Tag Archives: graston technique

Back Pain and Sciatica – Part 2

Last month I posted a case study showing how we treat back pain and associated ‘sciatica’ like symptoms here at Elite Physical Therapy in Traverse City.  You can find that article here:  http://www.elitepttc.com/back-pain-and-sciatica-physical-therapy-treatments/

This month’s case study is a little different in that the presentation and location of the pain were quite different but it still comes down to playing detective to determine where the patient’s symptoms are really coming from.  Before we get started here, I’m re-posting the picture of the dermatomes of the body (basically the sensory distribution of the nerves from the spine) so be sure to check that out.  Pretty cool how we were created for sure!Dermatomes

Case Study #2

The patient in this case presented to our clinic with pain shooting into the front of his hip and groin as well as down the front and side of his thigh.  He also reported minor back pain but it was nothing compared to the pain in his leg.  The patient reported having this pain on and off over the past couple years especially when exercising but recently it was much more constant and severe.  In the past he had been diagnosed with IT Band syndrome (pain laterally in the hip and thigh might make you think that), and more recently with a hip flexor strain (could also make sense now that he was having more pain into the front of the hip and groin).

Exam

  • minimal tenderness to the ‘hip flexor’ muscles anteriorly, slight weakness with manual muscle testing but no pain (probably not a hip flexor strain).
  • moderate tenderness and active trigger points in the lateral hip musculature that referred pain down the lateral thigh to the knee (could be part of IT Band syndrome).
  • springing of the lumbar vertebrae at L2 and L3 reproduced the typical symptoms  he felt into his anterior hip/groin as well as lateral thigh (Bingo!)

Treatment

Dry needling was performed at the levels of L2 and L3 along with electric stimulation for 10 minutes, and followed up with Graston Technique (GT) to decrease tone and improve mobility of the superficial fascia and muscles of the mid and lower back.

A couple exercises were given to maintain, and hopefully even improve, the mobility gained through the spine and hips as a result of the dry needling and GT.

Results

The patient reported a significant decrease in the anterior hip and groin symptoms as well as a moderate improvement in lateral hip and thigh symptoms.

During the second treatment session I decided to treat the muscles of the lateral hip as well since they also referred pain into the lateral thigh.  This was done with by dry needling + e-stim just like we had done in the low back.

By the third treatment session a few days later the patient was reporting a significant reduction in lateral hip and thigh symptoms as well.

Final Thoughts

It took a few more treatments to completely resolve this patient’s symptoms but it’s nice to see an immediate decrease in symptoms to know that you are treating the right areas.  With a thorough evaluation process it wasn’t hard to figure out that the patient’s symptoms were primarily coming from his spine which was quite a different diagnosis than what was previously thought.

A little detective work plus effective treatment tools like dry needling and Graston Technique can make a huge difference in patient outcomes especially in these ‘sciatica’ cases.  If you have similar types of symptoms or pain that just doesn’t ever seem to get better then give us a call!  If you have any questions feel free to email me:  joe@elitepttc.com

Dry Needling for Hip and Knee Pain

At Elite Physical Therapy and Sports Performance we strive to find new and innovative ways to treat pain and get you moving again.  Dry needling has been one on my go-to treatments for the past 3 years now, and the method I’m going to show you today works wonders for hip and knee pain.

The Vastus Lateralis (VL) is one of the four muscles that make up your quadricep and is the most lateral.  Trigger points in this muscle will often refer pain to the lateral knee.  Check out the photo below of the VL and corresponding trigger point referral patterns.

Vastus Lateralis Trigger Points

Even without active trigger points, the VL is often in a state of high tone which can significantly limit hip mobility in certain directions.  With it’s attachment all along the IT band, it can also create greater stress on the knee joint through that IT band.

In the video you’ll see the limitations in our patients hip adduction (her knee should hit the table when I try to lower the leg across midline).  Her right hip does this easily.  This is a fairly standard PT test, known as the Ober test in most circles.  In the video you’ll see how dramatically dry needling the Vastus Lateralis with a few minutes of muscle stimulation can change her hip mobility.

