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KB Tips

June 12, 2016

Asymmetric Resistance for Trunk Stability

When training in the gym, we tend to want to train one side of our body exactly the same as the other side, focusing on "symmetry." If we curl a 25 pound dumbbell with our right side, we try our best to perform the same number of reps with that same resistance on the left side.  When it comes to training for trunk stability, however, applying an asymmetric weight to each side may be more realistic and applicable to our everyday activities.  If we are squatting or lunging to pick something up from the ground, many times the weight distribution, especially if it is an irregularly shaped object, may be more to our right or left side.  One example is carrying grocery bags into the house from your car.  You most likely do not weigh the bags and place the exact same amount in each hand.  One hand always ends up carrying more.  When walking with the bags, we still try our best to maintain a stable upright trunk so that we are not leaning toward the right or left.  So why not incorporate this into training from time to time?    It may not be that terrible to train each side with a different amount of weight.  

Instead of Suitcase Deadlifting the exact same weight on each side, start off with a heavier weight in one hand for one set, and then switch for the next set.  The focus should be on performing the Deadlift without "giving in" to the heavier side, but by keeping your trunk upright.


Same thing with the Kettlebell Squat.  Try a heavier weight on 1 side.  


This can be done by just squatting with 1 kettlebell one 1 side, but then switch it up and use 2 different weighted kettlebells in order to apply a higher total amount of weight to your body.


Try a combo movement of a squat press using different weights.  Now you must stabilize your trunk with asymmetric resistance while transitioning from the ground to standing to pressing overhead, all while not allowing your trunk to lose control

This is just another way of introducing various perturbations to your body in order to train it to maintain and maximize its stability

April 24, 2016

Piriformis Syndrome or True Sciatica?

Sciatica seems to be the go-to diagnosis provided by a doctor, family member, friend or personal trainer, when someone complains of lower back, hip, or butt pain.  Once diagnosed by your doctor, you may be lucky enough to receive treatment by a Physical Therapist (if your insurance and busy lifestyle allow).  You should be aware of the possible sources of your pain, whether you receive professional attention for your condition or not. 

The sciatic nerve originates from Lumbar Spine, segment L4-5.  As the nerve exits the vertebral foramen, it may be compressed due to inflammation or irritation of the respective lumbar discs.  The bulging disc presses on the L4-5 nerve roots, which causes radiating symptoms down the back of the leg and into the calf, following the path shown in the picture.  Most frequently, the disc will bulge postero-lateral to the left or the right.  If it bulges to the left and presses on the nerve root, you will feel the symptoms down the back of the left leg.  If it bulges right, you will feel the pain in the right leg.  Although this is called Sciatica, it should be treated like any other bulging disc…initially with lumbar extension and neutral activities (avoiding trunk flexion) and trunk stabilization. 

Piriformis Syndrome is often misdiagnosed as Sciatica.  However, the source of the symptoms is not a bulging disc, but is more peripheral at the Piriformis Muscle. 


Due to increased activity level, such as running, the Piriformis Muscle, located at the posterior hip, tightens and compresses the sciatic nerve which runs between the two portions of the muscle.  This causes pain which is mostly felt in the hip/butt region, occasionally travelling down the leg as in Sciatica.  All the lumbar extension activities in the world will do little to reduce the pain.  While sciatica symptoms worsen upon trunk flexion, Piriformis Syndrome symptoms are less affected by this movement.  Acting as a hip abductor and external rotator, a beneficial treatment for Piriformis Syndrome is stretching (See video below).  Rest by backing off the activity is also a good idea initially.   Besides stretching the piriformis muscle, trigger point work and deep massage may also be helpful.  Below are three progressive levels of self-administering soft tissue mobilization to the Piriformis.




Place a tennis ball at the tender area of your butt where your piriformis muscle is (upper lateral quadrant of your glute).  The least aggressive is lying flat on your back with the ball placed at the muscle.  Place your weight on the ball and either remain still, or gently rock your hips left and right, rolling the muscle over the ball.  Progress to bending the knee on the affected side and slightly dropping the knee towards the other leg (intermal rotation).  This may expose the piriformis more to the surface.  Lastly, progress by bending the unaffected knee, crossing the affected leg’s ankle over the unaffected side’s knee and sitting on the ball.  This applies more body weight to the ball, creating deeper pressure to the muscle.  The figure four position also stretches the Piriformis while it is being massaged.   This is aggressive and not the most pleasant sensations, so go easy.

This video and many more can be viewed on the Herniated Disc, Bulging Disc and Spinal Stenosis - Physical Therapy Home Exercise Video Program:$26.95

 March 28, 2016

Things to Remember When Recovering From a Total Knee Or Total Hip Replacement

 Total Hip Replacement

When undergoing a Total Hip Replacement, there are two common approaches, Anterior or Posterior.  

Briefly, with both approaches, you will be able to weight bear on the surgical leg after surgey as much as you can tolerate when walking (unless the surgeon specifies otherwise).  You may be placed on blood thinning medication following surgery to prevent blood clots, and will have your blood checked by a Home Health Nurse or at a clinic throughout the weeks following surgery using PT/INR testing to see how quickly your blood clots.  The quicker it clots, the higher the chance of blood clots.  However, the longer it takes to clot, the more blood loss you may have upon simple cuts, such as when shaving (it is advised to use an electric razor during this time).  

