how skilled they are. It’s your health – put a little thought into your choice.

So there you have it. You are free to choose your physical therapy provider, and you should make a careful choice. It might make the difference between high quality, effective care that provides a solution to your problem, and mediocre care that consumes your money and your insurance benefits but does little to help you.

Sacroiliac joint – it might be causing your pain, and it’s not that hard to find out!

The sacroiliac joint. It’s an odd sounding name, but rest assured, it is real, it is a joint, and it can be source of low back pain, and even pain in the lower extremity. The name comes from the bones that form it. As we all know, a joint is formed where two (or more) bones meet, and it is often named for those bones. In the case of the sacroiliac joint, it is formed by the meeting of the sacrum (base of the spine) and the ilium (one of the bones of the pelvis).

It is a very strong and stable joint. The surfaces of the bones are irregular, allowing them to interlock to some degree. Between the bones is the synovium, a connective tissue the adds further strength. At the front and back of the joint are very strong ligaments that again make the joint stronger and more stable. Thankfully, it is very strong, because it puts up with a lot. Walking, running, going up and down stairs, jumping, sports activities and falls all can transmit an impact force up the lower extremity, across the sacroiliac joint and up the spine. Each joint along this path dissipates the force to some degree, but significant forces still have to cross the sacroiliac joint, and it stands up to them quite well.

The joint does move, but very little. There can be an up and down movement between the two bones, and there can be a little rotation at the joint. This movement has been researched extensively, and while there is some disagreement on the amount of movement and rotation, it is generally thought the amount of movement up and down is in the neighborhood of a few millimeters (a fraction of an inch) and perhaps two degrees of rotation, give or take a little. Weight bearing also helps to push the two bones together, adding further strength. A good paper describing the anatomy and function of the sacroiliac joint can be found at http://onlinelibrary.wiley.com/doi/10.1111/j.1469-7580.2012.01564.x/full. Consider yourself warned however, it is long and technical, but is well researched and a good resource for those interested in this topic.

While it is strong, it can also be a source of pain, whether due to injury, wear and tear, or even due to pregnancy. The problem basically comes from excessive movement, either the up and down movement, or the rotational movement. Injuries may include falls or motor vehicle accidents. Wear and tear, is well, wear and tear. A lifetime of hard physical work, repetitive stresses from sports or other activities might be a cause, among many others. The laxity (loosening) of the ligaments that occur in pregnancy might also lead to excessive movement of the joint. Pain associated with sacroiliac joint problems is typically located in the lower back and/or buttock, left or right but not usually both. You can have pain in the lower extremity, usually not below the knee, but it is possible to experience pain in the lower leg and foot according to some studies. You might even have groin pain or pain within the pelvis itself. The abstract of an interesting study of location of pain can be read here: http://www.sciencedirect.com/science/article/pii/S0003999300900807. I’m not sure I would want to be a test subject in a study like this!

So, it’s a strong joint, it doesn’t move much and it can cause pain. What’s the big deal? The problem for those of us that treat back pain is actually determining what is the source of pain. As we said above, the pain from the sacroiliac joint is usually located in the lower back, buttock or thigh, and may go down as far as the foot. This same pattern may arise from the lumbar spine as well. Notice I’m only saying lumbar spine, because within that area are a number of structures that could give rise to the very same pain. So, we have to differentiate between the lower back and the sacroiliac joint. You certainly wouldn’t want to direct your treatment at the sacroiliac joint, when it is the lumbar spine causing the problem, or vice versa.

Well, c’mon, it can’t be that hard, can it? In a word, yes. It can be that hard. Old habits die hard in health care, and old habits as they relate to assessment of the sacroiliac joint are a real problem. Maybe your practitioner pokes certain spots on your pelvis and says they aren’t even, looks to see if your pelvis is level, looks at your leg length, has you bend to see if your pelvis moves in some fashion, asks you to bend forward and wonders if your pain is there as you return to upright standing. Each of these relates to an old testing procedure, that in one way or another, through good research, has been shown to be unreliable. I cringe every time someone comes in my office with back or lower extremity pain, and tells me that so and so told them they have one leg shorter than the other, and that means their sacroiliac joint is “out”. There have been a number of methods taught to measure leg lengths. Back in the dark ages, when I went to school, we were told to lie the person on their back, tug their legs out straight and then compare the location of those little bumps at the inside of the ankle, and just like that you can assess leg length. Or, if you wanted to be even more accurate, while lying flat, you measure from the point of bone at the front of your pelvis (anterior superior iliac spine for you anatomy lovers), to the bump at the inside, or outside, of the ankle with a tape measure, and compare left to right. It sounded good then, and it sounds good now, but it’s not accurate. Studies show it’s not reliable, and the reliability when comparing the results of measurements between multiple examiners doesn’t hold up. When the amount of movement is millimeters, and amount of rotation is around two degrees, you better be accurate. You can read an extensive review of leg length measurement techniques here: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2628227/. So, what we thought we were measuring may not have been actual measurements, may not have had a correlation to the problem our patient was experiencing, or just may not have told us anything like we thought it did.

