MANHATTAN PT NEWS 1ST QUARTER 2010

Lower Manhattan Physical Therapy Yorkville Physical Therapy Lewisboro Physical Therapy
40 Exchange Place, 210 East 86th Street 890 Route 35,
Ste. 1414 Ste. 203 PO Box 104
New York, NY 10005 New York, NY 10028 Cross River, NY 10518
212 425 1060 212 249 0904 914 763 5941
www.lowermanhattanpt.com www.yorkvillept.com www.lewisborophysicaltherapy.com

WELCOME
Welcome to the first 2010 issue of Manhattan PT News! We hope that the young year has gone well for all of our patients,
friends, and referral sources. We have had a busy few months ourselves.

First, we would like to welcome our new Certified Hand Therapist - Kerry Bate, OT to our Yorkville office, where she has
started a brand new specialized hand therapy program, and Certified Orthopedic Specialist Zoya Resnik, PT to our Lower
Manhattan location, where she will be focusing on orthopedic and sports injuries of all kinds. Please look to our Therapist
Spotlight column to find out more about these two wonderful additions to our staff. Also in this issue, you will find
information about the rotator cuff muscle as well as ways to help prevent knee injuries. Finally, there was a much talked
about article in the New York Times that examines the state of Physical Therapy, and below you can find our take on the
important issues brought up. I certainly hope you enjoy this issue and we wish you the best as we quickly work our way
towards the spring thaw.

In health,
James Cavin, PT

ROTATOR CUFF
Patients that walk through their Doctor or Physical Therapist’s door with shoulder pain have the same question: “Is
it my rotator cuff?”. Often the fifth or sixth question is “what exactly is the rotator cuff?”. The fact that many times
patients question if their cuff is injured before they have an idea of what it actually is and does is strong evidence of its
importance and its susceptibility to injury. So, what is it and what does it do?

The most important step in identifying what a structure in the body does is to look at its anatomy. The rotator cuff is
actually comprised of four muscles, sometimes referred to as the “S.I.T.S.” Muscles. They are the Suprapinatus, the
Infraspinatus, the Teres Minor and the Subscapularis. The first three start on the back of the shoulder blade and travel
to the top of the humerus - the upper arm bone - and attach to a bony prominence on its side known as the greater
tubercle. The subscapularis starts on the front of the shoulder blade and inserts on the lesser tubercle of the humerus
a little closer to the front. These differences in location determine the muscle’s function. Imagine your arm hanging
straight down at its side. The first three act to rotate the arm outward, so that the front of your arm points away from
your body. The subscapularis does the opposite. It rotates the arm in towards your body. Hence the grouping of these
muscles into ‘the rotator cuff’. Rotating the arm is not their most important function however. Indeed, there are other,
larger muscles that are capable of performing these motions. To determine what makes the rotator cuff so important,
it is again important to examine the anatomy of the shoulder. There is a muscle called the deltoid which is the primary
muscle involved in lifting the arm. Due to its orientation, when the deltoid lifts the arm it pulls the head of the humerus
upward. When working properly, the rotator cuff muscles exert a downward force to keep the head of the humerus from
traveling up and away from the shallow shoulder socket, it sits in. If the rotator cuff does not do this, problems can result,
most commonly shoulder impingement syndrome. This in itself can result in further problems with - and even tearing of
- the rotator cuff as the supraspinatus is pinched between the tip of the shoulder blade and the humerus. Other problems
with the cuff include strains and tendonitis or other types of tendinopathy. Not surprisingly, due to its role in overhead
activities, problems often occur in athletes who throw or swim, or workers who frequently perform tasks with their arms
overhead, however, this is not always the case.

