The Spring 2006 West Valley College Sports Medicine Symposium was held May 5th. The symposium was organized by John Kao MD for an audience consisting of physical therapists, athletic trainers, and physicians. The purpose of the Sports Medicine Symposia series is to continue improving the standard of orthopedic medicine here in the Bay Area by providing orthopedic professionals an opportunity to share their knowledge with one another and with other medical practitioners. This year’s spring symposium focused on current challenges of treating the lower extremities.

The following local professionals gave presentations:

• John T. Kao, M.D.

• Grady L. Jeter, M.D.

• Robert S. Nishime, M.D.

• Thomas Elardo, D.P.M.

• Paul Christensen, DPT, OCS, ATC

• Rob Naber PT, OCS, ATC

• Ross Nakaji PT, OCS, ATC, CSCS

• Fabrice Rockich, DPT, OCS, CSCS

• Paul Starks, MA, ATC, PTA, CSCS

Physical Therapy of Los Gatos principal Rob Naber spoke about the evaluation and treatment of problems affecting the knee. Rob began by noting the value of recent knee research and the bearing of research findings on the practitioner’s approach to knee conditions and injuries:

“The knee is often the weakest link that defines and limits an athlete’s total competitive capacity. The knee is needed for speed, power and strength, but is also vulnerable to injury. A knee injury not only means missing practice or competition but may also lead to the loss of scholarship support and potential professional opportunities. Extensive research of the knee, and improved diagnostic, rehabilitation, and surgical methods have brought new hope to athletes and clinicians dealing with the challenges of the injured knee.”

– from Current Issues in Sports Medicine: The Knee presented by Rob Naber PT, OCS, ATC

One of the key takeaway messages from Rob’s presentation was the importance of quantifying the capability and condition of the knee while the joint is in motion. In the evaluation and treatment of anterior knee pain, for instance, measuring the concentric vs. eccentric torque capacities of the knee is critically important as a diagnostic aid and as a reliable indicator of treatment progress. In rehabilitation following surgical reconstruction of the anterior cruciate ligament, videographic analysis of lower extremity angles during landing and jumping provides data the therapist needs to design and carry out a course of treatment that brings about rapid restoration of function and corrects neuromuscular control deficiencies that would otherwise invite re-injury.

Using the links below, interested individuals can view visuals and handouts from Rob Naber’s presentation to the Spring 2006 West Valley College Sports Medicine Symposium. For more information about Physical Therapy of Los Gatos’ approach to the evaluation and treatment of knee problems, please call the clinic at (408) 358-6505.

Current Issues in Sports Medicine: The Knee (view presentation visuals)
Current Issues In Sports Medicine: The Knee (download text)

Jump Strength Training Program (download program description)

Jump Strength Training Glossary (download glossary)

This entry is adapted from a talk presented by Physical Therapy of Los Gatos principal Rob Naber at the Western Occupational Health Conference 2005, held September, 2005 in Monterey, California:

Active Range of Motion (AROM) refers to the range of motion for a specific movement that a patient can achieve without assistance, such as a measurement of how far the back moves when a patient bends forward to touch his or her toes. The distance or angle between the starting and finishing position is the AROM. A reduction in AROM can impair routine, vocational, and athletic movements and overall functional capability. Restoring AROM following injury, surgery, or the effects of an illness on the musculoskeletal system is often the goal of physical therapy and the principal reason that many patients are referred to physical therapy.

In the past, physical therapists used goniometers to quantify lumbar AROM. Though practical for AROM measurements around knees and shoulders, the goniometer was of of very limited clinical utility as a means of measuring motions of the spine and surrounding joints. Other tools and methods, such as flexible rulers and measuring tapes, suffered from a lack of precision and reference values, and were also of little diagnostic value.

In 1984, Mayer, et al. proposed a method using specific inclinometer measurements to enable quantification of lumbar forward bending AROM and discrimination between the contributions of the hip and spine to the overall motion. In 1986, Keeley, et al. published a follow-up article that validated the reliability of the inclinometer-based technique and presented the reference values needed to make measurements made in the clinic meaningful.