Beyond that, how do we know that if you have a short leg that it actually means anything about the state of your sacroiliac joint and whether it is the cause of your pain? Maybe you just have one leg a little longer or shorter than the other, you have all your life, and it has nothing to do with your pain.

So, the long and short of it is that all those techniques for evaluating the sacroiliac joint don’t tell us much. Now what?

Well actually, life got simpler. That’s a surprise, isn’t it. A fellow named Laslett studied the sacroiliac, and pretty much figured it out. He published a paper years ago that demonstrated a series of “provocation” tests could be used to assess the sacroiliac joint with significant accuracy. (The abstract is here: http://journals.lww.com/spinejournal/Abstract/1994/05310/The_Reliability_of_Selected_Pain_Provocation_Tests.9.aspx.) He went on to suggest that a McKenzie lumbar evaluation, combined with the provocation tests, made sacroiliac evaluation even more accurate, and published his findings (you can find the abstract here: http://www.sciencedirect.com/science/article/pii/S0004951414601252.) Provocation testing is simple. You stress the joint by pushing or pulling or twisting, simply applying a specific force to it, and look for a response. Add the McKenzie evaluation first, and you can, with accuracy, rule out the lumbar spine as the source of the pain, and then turn your attention to the sacroiliac joint if provocation testing is positive. It’s simple, and it works.

So there you have it! (I hope I haven’t lost you.) It’s not okay to be told you have a short leg, or a long leg, or your pelvis is not even, or your hips are “out” and all the rest of the things you hear from us health care folks. It is okay to have your back evaluated, then have some simple provocation tests performed, to know with reasonable accuracy that your low back, buttock or lower extremity pain is coming from your sacroiliac joint or your lower back. Treatment is generally just as simple. We can usually teach you some simple stretches that will take care of the pain, and get you up and going again.

Find a McKenzie credentialed practitioner, you can find one using the therapist locator at www.mckenziemdt.org. Your pain may be from the sacroiliac joint, it might be from the lower back. You deserve to have these areas properly evaluated, using techniques that have some evidence behind them (evidence based medicine – that’s going to be a great topic for another post), to determine where your pain is coming from, and how it can be best treated.

Shoulder pain, more common than you think!

Shoulder pain. It doesn’t make the news like back pain, but it’s out there. You reach in the cupboard and feel a little pinch. Go to put the seat belt on and it grabs you as you pull the belt across your body. Lay on that shoulder at night, and the pain awakens you. That beautiful child or grandchild wants you to lift them, and you can’t because you know it will be painful. Tennis or softball? You might as well forget them as the overhead movement really hurts. Maybe the shoulder is a little stiff, and you men can’t reach back to tuck your shirt in, or women can’t reach behind your back and fasten a particular article of clothing. You may not seek treatment – it doesn’t bother you that much, you can live with it (but it sure is a nuisance), or maybe you are just fearful that the solution will include surgery. The pain may at the front of the shoulder, maybe at the side, or it may radiate all the way to the forearm. Sometimes the pain is felt in the arm or forearm, without pain at the shoulder. The problem is, you thought is would get better, or just simply go away, and it hasn’t. Maybe the fear of how miserable (painful) the treatment is imagined to be is enough to prevent you from seeking treatment. Hopefully, a little information on shoulders and shoulder pain will help you change your mind and seek the treatment that may just rid you of the problem, quickly and with relative ease.

The shoulder is a great joint. It’s a ball and socket joint, and it moves all over the place. With increased mobility, however, comes instability. You shoulder depends on connective tissue around the joint, as well as strong muscles, for support and stability. That makes the joint complex, and you might think of that complexity as the cause of many of your shoulder problems.

The first thing that comes to most minds is the rotator cuff. Yes, it is called the rotator cuff. I’ve heard a number of variations, most common would be the “rotary cup”. That’s okay, we know what you mean. The rotator cuff is made up of four muscles (supraspinatus, infraspinatus, teres minor and subscapularis). They are muscles that originate on the scapula (shoulder blade) and attach to the upper part of the humerus (the arm bone). The tendons come together to form a cuff, supporting the joint, aiding in preventing dislocation. The rotator cuff muscles help to stabilize the ball in the socket, and also initiate movement of the arm. You could develop tendonitis, suffer a tear of the tendon (thus “rotator cuff tear”), or develop weakness of the rotator cuff muscles – any of which might (or might not) cause your pain. Notice I said “might not”. There are a number of studies out there, having people with no shoulder pain receive an MRI, and finding that a large percentage of them have partial tears of the rotator cuff. Those of you that like to read about these things might want to look at http://ajs.sagepub.com/content/23/2/142.short, http://onlinelibrary.wiley.com/doi/10.1111/1756-185X.12476/abstract or http://www.bjj.boneandjoint.org.uk/content/91-B/2/196.abstract. If you have enough of the cuff torn, you may not be able to lift your arm away from your side, creating significant disability.

