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Brian Schiff’s Blog

Injury Prevention, Sports Rehab & Performance Training Expert

Archive for 'health'

Femoroacetabular impingement (FAI) is now a common term in orthopedics. When I first started practicing physical therapy the term did not exist. As a matter of fact, I was told my hip had a bone spur in the early 2000’s, and I am sure it would now be classified as FAI. If you are unfamiliar with it, click here to read a prior post on the basics of it.

Today, as clinicians we face the tough task of helping patients overcome hip pain related to overuse injuries, acute strains, osteoarthritis, myofascial pain, etc. One of the biggest challenges is definitively identifying the etiology of hip pain. Hip pain can be extra-articular (outside the joint) or intra-articular in nature (in the joint). Consider this retrospective study published in AJSM in 2015 by Naal et al. on sonographic presence of groin hernias and adductor tendinopathy with FAI.

Differential diagnoses when ruling in/out FAI include:

  • Adductor (groin) strain
  • Rectus femoris strain or avulsion
  • Iliopsoas tendinitis
  • Athletic pubalgia
  • Trochanter pain/bursitis
  • Femoral neck stress fracture
  • Osteitis pubis
  • Cancer
  • Genitourinary issues
  • Low back pain

The list above is certainly not all inclusive. The key to obtaining a more accurate diagnosis involves taking a thorough history, performing a comprehensive exam, and getting appropriate imaging. Click here to learn about a paper on the diagnostic validity of tests to predict intra-articular hip pathology. Soft tissue pain related to muscle strains should improve with rest and treatment, whereas joint pain related to FAI is usually consistently painful or worse with increased repetitive activities such as running, dancing, twisting, jumping, cutting, etc.

Patients with FAI will often cup their hip and make what is referred to as the “C sign” when describing where they feel the pain.


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This exercise is intended for advanced users who want or need to increase shoulder, core and hip stability, while also seeking to improve hip disassociation. The core must function in an anti-extension and anti-rotation fashion throughout which is a safe and effective way to target those muscles while also providing a demanding strengthening exercise for the upper body and hips.

With that said, sufficient upper body strength is a must for this exercise.  Clients with wrist pain/weakness or elbow and shoulder pathology should only perform this exercise provided they have are symptom free and have moved through the following progressions. In many cases, it is best to start with tall planking and leg lift progressions on the floor before trying this exercise.

The video below will review the exercise in one of my latest columns for PFP Magazine.

Have you ever experienced a significant injury? If so, do you remember wondering if you would ever be whole again? Pain, fear and the inability to do your sport or physical activity can cripple the human spirit.

Over my 21 years as a physical therapist and fitness professional, I have witnessed how powerful the mind is and how critical it is to have the right mindset to overcome physical obstacles. Some people are mentally stronger than others – period. With that said, adversity and pain has a way of testing the spirit and will of an individual.

In any given week, I see at least 5-10 patients rehabbing an ACL injury. The injury, surgery and rehab is physically and mentally grueling. The injury itself takes the athlete away from his/her passion or sport immediately, while presenting them with a long path back to full health. Many suffer an identity crisis as they become isolated and away from their peers. Physical therapy that fully restores function is a must in this group of patients. For more on what complete ACL rehab looks like, click here to read one of my previous posts.

Fear of reinjury and persistent knee symptoms are common reasons for a lack of return to play after ACL reconstruction. Click here to read an abstract regarding kinesiophobia in this group of patients.

With any injury, it is only natural to worry about the outcome. Clients often wonder quietly whether they will be able to return to their previous level of play. In this post, I want to talk about the elephant in the room for patients coming back from an injury, and that is a legitimate fear of reinjury.

fear1


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It is that time of the year again. Everyone wants to lose weight and trim their waistlines. Abs, abs and more abs, right? I am all about some core training, but I am always concerned with some of the ab variations that I see commonly used at the gym and in group fitness environments.

Many exercise enthusiasts have tight hip flexors and poor abdominal control. Sprinkle in a history of low back pain or a prior disc injury along with straight leg abdominal exercises and now you have the perfect recipe for a possible back injury. Why is that? Well, the psoas originates from the lumbar spine and attaches to the lesser trochanter on the hip.

psoas

In the picture above, you can see how the muscle impacts the spine and hips. As you lower your legs toward the ground during an ab exercise, there is a reverse muscle action that takes place and resultant anterior shear force exerted on the lumbar spine. When the abdominal muscles cannot resist this motion, the lumbar spine hyperextends.

Many people will even report feeling a pop in the front of the hip while doing scissor kicks, leg lowering or throw downs. In many cases, this may be the tendon running/rubbing on the pectineal eminence. Unfortunately, long lever and/or ballistic abdominal exercises with inherently poor core stability/strength, fatigue and gravity working against you will create significant load and strain on the lumber spine. Ever wonder why you wanted to put your hands under your back while doing 6 inches? Your brain is trying to flatten the spine using your hands as it knows the hyperlordotic position is uncomfortable and threatening.

In light of this, I put together a little video for PFP Magazine revealing a safer way to work your abs and prevent undue stress and strain on your back. Check it out below.

Keep these modifications and progressions in mind the next time you hit the gym or a boot camp class focusing on core/ab training.

One of the more challenging issues I see in the clinic is pain in the upper hamstring region. Proximal hamstring tendinopathy, referred to medically as tendinosis, is common in runners and athletes. With that said, arriving at this diagnosis can also be challenging as proximal hamstring pain can also be caused by sciatica or referred pain from the low back region. A thorough clinical exam and good history will be able to definitively help diagnose the cause.

Chronic hamstring pain can occur as a result of a previous acute tear, or due to ongoing tendinitis that is aggravated by repetitive activity. Running, biking, rowing and even prolonged sitting can aggravate the hamstring tendons where they attach to the ischial tuberosity. There is also an ischial bursa that cushions this region that can become chronically inflamed. It is a common problem for distance runners and athletes involved in sprinting, hurdles, or cutting . Typical signs and symptoms include a deep, local pain in the buttocks/upper hamstring region that worsens with running, squatting, lunging and sitting.

Differential diagnoses include:

  • Sciatic nerve irritation (may be a co-morbidity in some cases)
  • Ischiofemoral impingement
  • Apophysitis or avulsion in adolescents
  • Deep gluteal muscle tear
  • Stress fracture (posterior pubic bone or ischial ramus)
  • Partial or complete rupture

Proximal hamstring tendinopathy is rarely painful during activities that do not involve elastic energy transfer or compression, such as walking on even ground, standing or lying down. Tears are typically accompanied by extreme hip flexion and knee extension during an acute injury (usually hear an audible pop).  In some cases, chronic pain may also be accompanied by an exaggerated pain response, referred to as central sensitization where the central nervous system conveys an amplified neural signal resulting in pain hypersensitivity.


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