Last week my colleague Dr. Anthony Falco discussed how you could see a physical therapist without having to see a doctor first. Doing so can save you a significant amount of money in your process to heal your ailments. With that being said, I want to take the time this week to touch on the importance of a strong symbiotic relationship between your physical therapist and strength trainer. A strong relationship between your physical therapist and strength trainer can not only help limit the severity of a training related injury, but can also lessen the length of time for recovery and also help correct injuries or performance inhibited by movement dysfunction.
Limiting The Severity of an Injury
One of the most common issues I have seen in the strength and conditioning field is related to lingering injuries that are never properly addressed. One of the main benefits I have seen come from sharing clients with my affiliates at Performance Physical Therapy is limiting not only the severity of an injury, but also being more efficient in recovery time. In most cases, a strength coach could further aggravate a healing ailment because they are not sure of what’s causing it. For example, a rotational athlete (such as a baseball player) could be dealing with a hip injury being caused by a misalignment of the pelvis that often comes from rotational movements such as throwing and hitting. If this athlete is either not seeing a physical therapist or that therapist isn’t in contact with their strength coach a significant furthering of that injury can occur. Instead of having a physical therapist diagnose and correct the hip alignment issue, time could be spent stretching what feels like a “tight,” hip flexor which will further exacerbate the injury. Working alongside a physical therapist cannot only limit the severity of an injury, but also decrease the amount of time spent recovering from a particular injury.
Limiting Injury/Maximizing Performance Via Correcting Movement Dysfunction
Another benefit I have seen from working alongside a physical therapist lies in preventing injuries before they occur or even improving sports performance via correcting movement issues. One of the biggest responsibilities of a strength coach relates to improving the movements of athletes and general clients. Sharing clients with a physical therapist can help with correcting movement issues related to particular muscular dysfunction and also help with exercises and modalities used to fix these issues.
Are your strength coach/trainer and physical therapist on the same page? Do they work together to ensure your health or nagging injuries are treated in the best way possible? If not, work with the team of Performance Physical Therapy and Challenger Strength and see how our concerted effort can best help your health and performance.
In New Jersey you have direct access to your physical therapist. This means that a physician referral or prescription is not required to see your physical therapist. If you have back pain after shoveling the driveway or a stiff neck from sleeping on a different mattress while traveling, you can come in to see your physical therapist without having to go see your doctor. In addition to painful conditions if you want to improve your balance, improve your range of motion and strength, or start a new exercise program your physical therapist can help with that too!
Being able to come see your physical therapist directly has multiple benefits. The first benefit is decreased time to starting care for your condition. Often with painful conditions the sooner you get into physical therapy the easier it is to resolve the symptoms and eliminate the pain. When symptoms become chronic it can take longer for all forms of treatment to help decrease those symptoms. Second, by seeing your physical therapist first you can choose conservative, non-pharmacologic care as the first treatment for your condition. The opioid crisis is real and all medications carry some risk of side-effects. Physical therapy is an extremely safe option to treat pain. Third, if a physical therapist thinks you need further evaluation is required, we have great relationships with the best doctors in the area and can connect you with the right physician for your problem-generally without a long wait!. Finally seeing your physical therapist directly can save you time and money. By getting PT first you can avoid having to schedule a visit and wait at the doctor’s office, pay a doctor’s co-pay or deductible just for the doctor to send you to your physical therapy anyway.
Physical therapists are experts in the neurological and musculoskeletal systems. We are trained to screen patients that are appropriate for physical therapy treatment and how to identify patterns of signs and symptoms that warrant further medical attention.
Will my insurance cover my care without a referral from my doctor?
Every insurance company is different. Many major plans will pay for physical therapy without a referral. When scheduling your first visit at our offices we will take your insurance information and verify your benefits to determine what your responsibility is and if your insurance company will require a referral or prescription from your doctor.
The direct access physical therapy law in New Jersey:
The direct access law in New Jersey states that patients can see their physical therapist without a referral. It also states that at 30 days from the start of care, the patients doctor should be updated regarding the plan of care, or if the patient is not making reasonable progress that the patient be referred back to their doctor. The law also states that during the initial evaluation if the physical therapist feels that patient is not appropriate for physical therapy treatment or further testing is required (x-ray, MRI, or blood work as examples) the physical therapist will refer to patient to the appropriate healthcare provider.
Dr. Anthony Falco
Last week, Dr. Anthony Falco discussed the role of the meniscus in the knee and when you should consider getting surgery to repair a meniscus tear. This week, I will discuss some things you should implement into your training program following knee surgery and how you can further progress after you have completed working with your physical therapist following surgery. Following any knee surgery it is imperative to build back adequate muscle mass in the quadriceps, re-establish proper landing mechanics and force absorption of ground forces during high power activities and solidify sprinting mechanics.
Eccentric focused exercises are your best friends
After knee surgery it is common to experience atrophy (diminished muscle mass) of the quadriceps of the repaired leg. While your physical therapist more than likely focused on building back lost mass, it is imperative to continue this focus once you have moved on to strength and speed training.