Your incision site will be bandaged and daily dressing changes are usually ordered.  After 10-14 days, the bandage and staples will be removed and replaced by steristrips. Do not pull the steri-strips off.  They will fall off on their own.  As the edges begin to curl up, you may trim them.


Once the wound is closed and there is no drainage, you will be able to shower.  In addition to the Home Health Nurse, you should take the responsibility of assessing for signs of infection, such as fever, redness, inflammation and/or pus discharge at the incision.  If your temperature is above 101 degrees, contact your surgeon.  

Use the incentive spirometer ten times per hour, at least twice a day.


Wear your TED Hose as directed by your doctor.  You may be allowed to remove them overnight and for sixty minutes twice a day (ask your surgeon). 


While lying in bed, keep your legs elevated by rolling up towels or pillows, and placing them under your ankles.  This will protect your heels from the pressure of the mattress.  Do Not place anything under your knees

Image result for elevate legs in bed

For the Posterior Approach, restriction of movement and positioning include:

  • No crossing your ankles
  • Do not combine hip flexion, adduction and internal rotation

      Image result for total hip precautions patient handout

  • If you sleep on your side, place a pillow between your knees
Image result for total hip precautions patient handout

  • No sidelying hip abduction exercise until 4 weeks post-op

  • No resistive exercises for 4 weeks (no weights on the surgical leg)
  • Walk, Walk, Walk!!!

For the Anterior Approach, restrictions include:

  • No crossing ankles

  • Initially, no Straight Leg Raises, no Hip Extension, no groin or hip flexor stretches, no Squats or Lunges.  Ask your surgeon upon follow up when you can begin these exercises, then see Total Hip Replacement DVD.
  • Walk, Walk, Walk!!!

In regards to walking following both Approaches, you may progress from a walker to a cane to no device if it does not cause an increase in pain and if you can fully weight bear on the affected leg without a limp.

Total Knee Replacement

Following most Total Knee Replacements, there are usually less movement precautions than the Total Hip Replacement.  Your staples will be removed within 10-14 days, steri-strips will be applied, and you will be allowed to shower following staple removal as long as the incision is not open or draining.  You may also be placed on blood thinners.  You will receive an Incentive Spirometer, and will be required to wear TED Stockings.  You will be able to Weight Bear on the affected leg as much as you can tolerate and may progress from a walker to a cane to no device as long as the quality of your gait pattern is not antalgic (no limp).  The initial focus is on gaining full knee extension range of motion. 

 You must be able to fully straighten your leg as soon as possible.  Flexion of the knee will be a challenge too.  However, it will come in time.  Extension is the priority.  Remember, you may not place anything under your knee when sitting or lying.  No pillows, no rolled towels, nothing under your knee!!! In fact, it is advised to place a pillow or towel roll under your ankle in order to assist gravity in fully straightening your knee.  

Following surgery, you may be sent home with a CPM unit which is a Continuous Passive Motion Unit.  This will move your knee from a bent position to a straight position for you, and you can expect to use it three times a day for two hours each time. 

You also will be given exercises to do (See Total Knee Replacement DVD), but should not perform Resistive Exercises for 4 weeks.  Remember, most importantly, Walk, Walk, Walk!!

If you are considering a Total Hip or Total Knee Replacement, there have been many advancements in the technology which claim to be less invasive, causing minimal muscle and tissue damage, thereby speeding up your recovery time.  Unfortunately, with newer techniques, there is less information regarding long term results.  There are pros and cons to the newer as well as the traditional surgical techniques.  It is good for you to do your homework on what is available, before making a decision.  Some doctors perform these newer techniques more frequently than other doctors, so take your time finding the right surgeon.   Research how many replacements and what types of replacements they do each year.  This will help guide you in your decision.

An example of a newer technique for a less invasive hip replacement can be seen HERE.  And for a more customized, patient-specific knee replacement, click HERE.  These are not the traditional replacement surgeries, and may offer faster recovery times. 

 March 13, 2016

Common Back & Neck Surgery Precautions

The video protocols offered by KB Fitness, LLC, include some of the more common and standard exercises that you can expect to be taught while receiving Physical Therapy during specific time frames following an injury or surgery.  However, each surgery/injury and each individual undergoing surgery or recovering from an injury are different.  We all heal at different rates, and some surgeries are more extensive than others.  There is an expected time frame for the patient to be able to perform certain activities, and that is what the protocols provide…a base or foundation to work off of.  The benefit of seeing a Physical Therapist is having the frequent one-on-one guidance as you progress through your protocol.  Your therapist will decide when to “hold you back” and when to “push you harder,” again using the protocol as a guideline. 

Unfortunately, not everyone has the time, insurance or the finances to allow them to attend Physical Therapy.  So the videos offered here were produced to help those who do not have the convenience of going to a Physical Therapy Clinic.  It is advised, however, that you take the Home Exercise Handouts that accompany each video protocol to your Physician during your follow-ups for him/her to check off which exercises you should and should not be doing at any particular time.  I have found that two different surgeons performing the same surgery may expect their patient to be functioning at different levels in their rehab, as some surgeons are more aggressive or conservative than others.  For example, some surgeons may send you home wearing a back brace, while others may not.  This is why it is very important to keep your doctor, surgeon, and/or therapists informed of what activities you are doing or intend to do following your surgery or injury, by showing them the Protocol Handouts.   

Although two different surgeons may have different expectations at certain times following surgery/injury, there are some common precautions that patients should be made aware of following surgeries, especially Cervical or Lumbar Spinal Fusion.  Here are some precautions to keep in mind that many surgeons do agree on….