While necessary as components of a complete evaluation, individual inclinometer measurements of lumbar AROM offer little information of clinical value and should not be used to report degrees of impairment. Multiple inclinometer measurements are necessary to determine the effects of the patient’s starting posture and the relative contributions of hip, pelvis, and lumbar joints to forward and backward bending. A patient can present with a normal lumbar AROM but still suffer from a “weak back” and recurring back pain and disability.

Physical therapy to restore a diminished lumbar AROM is not simply a matter of achieving a specific AROM value. A more nuanced therapeutic goal of restoring ideal ratios between the contributions of involved joints to composite lumbar motions will lead to more rapid and sustained reductions in impairment and more complete and satisfying recoveries.

Lumbar Spine Active Range of Motion: Significance and Relevance in Rehabilitation presentation by Rob Naber to the Western Occupational Health Conference 2005
Western Occupational Health Conference 2005: New Horizons in Occupational Medicine

Tennis elbow, also known as “lateral epicondylitis,” often affects active adults between the ages of 30 and 60 years, and causes pain on the outside of the elbow joint where the forearm meets the elbow. Internally, tennis elbow pain is localized where the muscles of the forearm merge into tendons and attach to end of the upper arm bone. A patient with tennis elbow will typically feel pain upon extending (unbending) the wrist (think of the wrist motion required to rev a motorcycle). As an aid to evaluation, a therapist can reproduce the pain by resisting the patient’s wrist motion. Sometimes tennis elbow can be so painful that the patient cannot raise his or her hand, even when no resistance is applied.

Although the condition is known by two names, neither is very accurate. You don’t have to play tennis to get tennis elbow! In addition to the high tensile stresses of the backhand tennis stroke, any other activity involving a firm grip, such as using a hammer or screwdriver, or heavy lifting, such as lifting suitcases away from the body with the palm facing the ground, can cause tennis elbow. And the “-itis” suffix of the name “lateral epicondylitis” signifies that the condition is characterized by inflammation, which is not the case. Factors normally associated with inflammation, such as certain white blood cells, cytokines, and chemokines, are not found at the site of the lateral epicondyle of the elbow. What surgeons do find, however, upon opening and examining an affected elbow, is disorganized connective tissue in the form of a characteristic yellow-brown scar. By contrast, healthy tendon tissue is glistening white and is composed of cells organized in neat rows along the axis of tension between the muscles of the forearm and the lateral epicondyle of the elbow.

Palliative measures for tennis elbow include rest and anti-inflammatory medication. Tennis elbow patients are also sometimes instructed to use a tight band around the upper forearm to help rest the painful area and protect it from damaging tensile loads. Although these measures are effective at reducing pain while they are used, they rarely result in full recovery, because they do not restore proper connective tissue alignment.

Fortunately, there are more effective measures. Twenty years ago, exercise physiologists discovered that eccentric exercise is a necessary component of rehabilitation from tendinitis. Eccentric exercise occurs when a muscle generates tension as it is lengthening. For instance, when you place a coffee cup down on a table, you are performing eccentric exercise: your biceps muscles must lengthen in a controlled manner to lower your forearm and place the cup down gently. You may think of eccentric exercise as the braking force needed to slow down the motion. The opposite of eccentric exercise is concentric exercise, which involves active muscle shortening.

Although the exact way in which eccentric exercise improves tendinitis is not known, researchers have discovered that muscle elasticity is a key feature of eccentric muscle contraction, and that eccentric exercise increases muscle elasticity. The leading hypothesis is that muscle tissues that have been made elastic by eccentric exercise effectively distribute and absorb forces that would otherwise lead to fraying of the tendon, formation of disorganized scar tissue, and tennis elbow pain.

At Physical Therapy of Los Gatos, treatment for tennis elbow begins with a thorough evaluation of the problem and a discussion of the patient’s rehabilitation goals. Movements associated with the activities that cause tennis elbow pain must be identified and analyzed. If the patient began having tennis elbow pain after playing tennis on rainy days, perhaps he or she needs only a short course of treatment and to stop hitting wet, heavy tennis balls. In other cases, we may find that improper use or involvement of the neck, shoulder, or wrist during sports or other activities has caused excessive loading of the elbow. In these cases, therapy includes instruction and retraining to balance the physical forces required for the chosen activity correctly.