Treatment for a rotator cuff problem involves looking for predisposing factors such as posture, abnormal motion,
weakness or tightness (or hyperflexibility!) at the shoulder and the joints around it, then designing personalized
exercises and manual mobilizations to address those specific problems. It should also involve observation of your
work environment and performance of motions used during daily activities to determine if any changes need to be
made to reduce the stresses on the shoulder due to the environment. For anyone experiencing rotator cuff or other
shoulder problems, the Physical Therapists at Lower Manhattan, Lewisboro or Yorkville Physical Therapy can perform
a sophisticated evaluation and then design a proper treatment program to eliminate your pain and restore your normal
function quickly and efficiently.

PREVENTING AND TREATING INJURIES TO THE KNEE

The knee is a relatively simple joint that is required to do a complex job: to provide flexible mobility while bearing
considerable weight during wildly varying physical activities. While walking down the street, our knees bear three to
five times our body weight. When climbing stairs, squatting or jogging, that force can multiply to seven times our body
weight. The force exerted upon the knee is absorbed by compact structures of bone and cartilage, supported by muscles
and ligaments. When the knee is overstressed due to high impact - which is often exacerbated by a movement system
impairment (MSI)—those structures can break down and a knee injury can occur. Whether caused by sports, arthritis
or everyday wear and tear, a knee injury can have serious consequences for the patient, leading to significant pain and
swelling, short-term immobility and long-term disability. At Lower Manhattan, Yorkville, and Lewisboro Physical Therapy
our mission is to work with our community of referring physicians both to prevent knee injuries in patients through proper
exercise and training and to effectively rehabilitate injuries should they occur.

With insight from our team of physical therapists specializing in orthopedic injury and prevention, this two-part article
should assist medical providers 1) communicate
with your patients to help them recognize and mitigate their risk of knee injury; 2) respond to injuries with appropriate
evaluation and treatment; and 3) understand how proper treatment of Movement System Impairments can significantly
shorten a patient’s recovery time, prevent further damage to the joint and promote better long-term results.

Anatomy of a Knee
The knee joint, which is the largest joint in the human body, actually comprises
two joints. The patellofemoral joint is the arthrodial joint where the thighbone connects
with the kneecap, and the tibiofemoral joint is the hinge joint between the thigh and
shin. These bones are held in place by a system of passive restraints, the fibrous ligaments that hold the joint in place.
The menisci are pads of cartilage that further stabilize the bones and provide shock absorbency. The joint is further
supported by muscle tissue, a system of dynamic restraints. When conditioned and strengthened, these muscles apply
forces that help hold the joint together and absorb forces arising from contact from the ground.

Knee Injuries Defined

Injuries to the knee can be grouped into two categories: acute macro-traumatic,
or injuries that result from a single event; and micro-traumatic, or repetitive injuries that
occur over time.

Acute Macro-Traumatic Injuries

An example of an acute macro-traumatic injury is a rupture or tear of a ligament, part of the passive restraint system of
the knee. Perhaps the most common among these injuries is rupture of the anterior cruciate ligament (ACL), a condition
usually caused by over-rotation of the joint during braking or cutting motions.

Acute macro-traumatic injuries include:

Ruptured anterior cruciate ligament (ACL), ruptured lateral collateral ligament, torn lateral meniscus, fractured patella,
acute dislocation of the patella, ruptured patellar tendon, ruptured quadriceps tendon and/or quadriceps muscle

Micro-Traumatic Injuries
Micro-trauma is due to overstress of normal tissue. Instead of damage from one event, the knee suffers many repetitive
injuries over aperiod of time. Another name for this condition is overuse syndrome. .Micro-trauma often occurs with sudden
increase in exercise level, such as when a runner increases distance or a tennis player plays more sets than normal.

Micro-traumatic injuries include:

Strained patellar tendon, Patellofemoral pain syndrome, strain of the quadriceps tendon and/or quadriceps muscle, or
tendinopathy of the hamstring, quadriceps or adductor muscles.
In next quarter’s issue, we will discuss the pros and cons of both non-surgical and surgical treatment of knee injuries, as
well as the role physical therapy plays in treating
Movement System Impairments, which are often the root cause of injuries to the knee.