  • Remember B-L-T!!!  This stands for absolutely No Bending, Lifting, or Twisting
  • Learn how to Log Roll and use it to get in and out of bed

This video was taken from the HomeBound & Deconditioned Video Series
  • If you are recovering from a Neck Fusion, wear the collar you received at all times.  You should also receive a shower collar after surgery
  • If you are recovering from Low Back Fusion, you must wear your back brace if walking more than 5 minutes.  You do not have to wear it if sitting or in bed (unless your surgeon says otherwise).  Wear a T-shirt under the brace to avoid direct skin contact with the brace
  • Do not lift objects greater than 10 pounds.  The time frame for this varies by surgeon so make sure you ask during your follow up visit, which occurs within 2 weeks following surgery
  • Limit your sitting to 30-60 minutes.  Follow this by walking or lying down.  You may sit in a recliner with your feet up
  • Walk, Walk, Walk as much as possible, but take frequent rests.
  • Ask your doctor about when you can return to aerobics or strenuous exercises, but it usually takes 3 months
  • If you have to climb stairs, do so carefully
  • Ask your doctor when you can shower as you may be advised not to get the surgical bandages wet.  They occasionally use waterproof bandages but this varies.
  • Do not pull off the steri-strips.  They will come off on their own. 
  • Go to the ER if you experience chest pain, difficulty breathing, prolonged nausea/vomiting, severe and uncontrollable pain, or are in a car accident.
  • Make sure to call the surgeon’s office if you incision opens, if you have a fever greater than 101, or there is drainage at the incision site 5 days after surgery.
  • No driving until you visit your surgeon at the post-op visit and get approval.  Remember, if you do drive prior to receiving permission and are in an accident, this may pose an issue in regards to your auto insurance coverage.  If you are still taking the narcotic pain medicine, your doctor may either tell you not to drive until you are off the meds, or he/she may advise you to wait 4 hours after you take the meds before driving.
  • Following Fusion of the neck or spine, Do Not perform ANY neck or back exercises until your doctor allows.  This may take over a month following surgery.  Just Walk, Walk, Walk!!!  The exercises on the Fusion DVD Protocols are to be performed to strengthen your neck or back only after enough healing has occurred and you receive permission from your surgeon.  You may receive Physical Therapy immediately following surgery.  However, this usually is to make sure you are navigating your home safely and following all post-surgery precautions.

February 21, 2016

Which Hand Should I Hold My Cane In?

If you are working with a client who is learning how to walk with a cane because of weakness/instability in one of their legs, it is adviseable to have them use the cane in the hand on the opposite side of their weaker or more "troublesome" leg.  

Although a cane is not to be used as a weight bearing device, as it is strictly for balance, holding the cane in the opposite hand will be more energy efficient for a client.  The reason is similar to the last post, which described the unilateral Farmer's Carry, a very useful exercise that strengthens the hip musculature particularly on the side opposite of the side carrying the weight.  

It all deals with Moment Arms, which are defined as the length between the axis of a joint (your hip in this example), and the line of force acting on that joint....kind of like a lever.  The line of force can be a weight, as in the Farmer's Carry, or a cane which provides a supportive force rather than a resistive force.   In terms of resistance, think about holding a weight with both hands at your chest.  Then hold that weight with your arms stretched out in front of you (lengthen the lever).  The longer the lever or moment arm, the more the resistance, and the harder the task feels.  On the other hand, when using an assistive device rather than a resistive device, the longer the lever (moment arm), the more assisted or easier the activity is.  

In regards to the Farmer's Carry, as described in the previous post, as a weight is carried in the left hand while walking, each time you stand on the right leg during gait, the right hip and trunk muscles have to work even harder to maintain stability due to the force applied by the weight on the opposite side.  If you carried the weight in the right hand instead, the right hip and trunk would not have to work as hard when in right single leg stance due to the shorter moment arm.  

In terms of a supportive device, holding the device (cane) in the hand further away from the weak joint will assist that joint in stability more than if the cane is held in the hand on the same side as the weaker leg.  This is because the Moment Arm is longer from the weak hip joint to the opposite hand than it is to the same side hand.  This is seen by the blue arrow on the picture below.  

Figure 1                                                          Figure 2

You can see that the Moment Arm is much shorter in figure 1 than it is in figure 2.  Holding the cane in the left hand provides more assistance to the right hip than it does to the left hip as a result.  Therefore, if you have trouble with your right hip and your balance is impaired because of it, try holding the cane in the left hand.  If the problem is your left hip, hold the cane in your right hand.  

This is also the reason why I progress my patients in the Single Leg Stance (SLS) activity described in the previous post from holding a support with 2 hands, to holding the support with the hand opposite the leg they are standing on, followed by SLS holding on with the same side hand, finally to SLS without holding onto a support.  When in SLS on the right leg, holding the kitchen counter with your left hand makes the task easier than holding the sink with the right hand.  

Keep these tips in  mind when training gait, balance, and hip stability.  


February 15, 2016

Single Leg Stance

One common exercise prescribed by Physical Therapists as part of balance and gait training is the Single Leg Stance.  Upon performing this activity, patients usually ask why they are doing it. They can not make the connection between this exercise and its usefulness in daily function.  

