What Are The Best Treatments For Patellofemoral Pain?
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Patellofemoral pain syndrome or pain under the knee cap is the most common diagnosis in the knee and a frequent reason patients seek out the care of their primary care physician or Physical Therapist. Patient’s with this condition often experience aching or sharp pain under or around the knee cap (patella) during squatting, running, jumping, stair climbing, hiking, and prolonged sitting. Pain results from abnormal contact between the knee cap and thigh (femur). Prior thoughts on this condition believed the knee cap was responsible for the abnormal contact and interventions were designed to target the patella.

Outdated theories including balance between the outer and inner quadriceps muscle have been replaced by better research indicating the hip may play a more significant role in the condition. The hip musculature including the gluts contribute significantly to the alignment of the thigh under the knee cap. As the alignment improves a greater portion of the joint surface area is able to distribute the forces across the knee reducing joint pressure and pain. The quadriceps function to dissipate the forces across the knee and should be targeted along with the hip musculature in this condition.

The Journal of Orthopedic Sports Physical Therapy recently published their clinical practice guidelines including the best available medical evidence and expert opinion on how to effectively diagnosis and treat this condition (Willy et al. 2019). Authors reviewed 4500 scientific articles on this condition between 1960 and present day. They selected 271 articles for the review and broke down their findings into the most supported risk factors, examination tests, diagnosis, treatments, and prognostic factors. Authors found most individuals with this condition improve with Physical Therapy interventions including activity modification and strength training. Patients may also benefit from short term (< 6 weeks) utilization of foot orthotics and taping for pain relief. Authors reported manual therapy and dry needling were not shown to be useful for this condition.

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What Are The Best Treatments For Femoroacetabular (Hip) Impingement?
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Hip impingement or femoroacetabular impingement is a diagnosis consistent with bony enlargement of the hip joint, abnormal contact between the joint surfaces, and associated hip pain and loss of function. As we have described in our previous blogs, FAI is the one of the fastest growing hip diagnoses due in part to greater utilization of imaging including MRI and more surgeons being trained in FAI procedures. Significant research questions remain in the diagnosis of FAI since many individuals without hip symptoms or loss of function demonstrate FAI and/or labral tears on imaging. In addition, the optimal treatment pathway is yet to be established to determine which patients require surgery and which will improve with conservative treatments including injections and Physical Therapy. To date, Physical Therapy remains the go to first line intervention for this condition and a recent review of the evidence documents which treatments are most effective for this condition.

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Mallets and colleagues in the International Journal of Sports Physical Therapy reviewed the available evidence on outcomes after short term treatments for patients with impingement (2019). Authors included 7 studies on Physical Therapy or injections for this condition. They found conservative interventions such as activity modification, education, joint mobilizations and strength training are effective in the short term for reducing pain and improving function in this patient population. Physical Therapy exercise interventions demonstrated moderate to large effect sizes on pain and function. In comparison, joint injections alone demonstrated small to moderate effects on pain and function. The authors concluded Physical Therapy treatments “may hold more promise for recovery than joint injections alone.”

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Which Lower Body Exercise Is Best For Hip and Leg Activation?
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Strength training is an essential part of any workout program. Participants should aim for 2 to 3 workouts per week targeting major muscle groups of the upper and lower body. Multi joint movements such as the squat or deadlift provide a more effective and efficient workout compared to single joint exercises (ex. leg extension machine). The exercise prescription (sets, repetitions, and intensity) is more important than a specific exercise when developing muscle strength, but exercise selection remains important for addressing individual needs (weakness, tightness) and when working with a Physical Therapist after returning from injury. A recent research study determined which exercises are best for lower extremity muscle activation.

Delgado and colleagues in the Journal of Strength and Conditioning Research examined the muscle activation levels of the back squat, romanian deadlift, and barbell hip thrust (2019). Researchers captured the activation levels (EMG) of the quadriceps, hamstring, and gluteus maximus muscles during each exercise in a group of trained (> 1 year experience) men. EMG data was collected under two conditions: a 60 kg weight and at the participants one repetition max.

Similar to a previous study, authors found greater gluteus maximus recruitment in the hip thrust compared to the back squat. Interestingly, the hip thrust’s gluteus maximus recruitment was not statistically different than the romanian deadlift. As expected, quadriceps recruitment was greatest in the back squat and this exercise effectively targeted the knee and hip extensors. Conversely, hamstring recruitment was greatest in the romanian deadlift. This study highlights the ability of multi joint exercises to target multiple muscle groups throughout the lower extremity improving effectiveness and efficiency in your workouts.