Just a quick note on the video.  This was originally created for my SportsRehabExpert.com website which is read by other PT’s, Athletic Trainers, Chiropractors, etc.  Sorry for all the medical talk but you’ll get the idea with the huge change in range of motion following the dry needling treatment.

Here are some of the common diagnoses you’ll hear from your doctor that will respond well to dry needling:

  • IT Band Syndrome
  • Runner’s Knee (distal IT band syndrome)
  • Patello-Femoral Pain Syndrome/Patellar Mal-Tracking
  • Hip Bursitis

There are many other ‘diagnoses’ that can benefit from improved hip mobility but those above are what we would see most frequently.  For those that are needle-phobic, we can get similar results using Graston Technique and other manual therapy techniques, it’s just often not quite as dramatic.

There are also a number of specialized motor control and strengthening exercises that need to be used following this treatment to maintain this new mobility.  Just because she can move her hip now on the table doesn’t necessarily mean its going to move that well when she is standing, walking, or running.  Strength must also be established in that new range.

Hope that was helpful to see plus you get a bit of a glimpse at what we do here at Elite Physical Therapy and Sports Performance.

Big thanks to our Athletic Trainer, Lydia Case, for being our ‘patient’!

Trigger Points and Shoulder Pain – Part II

originally posted on SportsRehabExpert.com

Joe Heiler PT

Shoulder pain is such a common diagnosis that we’ll see here at Elite Physical Therapy, and there are a number of structures that can be pain generators to the shoulder and arm. Last month I talked about trigger points in the posterior rotator cuff (Infraspinatous and Teres Minor) along with their common referral patterns. Another common shoulder muscle to find active trigger points is the supraspinatous. Active trigger points in this muscles can refer pain to the deltoid and down the lateral aspect of the arm.

Check out the typical trigger points and referral patterns below:

Supraspinatous Trigger Point Referral

Check out the video below for a demonstration of dry needling to the supraspinatous:

Case study:

Feel free to check out this case study but it was originally written for physical therapists and chiropractors. Ultimately the point is that a combination of dry needling and soft tissue mobilization, in addition to corrective exercises, can significantly decrease pain while improving range of motion and movement.

Current patient of mine presents with lateral arm pain of 3 months duration. No known cause of injury but diagnosed with tricep injury/tear.

Pre-Treatment

SFMA dysfunctional non-painful patterns:

  • all cervical patterns (mobility)
  • R shoulder medial rotation extension (mobility) – FN to the L
  • MS rotation R (motor control deficit) – FN to the L.

    SFMA dysfunctional painful patterns:

  • R shoulder lateral rotation flexion
  • MS extension (R UE pain)

    Special tests:

  • Hawkins + on the R
  • Passive shoulder IR 20 deg.

    Palpation:

  • Tenderness with palpation of both trigger point in the supraspinatous with referral of pain down the lateral upper extremity to the wrist (indicates that is the pain he gets into the upper arm)

    Treatment on Day 1 consisted of Functional Dry Needling to the supraspinatous (x2) with electrical stimulation followed by more superficial Graston technique to the R upper trap, supraspinatous, infraspinatous, and teres minor along with light strumming at the supraspinatous insertion. Corrective exercise included 3pt. thoracic rotation (UE positioned in internal rotation – hand behind the back) with manual assist to hold/relax work until pt. was able to control the full available range.

    Post-Treatment

    Functional Non-Painful patterns:

  • R shoulder medial rotation extension
  • MS rotation B

    SFMA dysfunctional non-painful patterns:

  • all cervical patterns (mobility)

    SFMA dysfunctional painful patterns :

  • R shoulder lateral rotation flexion
  • MS extension (R UE pain)

    ***both are still painful although intensity has decreased while motion has increased***

    Special tests:

  • Hawkins + on the R but much less intense
  • Passive shoulder IR 50 deg.
  • Graston Technique – Treating the Painful Shoulder

    Here is the video I promised using Graston Technique to treat soft tissue dysfunction in the posterior shoulder girdle using and in particular the trigger points that can refer pain to the front of the shoulder and down the arm.