If you want them to remember to perform this exercise consistently as part of their Home Exercise Program (HEP), you will have a better chance if you explain the functional value of it.  I usually explain to patients that in order for them to walk properly, they need to be able to maintain Single Leg Stance (SLS) on one side (Stance Phase) in order to swing the other leg forward (Swing Phase).  If you are not comfortable in Single Leg Stance, you will take shorter strides and may even shuffle. Although the patient may feel safer by minimizing time spent on one leg, the resultant shuffling poses a trip/fall risk.  This is why we focus on Single Leg Stance during our treatments.  

We break the task of walking down into its specific components, focusing on the parts that are most difficult for the patient.  Once they demonstrate improvement in each part, we bring it all together and have them perform the entire this case, walking.  

When evaluating patients, a Physical Therapist may perform the Single Leg Stance (SLS) Test to assess the patient's risk of falling.  Click here for testing details.  

During training, due to patient apprehension to perform SLS, I will have them first practice by holding onto their kitchen sink with two hands.  I will then progress them as follows:

1)SLS on level surface, 2 hands holding sink

2)SLS on level surface, holding sink with the hand that is opposite the stance leg

3)SLS on level surface, holding sink with the hand on the same side as the stance leg

4)SLS on level surface without holding sink

You can also modify the SLS by having the patient turn their head left, right, up, down to challenge the inner ear and visual systems, which will further challenge their balance.  You can begin with the patient's eyes open, then try it with the eyes closed.  You can even modify the surface they are standing on by having them stand on a pillow or Balance Pad. 

If your patient is unable to perform the SLS without holding onto the sink, then have them continue to hold the sink, and place the focus on maintaining proper upright posture while in SLS.  Cue them to avoid sidebending, performing a Trendelenburg stance, or allowing one side of the pelvis to drop while in SLS. With this, they will still be training the hip muscles of the stance leg for strength and endurance, even though the are holding onto the sink for balance.  

Another activity that will train your patient's hip while in SLS is walking while holding a weight in the hand on the side opposite the hip you are trying to strengthen.  Check out one of the older posts here.....

Farmer's Walk: By holding the weight in the right hand, whenever you are in single leg stance on the left leg, you are challenging the left hip and trunk muscles.  The weight in the right hand is applying a downward force toward the right.  Your trunk is fighting the right sidebending force that holding the weight in the right hand is introducing to your body.  The right side of your pelvis wants to drop when you are swinging your right leg forward because the "column of support" (your right leg) is no longer planted on the ground.  Since the right side of your pelvis does not have support of your right leg, the only way to prevent the pelvis from dropping and to keep your pelvis level is to contract your left hip muscles while in left SLS.  Holding additional weight on your right side makes this even more difficult, as more force is directed down to the right.  This activity will strengthen your SLS hip muscles and should be performed alternately.  Walk while holding a weight in your right hand....then walk while holding the weight in your left hand.  The weight should not be too light...start with 10-15 pounds.

January 11, 2016

Hip Replacement: What You Need To Know Part 4 - Prepare Your Home

So you have just had your Total Hip Replacement and will be returning home soon, if you do not transfer to an Inpatient Rehabilitation Center first.  The benefits of returning home are that you can sleep in your own bed without the daily distractions that you would have to deal with in a Rehab Center.  But you better be sure that you can safely navigate your home environment before you opt out of going to Rehab, because if not, you may end up falling at home and returning to the hospital needing a hip revision surgery or a hip surgery on the other side due to a fracture.  

Inpatient Rehab is beneficial because you will usually receive at least 5 hours of therapy each week.  On the other hand, if you return home, you may only receive Home Therapy 2-3 hours a week.  When your return home approaches, you will want to be proactive in preparing your environment.   You may also want to enlist the help of friends or family members for cooking, shopping, housekeeping, laundry and bathing assistance.  

You may have to make modifications in your home in order to maximize your safety.  Grab bars positioned in your shower will assist you in entering and exiting.  I do not advise the suction cup grab bars as they may loosen from time to time.  

If you live in a multi-story home, you will want to consider railings along the staircases.  

Following your hip surgery, you will most likely have difficulty transferring out of a chair, so an elevated seat (multiple pillows) with armrests and a firm cushion is preferred.  

You will also want to consider an elevated toilet seat so that your knees will remain lower than your hips (Total Hip Precaution). The Total Hip Precautions should be followed for at least 6 weeks after surgery, depending on your surgeon's orders.

You may purchase a shower chair so that you are at less risk of slipping in the tub.  

removeable showerhead will also be beneficial.  

For dressing, consider buying a long handle shoe horn and sock aid so that you will not have to overly flex at your hips.  

A reacher will help you pick objects off the floor if you drop something.  

Don't forget to remove all throw rugs and loose electrical cords that may be in the walk ways, as these are trip hazards.  

Some people set up a single area in their home where they will spend most of their time.  This area will have the telephone, television remote, medications, bottled water, books/magazines, etc..

If you are unsteady when walking, a 3-in-1 commode can be placed by your bed so that it can be used throughout the night if you need to use the bathroom.  It can also be placed over the toilet (after removing the basin) to elevate the seat or in the shower as a shower chair.

As insurance companies are covering less equipment nowadays, you may have to purchase most of the above mentioned equipment online or at a local medical supply store, Walgreens, CVS, Home Depot or Walmart.  

January 3, 2016

Hip Replacement: What You Need To Know Part 3

More Information About The Surgery

The Total Hip Replacement prosthesis is made up of a ball component and socket component.  These may be made of metal or ceramic.  Depending on your bone density, the components may be cemented into place or press-fit to allow the bone to grow into the components.  

