All posts by Ross Hutchinson

Ross has focused on rehabilitation programs utilizing tissue-training techniques to target injured tissue need with an extensive background in shoulder and knee programs. He has continued to improve patient transitional programs with sport and activity specific exercise using both land and aquatic programs. Ross also provides service as a Certified Strength and Conditioning Specialist.

What is a Physical Therapist?

Currently, there are an estimated 115,000 physical therapists practicing the United States. Physical Therapy was established during World War I with the inauguration of the Division of Special Hospitals and Physical Reconstruction In the Surgeon General’s Office. Some 2,000 reconstruction aides restored function to people with disabilities in army hospitals and to those with Poliomyelitis.

Today, Physical Therapists provide health care services to patients of all ages and health conditions. They serve:

  • Infants with birth defects to aid motor development functional abilities:
  • Survivors of strokes to regain movement, function and independent living.
  • Patients with cancer to regain strength and relieve discomfort.
  • Patients with low back problems to reduce pain and restore function.
  • Patients with cardiac involvement to improve endurance and achieve independence.

They also provide preventative exercise programs to promote general health andposture improvement and industrial safety and health.

Today, physical therapists serve a dynamic, comprehensive role in health care improving and maintaining the quality of life for millions of Americans

As Clinicians, Physical Therapists

  • Examine patients by performing tests and measures
  • Perform evaluations by making clinical judgments based on the data gathered during the examination
  • Establish a diagnosis by organizing evaluation results into clusters, syndromes, or categories to help determine appropriate intervention strategies
  • Determine a prognosis that indicates the level optimum improvement that might be attained
  • Provide Interventions
  • Evaluate the success of the interventions
  • Modify treatment to effect the desired outcome
  • Provide prevention and wellness (including health promotion) programs
  • Consult
  • Screen
  • Educate
  • Engage in critical Inquiry
  • Serve as administrators

The “Model Definition of physical therapy for State Practice Acts,” adopted by the American Physical Therapy Association, states that physical therapy includes:

  • Examining individuals with impairment, functional limitation, and disability or other health-related conditions in order to determine a diagnosis, prognosis, and intervention.
  •  Alleviating impairment and functional limitation by designing, implementing, and modifying therapeutic interventions.
  • Preventing injury impairment, functional limitation, and disability including the promotion and maintenance of fitness, health, and quality of life in people of all ages.
  • Engaging in consultation. education, and research.

TORN MENISCUS: When Do We Need Surgery?

man with sore knee

If It’s Aint Broke, Don’t Fix It

If you were told you had a meniscus tear either by physical evaluation or by testing such as MRI should you have a surgical repair?  If it’s not very painful, not locking and not changing functional tolerance, I say “No”.

Exam Findings – We evaluate using physical findings. Physical exam is as important as testing. You may have a positive test but no other symptoms. Symptoms such at locking or catching and high level of joint effusion (fluid) are as telling as tests when considering management strategies. Increased levels of effusion indicate severity of injury.

Common Symptoms: Popping, swelling and stiffness. Pain, especially when twisting or rotating your knee. Difficulty or inability straightening your knee fully or experiencing what feels like your knee were locked in place.

Location: The location (zone) of the tear is one of the important factors in determining treatment. Tears at the outer edge of the meniscus (red zone) tend to heal well because there is good blood supply. Minor tears may heal on their own with a brace and a period of rest. If they do not heal or if repair is deemed necessary, the tear can be sewn together. This repair is usually successful in the red zone.

The inner two-thirds (white zone) of the meniscus does not have a good blood supply, so it does not heal well either on its own or after repair. Typically the torn portion is removed (partial meniscectomy) and the edges of the remaining meniscus are shaved to make the meniscus smooth and limit catching.

Type of Tear: Also, the pattern of the tear may determine whether a tear can be repaired. Longitudinal tears are often repairable. Radial tears may be repairable depending on where they are located. Horizontal and flap (oblique) tears are generally not repairable.

Another factor when considering treatment is that repairs to the lateral meniscus (on the outer side of knee) typically heal better than repairs to the medial meniscus (on the inner side of the knee).

Physical Therapy: In many instance we can manage meniscal tears without the risk of surgery and the after effects of surgery. Meniscal rehabilitation can range from 4 weeks to 4 months. Typically we see results to independent programs by 8 weeks. High repetition low intensity exercise with decreased weight bearing can help heal meniscus tears and improve joint effusion. Muscle training to improve support about the knee and keep proper alignment through the entire limb. Modalities and NMES for muscle activation are effective treatments to restore normal function.

Activating Muscles

By definition, strengthening of muscles takes 6 weeks or longer. Strength is defined by the extent to which muscles can exert force by contracting against resistance. Quick changes in strength can often be attributed to changes in neurological activation. Few physical therapist and patients have 6 weeks or more to reach strength goals. We have to reach functional goals quickly to be reimbursed by the insurance companies and serve our patient needs.