    If you haven’t read the previous article discussing why we would want to treat this area, you can check that out here:  http://www.elitepttc.com/blog/trigger-points-and-shoulder-pain/

    If you have any questions concerning Graston Technique, Dry Needling, or shoulder pain please contact us at 231 421-5805 or Joe@elitepttc.com

    Trigger Points and Shoulder Pain

    There are a number of manual therapy techniques we use here at Elite Physical Therapy and Sports Performance, including Graston Technique and Trigger Point Dry Needling, to address muscular pain.  What many people don’t realize is that taut bands of hyperirritable muscle (a.k.a. trigger points) can cause local and referred pain.

    This article is one I wrote for SportsRehabExpert.com awhile back showing how trigger points in the back of the shoulder, specifically the muscles of the posterior rotator cuff, can refer pain to the front of the shoulder and down the arm.

    If you have shoulder pain that has not responded to other types of treatment, then check out this article and please contact us with any questions you may have!

    Manual Therapy Technique of the Week – Treating the Infraspinatous and Teres Minor 

    Joe Heiler PT

    I’ve become much more familiar with trigger point referral patterns and treating these out the past couple years since taking the Kinetacore Functional Dry Needling course.  A couple of the more common trigger points I end up dry needling and/or using Graston Technique to treat in the shoulder are the infraspinatous and teres minor.  Active trigger points in these muscles can refer pain to the anterior and middle shoulder, and on occasion will also refer pain down the arm.

    Check out the typical trigger points and referral patterns below:

    Infraspinatous Trigger Points and Pain Referral Pattern

    Infraspinatous Trigger Points and Pain Referral Pattern

    Teres Minor Trigger Point and Pain Referral Pattern

    Teres Minor Trigger Point and Pain Referral Pattern

     

    Case Study

    Current patient of mine presented with R shoulder and scapular pain of 2 year duration.  MS rotation limited to 50% bilaterally (DP) and R shoulder medial rotation extension (MRE) reach only to L4 (DP).  Palpation of the infraspinatous trigger point (most superior and lateral) referred significant pain to the anterior shoulder and slightly down the lateral arm reproducing her typical pain.  The teres minor trigger point referred pain to the middle deltoid area.

    Post trigger point dry needling of these trigger points the patient’s MS rotation improved to 90% (dysfunctional still but non-painful) and R shoulder MRE to T9 (still DP but much less pain).

    It’s not always this dramatic but this is also not the first time I’ve seen the great results like this.

    I’ll get a video up soon showing how we use Graston Technique to treat the posterior shoulder to reduce this type of pain and improve shoulder function.

    In the meantime feel free to contact us with any questions:  231 421-5805 or Joe@elitepttc.com

    Taping for Plantarfascitis/Foot Pain

    In this blog post I wanted to discuss the benefits of taping, specifically a technique known as ‘low dye’ taping, for relieving foot and heel pain while allowing the soft tissues of the foot time to heal. This is a technique we commonly use here at Elite Physical Therapy.

    Plantarfascitis is the common term for the pain in the arch of the foot or even in the heel.  It’s usually worse during walking or running – activities that really stretch that tissue on the bottom of the foot.

    Our treatment model for plantarfascitis includes:

    • soft tissue work using Graston Technique to the plantarfascia, as well as to the muscles of the foot and calf to promote healing and greater extensibility of the tissues.
    • low dye taping to support the foot in weight bearing and to allow for tissue healing.
    • therapeutic exercise to increase mobility through the foot, ankle, and calf, as well as strengthening for the musculature of the lower leg.
    • corrective exercise to address movement dysfunction or lack of stability further up the chain including the hips and trunk.  The underlying reason for your foot pain is often found here!

    Orthotics can be an important piece to the puzzle here as well, but they are quite expensive and not always a slam dunk to work.  A successful trial of low dye taping along with physical therapy is either going to eliminate the patient’s pain to the point that orthotics are not really necessary, or it’s going to relieve the symptoms enough that I feel more confident recommending orthotics as a more permanent solution.

    Check out the video below to see how we do it here at Elite Physical Therapy.  If you have experienced these types of symptoms and they just won’t resolve, feel free to contact me to see if physical therapy would be an appropriate intervention.