  Image result for total hip replacement components

You will either be put to sleep using general anesthesia, or may be given a spinal/epidural or nerve block which allows you to remain awake, but numbs you from the waist down.  

During the surgery, which lasts a few hours, the damaged cartilage is removed and replaced by the prosthetic components to allow proper function and alignment of your hip.  Plan to stay in the hospital for a few days.  

Initially, a foam wedge may be placed between your legs in order to maintain the hip precautions (prevent ankle crossing). 


A Physical Therapist will evaluate your strength, balance and your ability to transfer, walk and navigate stairs (if you have stairs at home) the day of the surgery or a day after, depending on the surgeon's orders.  If it seems that you will not be safe to return home, inpatient rehab will be recommended.  

Pneumonia is a potential risk following surgery due to pain medication, bedrest and anesthesia.  To help prevent pneumonia, a spirometer will be provided in order to minimize shallow breathing.  This measures the amount of air you inhale and exhale.  You must use this frequently throughout the day as an exercise.  

Your incision may be closed using stitches or staples which will be removed within two weeks.  A water proof bandage may be applied by the surgeon, which will allow you to shower without having to change the bandage.  

Image result for hip replacement incision site    

Image result for hip replacement incision site waterproof bandage

Exercise is critical in your recovery.  Following inpatient rehab, you may want to consider home care Physical Therapy.  On average, the return to light daily activities takes 3-6 weeks.  Your Physical Therapist may provide you with a Home Exercise Program which you should perform daily.  These exercises can also be purchased in video format HERE.  You can find videos on bed mobility, transfers, stair navigation, fall recovery, and emoblisms with the Tips for Knee Rehab: $16.95 DVD and Home Bound and Deconditioned DVD: $26.95

One common life threatening complication following surgery is the formation of blood clots in your leg veins.  

TEDs support stockings and blood thinners are usually prescribed by your surgeon as a preventative measure.  

Image result for TEDs stockings

Ankle pumps and daily walking will also be beneficial.  Warning signs of a blood clot are 

1)pain in your calf unrelated to the surgery site

2)redness, warmth and/or swelling of your leg.  

If you suddenly experience shortness of breath or chest pain, call 911 as this may mean that a clot has reached your lungs and you may be experiencing a pulmonary embolism.  

Following surgery, there is always a risk of infection.   If you suffer from a fever, chills, redness or swelling at the incision site, drainage from the wound or severe pain in the hip, you will need to call your surgeon immediately and follow all directions received. Also keep in mind that you will no longer be able to have dental work without taking antibiotics prior.  

If you plan on travelling after your surgery, consult with your surgeon to discuss how long you need to wait following the surgery.  You may also want to request a card that will tell all travel security agents that you have a prosthetic hip, as you may activate metal detectors following the replacement.

For the Total Hip Replacement DVD, which explains common Physical Therapy exercises and appropriate time frames following the surgery, click HERE.

December 29, 2015

Hip Replacement: What You Need To Know: Part 2

Make a list of questions to ask your surgeon.  Most of the time, you will already feel overwhelmed from all the helpful advice and information your family and friends are giving you.  When you finally see your surgeon, your head will be spinning.  Take a piece of paper a few days prior to your surgical consult and make a list of questions.  

Many of my patients complain that the doctor hardly spent any time with them during the initial visit and made them feel awkward when they asked questions.  My advice is to not leave his office until you have had your questions answered and are comfortable with your decision, whatever that may be.  Remember, if you have insurance, the surgery costs over twenty thousand dollars, so I think with that amount of money, you can at least have your questions answered and gain some sort of comfort level.  

Some questions may involve potential risks and benefits of the surgery, including long-term outcomes.  Other questions include:

What activities can I do following surgery?

When can I return to driving?

You should be aware that the hip replacement may loosen and become painful upon weight gain and excessive activities.  You should therefore avoid high-impact activities, such as running, jogging, jumping, and aggressive sports.  You will however be able to walk, swim, dance, drive, bike, bowl and eventually golf.    

What about the actual surgery....what is being done to me while I am under?  Here is a good animation of it.  Years ago the Anterior Approach was common.  Then the Postero-Lateral Approach became common and now, I have been seeing a great deal more Anterior Approach Replacements again.  One of the main benefits of the Anterior Approach is that following surgery, there will be less movement precautions for you as you recover.  The usual precautions following a Posterior Approach include, no flexion of the hip greater than 90 degrees, no ankle crossing and no internal rotation of the hip (do not allow the knees to face each other). 

Image result for total hip precautions posterior approach

This position is acceptable as the hips are not flexed over 90 degrees

Image result for total hip precautions posterior approach

Avoid flexing the hip more than 90 degrees


Image result for ankle crossing                                                    Image result for total hip precautions posterior approach

            No ankle crossing                                                       The right leg here is being internally rotated at the hip.

Stay tuned for more Hip Replacement Tips.

December 19, 2015

Hip Replacement: What You Need To Know

 Upon going to your doctor and hearing that the pain in your hip is due to extensive arthritis, you may be in a position of deciding on having a Total Hip Replacement.  Many times, patients who have heard this from their doctor attempt Physical Therapy before "giving in" to surgery.  They usually all ask the same questions...first one being "how do I know when I need to have the surgery?"  To answer this, I will ask my patient the following....

First, does the hip pain affect your quality of life, limiting daily activities such as walking or bending?  