Patients are like children and water. They always take the path of least resistance. In many cases our body will create compensatory movement patterns due to imbalances or injury. For our body to move efficiently we need all muscles to be active and work with appropriate force. You can’t strengthen a muscle that isn’t activated. The compensatory muscles are happy to kick in and perform the task, but perhaps with pain or decreased range of motion. A muscle that is inactive needs to be neurologically activated before it can become physiologically stronger.

Activation is neuromuscular education and movement training. Physical therapists are not personal trainers, we are neuromuscular experts. Finding imbalances or muscles that have become lazy and correcting muscles timing and coordination will improve specific joint function and often eliminate pain and improve function.

A common situation for muscle activation is following knee trauma. Our body protects our joint from injury by filling the knee with synovial fluid which in turn shuts down our medial thigh muscles to limit activity. We use exercise, as well as neuromuscular educational stimulation to reactivate the muscle group and restore function to the knee.

Following proper muscle activation exercises can be performed and over longer periods strength and power gains as well as muscle growth can be achieved.

Physical Therapy and Neck Pain

Physical therapy is a process of using knowledge of anatomy and physiology with exercises, soft tissue healing, posture and body mechanics and applying these principles of healing specific tissues following injury. Physical therapy conditions focuses on the spine and its joint structure including spinal segments, muscles, tendons, and ligaments.

Major goals of physical therapy with respect to neck injuries are:
· Correct spinal positional faults or limitations of spinal motions.
· Appropriate stretching and strengthening through cervical spine.
· Educate patients on proper posture and ergonomics.
· Accelerate the stages of healing by reducing pain and reducing the inflammatory cycle.
· Activity modification to reduce or eliminate future occurrences.
· Manage exacerbations.

A physical therapist can make sure you are practicing optimal exercises for your condition, and can modify the exercise as you progress. Many patients do NOT require referral from a physician to be seen by a physical therapist. You can check with your insurance company to see if a physician’s referral is required. If a referral is not required you may be seen directly by one of our Physical Therapists.

We use techniques including traction, joint mobilizations, soft tissue mobilizations, muscle energy techniques and stretching to assist in aligning the cervical spinal segment. Once aligned, the cervical spine will be allowed to move as needed to restore normal joint mechanics. Eliminating impingement of nerves, physical blocks in the spine or facet joints.

Appropriate stretching and strengthening through cervical spine.

Classically we “stretched then strengthened”. In truth both are needed to restore normal function. The Cervical spine has three planes of movement. Flexion motion is like nodding, rotation is like shaking your head “No”, and side bending is bringing your ear to your ear to your shoulder. Stretches generally begin in each plane and then become more advanced to use motions from multiple planes.

Strengthening begins with extension strengthening and achieving neutral spinal position. Scapular strengthening and postural exercises are included early in cervical programs. Then typically exercises in the other two planes are included. We finish cervical strengthening with compound motions of the neck and UE strengthening. The therapist will use their clinical judgment as to when to bring in each level of stretching and strengthening.

Educate patients on proper posture and ergonomics.

Good posture is imperative in recovering from neck injuries. Pain is your body telling you that something is wrong with your alignment and soft tissue is being stressed in some way. Changing posture can alleviate the stress and eliminate the pain. Sit up straight! It feels better and puts the least amount of strain on your spine! If you sit or bend too often or for too long a period of time, bend in the opposite direction to balance the stresses out and relieve muscle tension. Thinking of military type posture with shoulders squeezed and chest out, chin in, stomach tight with standing, walking, lifting and bending. Ergonomics for each situation can be evaluated and corrected by a physical therapist.

Accelerate the stages of healing by reducing pain and reducing the inflammatory cycle.

We use soft tissue mobilization, massage, relaxation techniques and modality treatments to assist in pain and inflammation reduction. This coupled with improved muscle balance with respect to flexibility and strength, proper posture and body mechanics is a significant help the therapy process.

Activity modification to reduce or eliminate future occurrences.

“Time waits for no one”! Unfortunately with injuries our life doesn’t stop. Modifying how we go about daily activities may also assist in our speed of healing. This includes body mechanics but also eliminating activities that are exacerbating our injury or limiting how much time we spend performing each activity. For example: taking breaks each hour from computer work to walk around or stretch or carrying less groceries in with each trip from the car. Careful progressions in overall activity can be helpful in recovering.

Manage exacerbations

As hard as we may try it is likely that some situation will occur that will flare up our symptoms or we will have a lapse in judgment of what our injury will tolerate. When these exacerbations occur quick management is important to limit the duration and intensity from what may be weeks to months to only a few days. Quick attention with your therapist or using the principles that have been learned from your sessions in therapy will limit exacerbations.