While I have no problem with seated leg extensions early on in the rehabilitation process, I believe other alternatives should be utilized in strength training protocol. Essentially, seated leg extensions limit activity of the hamstring while the quadriceps is contracting. This never really happens in sports. So, I prefer the terminal knee extension (TKE), as a quadriceps building exercise that allows the hamstring to work in addition to the quadriceps. Basically, anchor a band and place it around your knee. Slightly flex your knee forward before pulling it back into extension and contracting your quadriceps. While many other quadriceps dominant movements can be performed to build muscle mass (lunges, split squats etc.), here are my general hypertrophy guidelines to follow:
Absorbing forces, re-conditioning tendons and ligaments and sprinting technique
While building mass back in the quadriceps you should also focus on re-introducing your tendons and ligaments to power movements such as jumping and sprinting. It is important not to jump right in to high intensity jumps and sprints as your body may not be ready to handle the demand places on the knee and surrounding areas.
Extensive plyometrics are lower intensity jumps that are essentially “hypertrophy for jumping.” Meaning, they rid of use of the stretch shortening cycle (reactive stretch reflex of the ligaments and tendons involved in maximum intensity jumping and sprinting). We accomplish this by implementing pauses or performing short rhythmic jumps. The main goal is to re-condition the tendons and ligaments and prepare them to handle higher intensities. Also, it teaches them how to behave again so performance is maximized later on. During these exercises the focus should be on sound and clean landing mechanics. Here is what you should look for:
Low Intensity Sprinting Start Types
Lastly, it is extremely important to reaffirm good sprinting technique while not exposing an athlete to sprinting variations that produce too much power. That is, low start types (push-up, mountain climber, etc.) or start types that involve excess power building via medicine ball throws.
Overall, it is important to progress through movements with a plan once an athlete has moved through a full rehabilitation program and can begin training!
The meniscus is a structure in our knee joint that provides smooth joint motion, shock absorption, joint stability, and nutrition to our knee joint. Each knee has a medial meniscus and a lateral meniscus. Together the medial and lateral menisci also enhance stability of the knee joint. They sit on top of our tibia (shin bone) and create a concave surface for the end of the femur to fit into, think of a golf ball on top of a tee - the menisci are like to lip of the tee that keep the ball in place.
As you can see below (link to image at bottom of article) the medial meniscus is larger and half circle shape and the lateral meniscus is smaller and more circular. The medial meniscus is more firmly attached to the surface of the tibia by ligaments compared to the lateral meniscus. The decreased mobility of the medial meniscus makes it more susceptible to injury.
Both menisci receive blood flow to the outer edges however further towards the center of the knee joint the blood flow becomes poor. This is an important point as any meniscal injury on the outer edge with good blood flow is more likely to heal than an injury on the inner edge with poor blood flow. The portion of the meniscus that does not receive good blood flow receives its nutrition through the lubricating fluid in the joint called synovial fluid. Movement and exercise are essential to deliver nutrition to the menisci.
There are also nerve endings that run to each meniscus. Some of these nerve endings provide sensation and others are mechanoreceptors that tell out brain how much pressure is on our knee and what position our knee is in.
Meniscal tears are a common injury. They can be traumatic - like twisting a knee during a sport. They can also be non-traumatic or degenerative meaning that over time the meniscus starts to get worn out. Clinical examination including a detailed history and physical exam by a physician or physical therapist can be very accurate at identifying a meniscus problem. Sometimes an MRI may be done to visualize a tear and identify the size, type, and location of the tear.
When a diagnosis of a meniscus tear is made there are options for treatment. Two common options are arthroscopic surgery or conservative management. Over the past 20 years the use of arthroscopic surgery to treat meniscal tears has expanded significantly. Specifically in the case of adults with degenerative (non-traumatic tears) the rates of surgery have gone through the roof. Unfortunately many studies have identified little to no advantage to this type of surgery for treating these types of meniscus tears. Conservative management, including exercise, is much less expensive and invasive and has no negative side effects has been shown to be better or equally as effective as surgery in some studies!
Here at Performance Physical Therapy & Sports Conditioning we specialize in treating pain, identifying problem areas to address, and designing an individualized treatment plan to address those problem areas. In the case of a meniscus tear, strength, flexibility, balance, joint mobility, and function are all thoroughly assessed. A combination of mobility exercises, strengthening exercises, and manual therapy can be customized to treat a meniscus tear effectively and efficiently.
If you are having knee pain or have been diagnosed with a meniscus tear, give us a call! Don’t rush out and have an arthroscopic meniscectomy if you have not seen us first. Based on the latest science conservative management with manual therapy and exercise should be the first line treatment for meniscal tears and surgery should be the last resort.
Next week Coach Gerry will discuss his approach to starting a strength training program with a client who has been discharged from physical therapy following a knee injury or surgery.
Dr. Anthony Falco
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Knee Image: http://www.vangsnessmd.com/wp-content/uploads/2015/02/proc_img_meniscal01.jpg
Gerry DeFilippo: ISSA CPT- CPPS, AAPS. Founder/Owner: Challenger Strength.