Is the pain constant no matter what you do?  

Are you unable to lift the affected leg in and out of bed or a car due to pain and stiffness?  

Do anti-inflammatories and physical therapy help reduce your pain?  

Have you had to use a walker or cane due to the pain?  

If the answer is yes to most of these questions, then surgery is probably unavoidable.  

Many times, a patient was referred to Physical Therapy from their Family Physician.  They begin therapy with me, but ask what type of doctor they should see specifically for the hip.  An Orthopedic Surgeon would be the specialist for this surgery.  However, if my patient has other medical conditions such as heart disease, then they should also see their Cardiologist.  But these arrangements will be coordinated by the Orthopedic Surgeon as the surgery date approaches.  

You can also expect to have blood work, a urine test (to check if you have a urinary tract infection and need a Urology consult), and an EKG.  Remember to provide all of your medical providers with a detailed past medical history.  If you do not have high blood pressure because it is being controlled by medication, YOU STILL HAVE HIGH BLOOD PRESSURE!  If you are being treated for something with medication, then you have that diagnosis.    

You may be advised to donate your blood just in case there is blood loss during the surgery, requiring you to have a transfusion.  Your doctor may advise you to lose weight before surgery in order to minimize stress on the new hip.  Major dental procedures and cleanings are recommended prior to surgery to minimize the risk of infection following surgery, as bacteria can enter your blood stream during dental work, causing an infection.  

More tips on the Total Hip Replacement to come....

December 10, 2015

The UBE 

The UBE, or Upper Body Ergomometer is a great rehab tool for shoulder injuries.  It is similar to a stationary bike, except it is 'pedaled' using your arms instead of your legs.  The video above shows the UBE being used in the forward direction.  Many shoulder issues have contributing factors such as poor posture, including rounded shoulders, forward head, and scapuale protraction.  I have found that performing the UBE in the forward direction initially may aggravate the symptoms, as the pushing motion may feed into scapula protraction and forward head posture.  I prefer to begin using the UBE in the retro or reverse direction.  Performing it in this direction will actually engage scapula retraction as a result of the pulling rather pushing motion of the UBE pedals.  This may be helpful particularly for clients suffering from shoulder impingement.  Also take notice of trunk rotation while your client uses the UBE.  In order to incorporate some trunk stabilization, cue your client to keep his/her trunk as still as possible while moving their upper extremities.  Now it is a workout for the arms and the trunk.  

As for positioning....I start with my client sitting in a chair facing the UBE.  They should be close enough to comfortably hold the handle of the pedal with it at its furthest position in the revolution from them, with their elbow very slightly flexed.  I do not want them to hyperextend their elbow as they pick up speed.  Basically, you do not want to "over reach" in order to complete a full revolution, and your elbows should never lock out at any point in the revolution.  


Some progressions....I will usually start with my client sitting, performing retro UBE.  I then have them include forward UBE while controlling the amount of scapula protraction.  I want them to maintain scapula stability throughout, and not allow their shoulder blades to just "go along for the ride."  I also cue them to control and minimize trunk rotation during the exercise.  Then I will include retro UBE in stance, which is more demanding on the trunk, as you can no longer rely on the seat to keep your hips in place.  Then, add forward UBE in stance.  Many times I will have my client perform a few minutes in the retro direction, followed by a few minutes in the forward direction.   

November 30, 2015

Protect Your Shoulder

Most of us have felt a sore shoulder at one time or another, especially if we exercise regularly or perform a repetitive activity at work.   The pain may be felt at the front, side or rear aspect of the shoulder.  A common cause of anterior shoulder pain is poor posture and/or inefficient movement mechanics, where the humeral head is not stabilized in the proper position, and therefore migrates anteriorly in the gleno-humeral joint.  If this happens often enough, it may actually stretch the anterior shoulder capsule, causing more problems and more pain.  This is why we must remember to "pack" the shoulder during upper body activities, and must always be mindful of scapula stabilization.  Click HERE for some Scapula Stability exercises.   

I was just contacted from someone suffering from daily shoulder pain.  He even complained of pain throughout the night.  The pain was in the left shoulder, and unfortunately, he prefers to sleep on his left side.  This makes it feel even worse in the morning.  

My advice is to try not to place body weight directly on that shoulder, at least until it becomes less reactive.  One technique is to try to sleep on your back.  However, depending on the tightness of your chest muscles, after a while this position can also apply stress on the anterior shoulder capsule.  

In the pictures above, when I lie on my back, depending on how firm the surface is, my elbow rests at a lower level than my shoulder.  This will be more obvious with someone with very tight pectoralis muscles.  If I am having anterior left shoulder pain, you can see that lying on my back, the elbow joint is below the shoulder joint, which may allow the humeral head to press into the anterior aspect of the shoulder capsule.  This can be resolved by placing a pillow or towel roll under the tricep/elbow.

Here, the towel is too high under my upper arm.  The elbow is still not in line with my shoulder.  This may actually increase my symptoms as the towel may be pushing the humeral head even harder into the anterior shoulder joint capsule.

Moving the towel more towards my feet, you can see that my elbow is now in alignment with my shoulder joint.  Less stress is placed on the anterior shoulder capsule by the humeral head and this may be just enough to decrease the inflammatory response.  As a result, the pain will decrease, allowing a better night's sleep.  The towel under the affected arm may also act as a block to limit my ability to roll towards that painful side while sleeping.  This will keep  bodyweight off the painful shoulder, and prevent further irritation from creating a greater inflammatory response.  The healing process will now be able to progress! 