Target Tissue Training – Part One: Articular Cartilage

When treating cartilage injuries, stress-loading techniques are valuable as Physical Therapists encourage tissue healing. Lack of stress leads to poorly organized tissue growth. Progressing too fast, or too heavy can slow healing. Only when articular tissues begin the proliferative phase of healing should stress-loading techniques begin.

Cartilage distributes body weight in the joint. In joint (articular) cartilage, stress or misuse can create synovitis, and effusion (increased synovial fluid in the joint). Prolonged fluid in the joint may might:

  • decrease the nutrition to internal joint structures due to harmful proteolytic enzmes
  • cause thinning of the articular carti-lage
  • decrease joint range of motion from the abnormally high joint pressure.

Beginning with ROM exercise, and slowing the rate of synovial fluid production in the joint with the use of ice is very effective. Progressing from Passive range of motion, to Active range of motion exercises, with help from thermal modalities (cold) will decrease joint effusion and helps internal joint structures to heal.

Begin stress loading the joint slowly and then increase the stress as the tissue moves to the final healing phases to facilitate appropriate growth. Research has shown that stiffness of cartilage tissue can be improved. By using a daily protocol of 1000-1500 repetitions of a functional activity (without fatigue), for a period of 3-6 weeks for compression and decompression stimulus.

It has been suggested that the intensity level be 30 % or less of maximal non-painful levels. Stress levels can be increased as maximal non-painful levels increase. By testing the patient in a functional closed kinetic chain test at Accelerate Physical Therapy, we determine how to stress the tissue. In our Load Tolerance Test, repetitions for both testing and training should be consistent in speed, and have solid control of the movement. Otherwise, compression forces can spike with high-speed loading, or gradually increase with cyclic loading. Either could retard healing.

Traditional therapy programs account for joint health with passive range of motion progressing to active assistive and active range of motion and modality use. Load Tolerance Testing followed by articular cartilage compression training allows us to objectively assess and progress cartilage tolerance for weight bearing activities.

Target Tissue Training – Part Two: Functional Stress for Tensile Tissue

When a therapist approaches a patient’s rehab program, we must consider the severity of injury. We design our programs to appropriately stress the injured tissue.

In treating tendons and ligaments, we consider the mechanics of injury, adaptation to activity, and healing response during rehabilitation. A  single high load strain, repetitive loading or misuse injuries can cause sprains, partial tears or ruptures in ligaments.  Muscle will rarely contract hard enough to tear a tendon. Achilles and patellar tendons rupture in combination with external forces.

Repetitive strain begins with micro damage, resulting in pain, swelling and degradation of the tendon/ligaments mechanical properties.  This can make the tissue more susceptible to traumatic overload injuries. Tensile load is experienced in small percentages.  Stretching tendon length to 1.5%-3.0% past it’s full length is common in normal activities. Injury is created usually with a stretch of 10% more than a tendon’s full length.

After a soft tissue injury the tendon/ligament will go through a typical soft tissue healing phases: Inflammation (3-7 days to 6 weeks); proliferation (2-3 weeks); remodeling (after 2-3 weeks for more than one year).  All these phases overlap.

Through the remodeling phase, the tissue fibers increase cross-links and align in the direction of tensile load.  Rehabilitation provides progressive loading that avoids inflammation. We cannot impede the healing process or cause scar tissue to form. The paradox of functional tissue training comes in balancing between sufficient loading to guide the healing process, and overzealous loading, which continues inflammation and tissue degradation.

We minimize inflammation with early mobilization and PROM-AAROM program. This may be increased as the tissue progresses into the remodeling phase by progressive AROM, isometric and eccentric exercises followed by high repetition progressive exercises including CKC with proprioceptive and perturbation activities assisting in return to normal upper level activities.

Careful management of exercise type and intensity for tendon or ligament injury relative to the phase of recovery the tissue is the key.  Optimal management will produce minimal pain, faster healing, and return to normal activities.


About the Author:
Ross Hutchinson, PT, CSCS, has been actively involved in Colorado physical therapy since 1991.
You can contact Ross at his Arvada, Colorado office.

Golf: Dynamic Stretches

A pro golfer typically might warm up 90 minutes to 2 hours before walking out to the tee.  His routine would consist of stretching, putting hitting, practicing short game and then back to any special shots and out to the green.  A typical routine for a recreational golfer would be different.  Get out of the car, find your friend and get whatever you forgot at the pro shop, swing a couple practice shots, and go to the tee.  Typically we don’t warm up until half way through the front nine.  The question is what is a quick time efficient way to warm up before golf with our busy lives.