However, regardless of the other required elements of effective treatment, rehabilitation of tennis elbow will include progressive, eccentric muscle training. Eccentric muscle rehabilitation involves using wrist motion to lower a weight over the edge of a table while the forearm is supported. The patient uses his or her forearm muscles to raise the weight and then lower the weight in a controlled manner. The greatest eccentric muscle force occurs when the patient changes the weight’s direction of motion from downward to upward. Therefore, the amount of weight and the speed at which the weight is moved downward and upward can be varied to increase or decrease the intensity of training. As training progresses, the amount of weight and the speed of weighted movements are both increased. Effective eccentric muscle rehabilitation can also be accomplished using elastic resistance bands.

When going over the instructions for eccentric muscle training, patients might be surprised to hear that their tennis elbow pain should increase towards the end of each exercise session. This is a case where “no pain, no gain” applies. Insufficient loading of the tendon (inadequate intensity) or loading along the wrong axis, will delay recovery.

Progressive, eccentric muscle training is the only type of exercise known to increase muscle elasticity and tendon strength and is the process by which disorganized connective tissues associated with tennis elbow pain are remodeled to become functional once again. In the treatment of tennis elbow, progressive eccentric muscle training as prescribed by a qualified physical therapist is a reliable and effective means of achieving specific recovery goals. The precise method, intensity, frequency, and duration of eccentric muscle training must match the recovery goals of each patient, allowing the tennis player to return to playing tennis and getting the carpenter back to work swinging a hammer without pain.

Osteoarthritis is a degenerative joint disease marked by joint inflammation and deterioration. Osteoarthritis is common: according to the Arthritis Foundation, nearly 21 million Americans, or 7% of the US population, are affected by osteoarthritis. The incidence of osteoarthritis goes up sharply with age.

Considering its prevalence, you probably already know someone who has been diagnosed with osteoarthritis. If that person is a competitive or recreational runner, one might expect to hear others say, “All that running. It’s no wonder he’s got arthritis.”

The fact is, there are plenty of non-runners with osteoarthritis, too, and there is a lack of evidence to support the notion that running causes arthritis.

In his excellent book, “Lore of Running,” Dr. Timothy Noakes cites a variety of research studies designed to examine the relationship between running and arthritis. Studies published in 1994 and 1997 determined that recreational joggers are not at any increased risk of developing osteoarthritis. A study published in 1985 found that the incidence of osteoarthritis in a group of runners who competed between 1930 and 1960 was lower than a matched group of swimmers who competed at the same time. A Danish study published in 1990 found that a group of athletes that ran 20 to 40 km per week for 30 years had an incidence of osteoarthritis that was no different from that of a comparison group. And a 1986 study found that runners with an average age of 60 who had run an average of three hours per week for 12 years did not have a greater prevalence of osteoarthritis than a comparison group.

Though at no greater risk of developing osteoarthritis than others, runners can and do experience pain from soft tissue injuries, such as hip bursitis, iliotibial band (ITB) friction, and tendonitis. Pain resulting from these other causes can be serious enough to interrupt training and recreational running. The runner with poor mechanics may never train long enough to develop osteoarthritis from running. And clearly an athlete who has jogged for 30 years has the correct biomechanics to run without breaking down.

Excluding injuries resulting from falls, runners’ injuries are almost always due to progressing their training too quickly or overloading the muscle support around the affected joint. A runner’s muscular strength around his or her load-bearing joints must be considerably stronger than that of non-athletic individuals of the same age and sex. Furthermore, different types of running such as sprinting, long-distance, cross-country, and asphalt training have different muscle support requirements.

The running program at Physical Therapy of Los Gatos is a goal-directed training program designed to prevent running injuries, get runners who have been injured or recovering from orthopedic surgery back into training, and increase running speed. The evaluation for the running program includes a comprehensive interview process where we measure baseline parameters of running fitness, uncover specific deficiencies, analyze your running form, and help you clarify your goals. For additional information on preventing running injuries, rehabilitation of running injuries, and increasing running speed, please contact Physical Therapy of Los Gatos by calling (408) 358-6505.