November 22, 2015

Neck Pain Tip

A normal spine has both lordotic and kyphotic curves.

As we age, many of us begin to display a "flattening" of the lordotic curves.  

To help maintain proper muscle length as well as minimize the stress on ligaments and other soft tissues, Physical Therapists and Chiropractors attempt to help maintain proper spinal alignment to "regain" the proper curves.  We educate our clients on corrective postural exercises, stretches and stabilization activities.  

Neck pain is a common diagnosis.  Many patients complain of difficulty falling asleep at nights due to persistent neck pain.  One possible reason for this pain is poor support of the cervical spine.  As shown above, your neck should have a lordotic curve.  If you sleep on a pillow that does not support this curve, further flattening of the curve may result, thereby causing more discomfort.  The longer you sleep on your back, the force applied to your neck from gravity may further exacerbate your condition.  You can easily go to the store to purchase a pillow specifically made for this...

However, if you do not have the time, money or the ability to leave your home, you can make your own supportive pillow.  All you need is a pillow, a bath towel and a pillow case.  Keep your pillow in its case.  

Fold a bath towel so that it is the width of the pillow

Roll the towel so that it "fits" the natural curve of your neck.  Too thin of a roll will not support your neck.  Too thick of a roll with cause more discomfort.

Try it out first.  Lay on your back with your head on your pillow and the towel roll supporting your neck.  Is this comfortable?  If so...

Take the towel roll and slide it in the pillowcase towards the bottom of the pillow where your neck would be when lying in your bed.  If you did not roll the entire length of the towel, let the remaining towel lay flat on the pillow within its case

You can see the towel is rolled up at the bottom portion of this pic within the pillow case.  The top of the pillow remains flat and smooth to support the back of your skull.  

Try this before you go out and spend your money on a Bed, Bath and Beyond pillow.

November 12, 2015

The Strassburg Sock

The Plantar Fascia is a band of tissue on the bottom of the foot, and is a common site of foot/heel pain.  Pain is usually felt at the heel, particularly in the morning when you first step out of bed.  The intensity of the pain may somewhat subside as you continue walking, as this stretches the plantar fascia, thereby reducing the stress placed at its attachment site to the heel. 


Physical Therapy is very beneficial in treating plantar fasciitis.  However, a typical PT session only lasts around 1 hour for 2-3 times a week.  What do you do the rest of the time to continue treating your condition?  

You will most likely receive a Home Exercise Program.  A video version of this full protocol can be purchased HERE.  You will learn stretches (particularly dorsiflexion of the foot and extension of the big toe), strengthening exercises and stability exercises for the foot and ankle.  


Why is the pain most intense first thing in the morning upon your initial steps?  

Most of us sleep under the sheets.  

If we sleep on our back, the weight and pressure of the sheets will push our feet down, pointing the toes away from us (Plantarflexion).  This will shorten the plantar fascia as well as the calf muscles.  When we first stand on our feet out of bed, there is an immediate stretch to the plantar fascia which will cause a strain to the already inflamed region.  Intense pain is the result.  

The goal in rehab is to stretch the plantar fascia in order to reduce the stress placed on it.  If we sleep 6-8 hours through the night on our back, the recovery process will be slower because all of the treatment that we receive during the day will be somewhat counteracted overnight due to the sheets and sleeping position.  

The Strassburg Sock may help to speed up the recovery process, by continuing the 'stretching' treatment overnight.  

This is to be worn the entire night.  You can see it maintains the foot/ankle in dorsiflexion and applies an extension force to the hallux (big toe) which further stretches the plantar fascia.  Upon waking up the next morning and standing on your feet, the affected foot will already be 'pre-stretched.'  This will minimize the initial stress to the plantar fascia and reduce the inflammation and pain upon weight-bearing.  

November 7, 2015
External Cues To Prevent Falls

Many times an elderly patient will receive Physical Therapy following a fall.  When I assess their walking/gait pattern, I notice that they shuffle their feet.  They do not have a distinct heel strike and push off.  If they are shuffling, then they are not lifting their toes (dorsiflexing their ankles).  This may be the cause of their fall.  It is my job, then to correct this.  Sometimes, especially if they are recovering from a stroke, they do not have sufficient strength in the affected ankle/foot to allow them to raise their toes.  This may require an AFO (Ankle Foot Orthosis) which is a piece of plastic that extends from their upper calf, to the bottom of their foot.

The solid plastic orthotic will not allow the toes to drag, thereby preventing foot slap or foot drop.  However, if they shuffle their feet out of habit or have slight weakness in the ankle, that can be improved with strength training.  Treatments will focus on strengthening exercises, as well as providing multiple cues in order to re-establish this action (lifting the toes) and create a "new habit".  

One common exercise performed with elderly patients is the Seated March or Hip Flexion.  This activity strengthens the hip flexors, which assist in advancing the legs when walking, lifting the legs into bed or transferring into a car.  Many patients will focus only on lifting the knee in the air.  Upon observation, I will notice that the foot/ankle on the side that is being lifted is still plantarflexed or pointed down.  Verbal cues to lift the toes during this exercise may correct this, but you will need to repeat the cues frequently.  One solution to this is to include manual cues such as placing a light ankle weight around the foot.  This will provide the patient with a tactile cue (the weight will push the toes down towards the floor).  This will also provide a method for strengthening the dorsiflexors which are responsible for lifting the foot/toes during gait in order to maintain foot clearance and prevent recurrent trips and falls.  