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Dry Needling Improves Pain, Mobility, and Function In Patients With Hip Arthritis
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Hip arthritis is a painful condition causing pain, loss of range of motion, and lost function in many middle to older aged adults. The pain from hip arthritis is multifactorial in nature arising from the cartilage and joint surfaces as well as the surrounding soft tissues. Physical Therapy consisting of manual therapy and strength training remains the first line treatment for patients with hip arthritis. High level exercise has previously been shown to preserve the patient’s native hip delaying the need for a total joint replacement. Previous research has documented the benefits of joint mobilization and manipulation in patients with hip arthritis, but recent research has highlighted the benefits of dry needling by Physical Therapists in this condition.

Ceballos-Laita and colleagues conducted a double blind, randomized controlled trial on the effectiveness of dry needling in patients with hip arthritis (Musculoskelet Sci Pract. 2019). 30 patients were randomized to either dry needling or a sham needling group for 3 treatment sessions. Patients’ pain, function (gait and strength), and range of motion was assessed at baseline at at the conclusion of the treatment sessions. Authors found significant improvements in pain, range of motion, and function after the dry needling treatment compared to the sham group. Interestingly, the sham group reported increased pain and decreased hip range of motion at the conclusion of the trial. This study indicates dry needling may be included in a Physical Therapy treatment plan for patients with hip arthritis to reduce pain and facilitate a rapid transition to an exercise program.

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Why Does My Neck Pain Improve After Spinal Manipulation?
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Spinal manipulation is one of the oldest medical treatments dating back to Hippocrates and the ancient Egyptians. Theories behind its’ beneficial effects are as old as spinal manipulations use but many have erroneously detailed a purely mechanical effect of the treatment. It is not uncommon to hear patients report, “my spine was out of position/alignment/place and the manipulation placed the spinal vertebrae back into place.” Research does not deny the pain relief of the treatment but it has disproven this alignment theory with prior investigators reporting no change in vertebrae position on advanced imaging before or after successful spinal manipulation. In short, our spinal manipulations are working but for a different reason than previously described. Spinal manipulation remains an important intervention in our Boulder Physical Therapy practice for multiple conditions including headache, neck and back pain but our theories on its’ mechanism continue to evolve. Current research documents a multifactorial and complex cascade of events taking place in the central and peripheral nervous system, circulatory system, and spinal tissues. A recent research study highlights some of the important circulatory changes responsible for a reduction in pain after a Physical Therapy spinal manipulation.

Lohman and colleagues in the Journal of Manual and Manipulative Therapy examined the immediate circulatory changes after spinal manipulation (2019). Authors randomized patients with mechanical neck pain to either a spinal manipulation or sham/placebo group and measured blood concentrations before and after the manipulation. Authors found significant increases in blood samples of oxytocin, neurotensin, and orexin A. These neuropeptides are known to positively impact the expression of pain in the brain and likely explain in part why patients with pain experience short term relief with spinal manipulation. Long term relief from spinal pain will be found through a Physical Therapy strength training program, but patients can continue to benefit from spinal manipulation to reduce their symptoms and allow a rapid transition into exercise.

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Jeff RygComment
Which Running Gait Mechanics Predict Knee Injury?
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With access to miles of paths and acres of open space running remains one of the most popular outdoor activities in Boulder. Despite its’ accessibility, low cost of participation, and health benefits running related injuries keep many from training or competing at their preferred levels. One recent area of research has focused on gait retraining by Physical Therapists to reduce forces among runners. Although an “ideal” running gait does not exist some factors including foot strike, impact forces, vertical translation can help us differentiate injured from non injured runners or determine who is at a greater risk of injury. A recent study determined additional factors which can help identify injured runners.

Dingenen and colleagues in the journal Physical Therapy in Sport analyzed the running gait of 42 recreational runners (2019). About half of the participants currently experienced pain on the front or side of their knee. Researchers assessed their lower quarter mechanics to determine how those with knee injuries differed from their non injured peers. Researchers found the injured runners demonstrated greater degrees of opposite sided pelvic drop and knee adduction (inward movement) during their running analysis. We often find these running gait impairments in runners with hip abductor (glut) weakness. Increased inward motion or “wag” of the knee in stance increases forces across the knee joint. Conversely, a level pelvis and stable knee helps dissipate the forces of running over a greater surface area in the joints.

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