The answer is dynamic stretches. Dynamic stretches Dynamic stretching is useful before competition and has been shown to reduce muscle tightness. Muscle tightness is one factor associated with an increase occurrence of musculotendinous tears. More recent scientific studies seem to suggest that dynamic stretches before competition are preferably to static stretches. This may be particularly true for strength and power athletes.

All exercises should have 5 second holds and be done 5-10 times.
Standing Cat n Camel/ Pelvic Rotation
Begin in your address position, arms across chest. Tuck the pelvis under then arch the back, creating a rocking of the pelvis into anterior and posterior position and return to a neutral spine.

Trunk Rotation/ Vertical and Horizontal Axis
Standing in your address position, bring the palms together. Inhale as you rotate from the core and bring the both arms back. Mimic backswing then follow through with a stop at the address position.

Try the same exercise at chest to shoulder height twisting trunk and keeping arms in the parallel to the ground.

Standing Hip Stretch
Use a golf club for assistance with balance. Place one ankle on the outside of the opposite knee. Inhale as you bend your stance knee, sitting back as if you are sitting on a chair. Bring the chest toward the shin, rolling the shoulder blades together.  Reverse legs.

Shoulder Rotation Stretch
Place the club or towel in your right hand, palm facing the ceiling. Bring the right arm over your head and the right palm behind your back. Bring your left arm behind your back and clasp the club or towel.  Move the club up and down your back stopping when you feel a stretch and squeezing the club together.

Upper Trapezius Stretch
Bring the right ear toward the right shoulder. Inhale as you press your left arm toward the floor, exhale and relax the left arm.

Standing Shoulder Blade Stretch
Bring the club to shoulder height, bend your knees and tuck your pelvis under. Inhale as you press your arms away from you, tucking your chin into your chest. Exhale, lift the head and squeeze the shoulder blades together.

1) National Strength & Conditioning Association. Essentials of strength training & conditioning. Champaign, IL: Human Kinetics. 2000
2) Yamaguchi, T., Ishii, K. Effects of static stretching for 30 seconds and dynamic stretching on leg extension power. J. Strength Cond. Res. Aug;19(3):677-83. 2005
3) Shrier, I. Stretching before exercise does not reduce the risk of local muscle injury: A critical review of the clinical and basic science literature. Clinical J. Sports Med. 9: 221-7. 1999

Golf Exercise

General Exercise—an area of the game often ignored by amateurs
Most non-professionals rush from work to their cars, show up at the course, take their clubs out of the trunk, hop on a motorized cart to the tee, and start swinging! This can be very dangerous!

Forever looking for that magical move that takes strokes off your score probably leads you straight to the driving range to hit a few hundred golf balls. Sure! Practice makes perfect, right?  Even simple pre-season training drills will improve your swing, game and help prevent mid-season injuries for years. Let’s go golfers, other sports have pre-seasons. Let’s catch on!

What’s the bottom line?

The goals of any golfer are:

Increase range of motion in the golf swing.  Improved flexibility allows a complete backswing and extended follow through.  Having this full ROM will decreased chance of injury.

Add control and power to the golf swing.  Well trained muscles increase control and ability to generate more club head speed.

Improve energy and endurance.   muscular control will improve function and muscles will tire less through each round.

Reduce chance of injuries on the golf course through stretching and identifying uncomfortable movements.

Analysis of “Your Swing”

Leg and hip is responsible for power production initiation of the golf swing.

Trunk muscles transfer power from the legs to the torso to accelerate the club head.

Chest and shoulder muscles produce the actual swing action and play critical role in club head speed.

Arms are responsible for club control and largely determine club head impact.

Off-Season:
Three strength training sessions per week for general base and core strengthening, as well as for muscle control is sufficient. During the off season months is the best time to focus on overall muscle strength and enhance golf driving power.

Examples of exercises include all on machines: leg press, squats, hip abduction and adduction, trunk rotations, push ups, planks, standing hip extension, abdominal crunches.

Pre-Season:
Once you have a strong base and balance of muscle, you can maintain by reducing your total body strength training sessions to twice per week. Now is the time to develop sport specific skills utilizing tiny, but key muscles such as low back and rotator cuff musculature.

This program might include progressing to free weight and cable or theraband as resistance.  Exercises would include leg press, squats, hip abduction and adduction stepping with theraband resistance, standing cable trunk rotations, push ups, planks, U stance training with theraband leg swings, hip extension, trunk rotation and abdominal crunches.

In-Season:
Practice and Play! To prevent injury after long activity days with multiple rounds, you must take care of the sport specific muscles. Stretching muscles used will aid in not only assist in a better golf swing with a larger range of motion, but injury prevention as well.

The basic flexibility exercises that are relevant to golfers are standing or seated hamstring, lower back, and upper back and shoulder stretches.

These stretches will allow for the ability to play and practice more golf with fewer aches and pains at the 19th hole as well as on off days.