How the Physical Therapist Can Help

The key benefit of physical therapy in treating injuries to the knee should not simply be the rehabilitation and
strengthening of the injured tissue, but also the identification and treatment of movement system impairments (MSIs).
MSIs include tissue and motor control impairments that result in insufficient, altered or excessive movement.
They are frequently the mechanical cause of pathophysiological injuries, especially non-contact injuries. In the wake
of a serious acute macro-traumatic or micro traumatic injury, or without a screen of function motion, Movement System
Impairments are commonly overlooked. However, if left undiagnosed and untreated, MSIs can undermine a patient’s
recovery and ultimately lead to a repeat injury. Even in the best-case scenario, they will result in decreased performance
due to inefficient use of the musculoskeletal system.
At Lower Manhattan, Yorkville, and Lewisboro Physical Therapy, we have the
clinical expertise to diagnose MSIs, and to work with you to develop an interventional patient care program that can
decrease recovery time, prevent further damage to the joint and create better long term results.

For more information on how our knowledgeable team of certified physical therapists can help your patients recover from
knee injuries, contact us today.

PHYSICAL THERAPY AND “TRICKS”

Quite a stir was caused this quarter in musculoskeletal circles by an article in the New York Times by Gina Kolata. The crux
of the question that she was asking was whether physical therapy had been proven beneficial in treating injury, and as
she sought her answer, she focused on two basic areas. First, the use of modalities such as heat, ultrasound, electrical
stimulation, and ice. The second was exercise, and whether or not physical therapists are necessary for the prescription
and supervision of such exercise.

Let us talk about modalities first. Thermal modalities such as heat and cold have been used for centuries for therapeutic
purposes. There is a significant body of evidence showing acute physiological changes with their application, such as
decreased inflammation and cell death with cryotherapy; increased tissue flexibility with heat; and decreased muscular
spasm and pain with both. Similarly, ultrasound has been shown to generate heating effects, decrease inflammation
and increase cell permeability; and electrical stimulation (with various parameters) has been used to increase strength
and decrease muscle spasm and edema, in addition to decreasing pain. Acute physiological changes and improvement
in symptoms is not the name of the game, however. A medical professional’s goal should be to correct the root of the
symptoms, rather than the just alleviate them. And in this, modalities tend to fall short. As many patients will attest,
they often provide temporary relief, but upon the completion of a proper course of a physical therapy, those who received
modalities and those who did not tend to have similar outcomes. Additionally, the goals of decreasing muscle spasm,
inflammation and pain can often be conveniently addressed by taking muscle relaxers, NSAIDs or corticosteroids, or
narcotic or non-narcotic pain medications with your Medical Doctor’s prescription. Furthermore, the application of heat
and ice can be done at home; it certainly does not require someone with three years of graduate school to put an ice
pack on a sprained ankle. Ultrasound and electrical stimulation are a different story when it comes to getting your hands
on the devices and knowing when and how to properly use them, but again, they should not be the basis of a physical
therapy program. Ms. Kolata’s experience with physical therapy—receiving ice and heat, massage and ultrasound—is a
textbook example of how not to provide PT in the vast majority of cases (she does admit that she only went once or twice,
and often the first session will be spent performing a comprehensive evaluation and determining a treatment plan, and if
she was acutely injured, exercise may not have been deemed immediately appropriate).

When physical therapy first came into use in treating musculoskeletal disorders on an outpatient basis in the 1960’s
and 1970’s these modalities and others were used extensively, despite Physical Therapist’s skills in using exercises to
treat neuromuscular disorders. As the research supporting therapeutic exercise increased and physical therapy evolved
in response to the new science, the perception of physical therapists as pharmacists dispensing modalities on the
orders of a Medical Doctor sometimes remained. As a personal example, about three years ago I contracted to replace
a therapist at an outpatient clinic. One of the patients I inherited had shoulder impingement and had been receiving
electrical stimulation at the end of his treatments. He was still having pain with overhead activities, but he no longer
experienced pain at rest and I made the decision to eliminate the electrical stimulation. The patient complained to my
client that I was no longer providing the services the insurance company was paying for (incidentally, the vast majority of
insurance companies do not reimburse for modalities and the physical therapy clinic that uses them exclusively will not
be in business for very long).