Above, you can see the Seated March performed without any cues.  You can see how the toes on the foot being lifted remain pointed toward the floor


In these pics, an ankle weight is wrapped around the lifting leg's foot.  This provides a constant downward pressure or stretch sensation to the lower leg throughout the entire exercise set.  This will cue the patient to lift the toes in order to "prevent the weight from sliding off the forefoot."  By doing this, you are strengthening the dorsiflexors of the ankle as well as creating a new movement habit.  This will hopefully help your patient/client to raise their foot/toes when walking to assist in fall prevention.  Holding the foot in the dorsiflexed position isometrically during each repetition in order to prevent the weight from falling off will also improve the endurance of the dorsiflexors.  If you want to create a new movement habit, "repetition, repetition, repetition" is the key.  

August 17, 2015

Shin Splints

Shin Splints is a very common diagnosis, especially among athletes.  The following video briefly discusses possible causes and tips for prevention of Shin Splints

Click HERE to purchase the full Shin Splints Rehabilitation Exercise Video Protocol

August 3, 2015

Total Hip Replacement

There are two surgical approaches for a Total Hip Replacement, Anterior and Posterior.  The video below describes what to keep in mind immediately following surgery and answers many common questions from patients such as:

1)What movements should I avoid doing following surgery?
2)What do I do to prevent blood clots?
3)How often will I be seeing my surgeon following the surgery?

Click HERE to purchase the full Total Hip Replacement Video Protocol
July 26, 2015
Why Does My Hip Hurt?

Click Here To Purchase Hip Pain DVD

July 19, 2015

"If You Keep Picking At It, It Will Never Heal"

Recovering from a lower back injury is similar to any other injury.  If you fall and cut your knee, the healing process will be postponed if you constantly pick at the scab.  When you are rehabilitating from lower back pain, the more frequently you irritate the injury, the longer it will take to heal.  This means that you must protect your spine during everyday routine activities.  

Stu McGill describes your lower back as a savings account, advising you not to "spend" it frivolously.  If you continue to unnecessarily involve/mobilize the spine in activities that do not require its involvement/mobility, then when you do "need" the spine, it will not be there for you at 100%.  

One example of this is the simple task of tying your shoes.  Following a lower back injury, you may find yourself trying to figure out a pain free way to perform this task.  I have noticed that the less I flex my spine, the less I irritate it.  This is most noticeable during the acute stage following an injury or flare-up.  

Most people will tie their shoes in the above position.  Notice the amount of flexion in my spine.  If I have been diagnosed with a bulging or herniated disc, this will be very painful initially.  As I begin to heal, this position may become less painful. However, the repetitive flexion of the spine may cause irritation at the injury site, leading to further "disc creep" and eventually a larger herniation or bulge, which will become extremely painful.

  This position is slightly better for the back than the prior one, as there is less spinal mobility (flexion) needed.  However, like the bank account, if you can avoid or minimize your spending, then avoid it.  Your goal is to minimize stress on the lower back.  

In this photo, you can see that I maintain a straight spine, while hinging at my hips in order to reach my shoe.  This minimizes lower back involvement, as it requires motion only at your hips (hip hinge).  Your foot position/stance can be adjusted to allow you to reach your laces while maintaining a straight lower back.  If you can make this your new shoe lace tying technique, you will relieve your lower back of unnecessary strain.  If you incorporate this idea into other daily routine activities, it will help you to avoid future lower back irritation.


July 5, 2015

When Verbal Cues Are Not Enough....Continued

In the previous post, we discussed how providing verbal cues many times does not get our clients or patients to perform therapeutic activities using proper technique.  Therefore, we must use other, more physical cues in order to reach our goals.  Another common every day functional movement that we perform is the Lunge.  Upon initially asking a client to perform a lunge, we may see this....


In the second and third images, you can see a forward head posture and rounded upper back (protracted scapula), as well as a slightly rounded lower back.  I can choose to verbally overwhelm the client as she moves from static stance into her lunge position by asking her to tuck her chin and squeeze her shoulder blades together, while maintaining proper foot position and correctly dropping her body into the lunge.  However, too many verbal cues can be confusing.  So many times I will attempt to correct this one issue at a time.   

Here, I decided to focus on correcting the upper body, as her chief complaint is upper back and neck pain.  I provide her with a resistance band which she holds at chest height, with her hands shoulder distance apart, keeping slight tension on the band.  I then ask her to pull her hands horizontally apart, stretching the band while performing a vertical lunge.

You can see in the second image, that the lower back position corrects and remains slightly arched and the upper back and scapula are less rounded and protracted than when she performed the Lunge without the band.  However, the forward head position remains.  

Now, I only have to verbalize one correction, "Tuck your chin." I do not have to verbalize correcting her lower back, upper back or scapula position because the resistance band does that for me.  I am not happy with her back leg as she is shifting her weight forward, and I wanted her to perform a Vertical Lunge.  A quick cue of "lower yourself straight down toward the floor without allowing your knee to touch the floor" gives me the next rep.....


Here, her head is better aligned, her shoulders are retracted, thoracic spine is less rounded, she maintains the arched lower back and she is lunging more vertically, rather than shifting her weight forward.  On three reps, she was able to correct most of her technique.  After a bit more fine tuning and performing a few more corrected reps, try the Vertical Lunge without using the resistance band to assess carry over.