You may have heard of the “labrum”. It’s simply a rim around the socket that adds depth, and contributes to the stability of the shoulder. It can be torn, and you might have heard of a SLAP lesion, which is simply a tear (Superior Labrum Anterior to Posterior). A tear might lead to terrific instability and problems at the shoulder, or it might mean nothing – kind of like rotator cuff tears.

Impingement syndrome is another common diagnosis, and put most simply is pinching (impingement) of the rotator cuff tendons. It’s a diagnosis that is widely used, and in this day of tests, x-rays, scans and so on the term may fade as we can be more specific in the diagnosis. Simply put, impingement syndrome could be considered the “umbrella” under which many more specific diagnoses reside. Again, those with inquiring minds may want to read this – http://www.uhasselt.be/Documents/UHasselt/initiatieven/2012/schouderklachten/1-Overzichtsartikel-All%20in%20one/1-A4-Shoulder-Matsen-Evidence%20Relevant%20to%20the%20Diagnosis%20of%20Imping%20Syndr-JBJS-2011.pdf. Surgery may be required for impingement problems, but most are treated conservatively with physical therapy or perhaps injection. As we understand the various problems that live under that impingement “umbrella”, we are becoming more effective in treating the various problems with physical therapy, often with very simple exercise routines.

You may have noticed that even though we can see a lot of “things” on x-ray or MRI, that may or may not be the cause of the problem. Imaging is helpful, don’t get me wrong. It’s nice to know if there is a fracture, dislocation, bone tumor, advanced arthritis, bone spurs and all the rest that can be seen on these various pictures. However, they are only one part of the clinical picture. It is important to take a careful history of the problem, listening carefully for any details that may provide a clue to what treatment is going to be effective in treating the problem. It is also important to perform a careful examination. While these things take time, they are crucial to your care. If your health care provider doesn’t listen, give you adequate time, makes you feel rushed, or doesn’t take the time to adequately examine your shoulder (or any other part of you), or answer your questions, consider finding one that will. It’s not enough to just look at the pictures (imaging studies).

You may notice that we don’t try to name a specific tissue that is at fault. We could try, but chances are we would be wrong, or it wouldn’t be relevant. You may have a rotator cuff tear on MRI, but it may have nothing to do with your pain, for example. It is more important to identify the behavior of the problem, and develop a plan of treatment depending on the behavior. It’s not that complicated. What causes the pain? Is it loss of motion? Chances are simple stretching exercises can fix it. Does it relate to the muscles? Strengthening exercises will probably help – for one of two reasons actually. If it’s an injury to a tendon (commonly called tendonitis, but that name is changing quite often to tendinosis, but that’s a topic that deserves its own post), strengthening exercises will actually help to heal chronic changes in the tendon that have occurred as a result of tearing or other injury to the fibers of the tendon. If the muscles are weak, and certainly the rotator cuff muscles can be weakened from a variety of causes, strengthening may help. It’s the behavior of the problem that leads us to the solution.

Now, if you are feeling confused, please don’t be. You have a sore shoulder. It’s our job to help you. Most shoulder problems are going to get better with conservative care – meaning things that don’t involve surgery. There, now you can breathe easier. Most physical therapy treatments are relatively simple, typically involve exercise as their major component, and really aren’t painful (unless you consider all exercise to be a pain). As new research is being published constantly, we continually gain insight into better treatments, whether it is for shoulders or any other part of you. The term we use is “evidence based practice”. In other words, is there evidence (research) that supports your treatment approach, and if not, is there a better way to treat that problem that the evidence supports? Evidence based practice is a hot topic right now, and will be a good topic for another post.

Perhaps you have a massive rotator cuff tear, or a labrum tear that has created a marked instability of your shoulder. Maybe the impingement is so bad that physical therapy cannot help. These conditions create a significant disability and certainly diminish the quality of life. Surgery in these cases can definitely help. Most rotator cuff tears, as well as labrum tears, can be repaired. Bony problems causing impingement can be corrected. These procedures are typically done through the arthroscope, in an outpatient setting. Shoulder replacements can also be performed, however are a little more complicated. As one might imagine, surgery is a more painful solution, but one that corrects a disabling problem. Physical therapy is typically required after surgery to aid in restoring motion, strength and function.

Now, that’s a long-winded discussion of shoulder pain. It doesn’t address every shoulder problem – that would take a whole book. Hopefully it has helped you realize that your shoulder problem can be treated, it’s probably not all that complicated, probably won’t hurt more than a little if at all, and treatment can get you back to the things you enjoy, like throwing a ball, reaching into the cupboard, lifting your child or putting your arm around your sweetheart. If you don’t know your local physical therapists, ask around, find out where the best physical therapy office is in your area and give them a call (consider going to https://www.mckenzieinstituteusa.org/ and using the therapist finder for a McKenzie trained provider in your area, or http://www.apta.org/for their therapist finder).