Shirley Sahrmann PT, PhD a professor at Washington University and one of the world’s preeminent specialists in
corrective exercise, once told me a story about treating one of the orthopedic surgeons who regularly sent her patients.
She performed a comprehensive evaluation, found that he had certain postural deficits and abnormalities in movement
that were contributing to his symptoms, explained to him how to correct them and provided him with a home exercise
program to begin correcting those problems. His question after the hour they spent together.

“WHEN DO I GET THE PHYSICAL THERAPY?”

Clearly, Physical Therapists have some work to do as a profession to address these misconceptions and make sure that
their actions emphasize the much larger role of corrective treatment, rather than treatments primarily used for reduction
of symptoms.

Which brings us to the next question, why cannot you just do the exercises at a gym? The answer to this is that
rehabilitating an orthopedic pathology is a much different animal than simply strengthening or stretching a muscle. For
example, lists of exercises you might find in a magazine or a book to “Treat the back”, are at best well-balanced programs
designed to train all related structures equally, and are completely inappropriate for actually treating the injured back.
The problem is that in an injured back the structures require unequal treatment designed to correct the abnormalities that
were precipitating the injury in the first place. There are many different possible causes of injury to the same body part
and it almost always takes a medical professional to properly diagnose and treat it. That part is essential and cannot be
emphasized enough. The supposition that someone can go to the gym and perform exercises that have been provided
by their Physical Therapist is logical, but in reality is a bit more complicated. The success of this depends significantly
on a person’s body awareness, their understanding of the exercise, and the underlying goal that the Physical Therapist
has in mind and its resultant complexity. Many times even those people who are active and perform resistance training
regularly can have trouble with corrective exercise. An example of this can be found in Ms. Kolata’s article when she
incorrectly identifies calf raises as belonging to a group of exercises called “eccentric”, when all exercises that involve
motion and are repeated have an eccentric muscle component (unless they are performed on a specially designed
machine designed to eliminate it). Oftentimes there is something in particular in an exercise that a therapist is after
rather than just the motion itself. Only when proper and consistent performance of an exercise is achieved should
the therapist add it to a home exercise program. As the treatment progresses the home program should become more
complex, and eventually, the patients should be discharged to continue an appropriate exercise program on their own.
Despite the above defense, it is important to recognize that Ms. Kolata’s articles bring up very valid points. Modalities are
likely used more frequently than necessary in general, whether it is because it was prescribed by the Doctor, requested
by the patient, or chosen by the therapist. Whatever the reason, the therapist who utilizes modalities should take care
to explain exactly what ends are to be achieved from their use and make sure that the focus is on correcting the cause
of the symptoms, not just the symptoms themselves. Regarding exercise, therapy should involve careful evaluation
and appropriate exercise prescription with the goal of not only resolving the patient’s symptoms and returning them
to function, but also ensuring that the patient has the tools to continue to exercise independently to reduce the risk of
re-injury. Finally, as with all medical sciences, there are always more questions to be asked and more hypotheses to be
tested. Probably the most important point that can be taken from in the article is that we are not yet finished - nor will we
ever be - learning all we can know about the human body and how to heal it.

THERAPIST SPOTLIGHT: KERRY BATE

Kerry is a certified Hand Therapist with thirteen years of clinical experience. She holds a Master’s Degree in Occupational
Therapy from New York University, as well as a Bachelor’s Degree from Villanova University. Kerry specializes in treatment
of traumas to the upper extremity, such as fractures of the arm, wrist, and hand; lacerations of nerves, tendons, and
other tissues; burns and crush injuries or amputations. She also has expertise in addressing repetitive stress disorders,
including carpal tunnel syndrome, trigger fingers, tendonitis, and other “overuse injuries”. Furthermore, Kerry is an expert
in fabrication and custom-made splints to meet all patients’ needs.