    I also shot a video demonstration of using Graston Technique to treat the foot a few weeks back.  You can find that video here:  http://www.elitepttc.com/blog/?p=415

     

    Graston Technique and Plantarfasciosis

    I can’t believe it’s taken me 3 years to think of this but I decided it would be helpful to shoot an educational video about Graston Technique and how we use it here at Elite Physical Therapy.  More and more doctors in this area are recommending Graston Technique specifically, but often the patient has no idea what it is.  Hopefully this video will help to explain.

    I also show a quick demo of how I would treat plantarfasciosis (the chronic equivalent of the more popular term plantarfascitis).  I’ll be posting more examples of how we use Graston Technique, but for now this is one of the more common areas we treat.

    Graston Technique Interview – Joe Heiler and Ashli Linkhorn

    I recently did an interview on the GT forum along with Ashli Linkhorn (head chiropractor – NCCA Women’s College World Series) in which we discussed the benefits of Graston Technique and how it can be used as part of the rehabilitation process with baseball/softball players.  Some nice info in the interview although I really can’t stand listening to myself on these things.  They will be doing one podcast per month so if you’re interested in GT, or are a practitioner, hopefully there will be some valuable info.

    Graston Technique in the Treatment of Injuries to Baseball Players

    http://www.conferencingexchange.com/GT

    If you have any specific questions about Graston Technique you can email me:  joe@elitepttc.com or head on over to the GT website.

    Explaining Pain

    Pain is something many of us deal with everyday, whether it our own or working with others to help them overcome that pain.  At Elite Physical Therapy, we feel that it is very valuable for our patients to understand how pain works, and how we should deal with pain during the different stages of healing.  Chronic low back pain and neck pain are two very common cases where this new science is having a valuable impact.

    This is a great video by Lorimer Moseley explaining pain and how it is processed by our brains.  Dr. Moseley and Dr. David Butler are definitely changing the way we think about pain in the medical professions.

    https://www.youtube.com/watch?v=gwd-wLdIHjs&feature=player_detailpage

    The take home message is that with chronic pain, the tissues are often completely healed, but the brain still perceives pain.  In this situation, movement and activity are often the best medicine.  You can’t hurt anything so try to do as much as you’re capable of doing without going overboard.  You may just gradually improve your functional abilities while decreasing pain using this approach.

     

    Shoulder Rehab Part II

    In Part I, I discussed how physical therapy of the shoulder using traditional rotator cuff exercises really gets me fired up.  Traditional methods of shoulder rehab often train the muscles of the shoulder in a way that they are not really used in normal everyday function.  If you haven’t caught that article yet, I suggest you read that one first.

    In this article I want to address a couple other pieces of the puzzle:  motor control and regional interdependence.

    There are many cases in which a certain movement may look dysfunctional in a standing position, but may actually be completely functional in other positions where the patient is more unloaded like lying on their back or stomach, side lying, on hands and knees, or even in kneeling.  In these positions there are fewer joints and segments to control and in most of these cases less gravity to deal with.

    Unless the movement pattern is tested in multiple positions, it is not possible to know with any certainty that the movement is limited because of a true mobility issue (think joint restriction or ‘tight’ muscle) or if it is because of a lack of motor control.

    Here is a great example looking at a functional reaching pattern behind the back.  In standing, you should be able to reach up behind your back and touch the bottom of the opposite shoulder blade as in the picture below:

    So this past week I had a patient come in that could only reach to just below her belt line.  She had been given stretches to increase that movement but they really hurt her shoulder to perform.  If you’ve ever had a shoulder problem or therapy after a shoulder surgery then this exercise will look very familiar:

    Shoulder Internal Rotation Stretch

    When I had her lie down on her left side, she could reach all the way up her back and touch the opposite shoulder blade!  So why could she not do it in standing but had no pain and no difficulty lying on her side?

    By going to a more unloaded position in side lying, the other joints of the body are taken out of the equation, and there is much less to have to control.  In this position she could be successful.  This is a great example of poor motor control, not a loss of shoulder range of motion.  So of course the first question she asked me is why did she spend the last 4 weeks in therapy and at home trying to stretch out her shoulder?

    During the evaluation is was also discovered that she had some loss of mobility in her neck.  Because the neck movements were not painful, these were addressed first using cervical manipulation and then I followed that up with some soft tissue work using the Graston Technique through her upper trapezius, levator, and rhomboids.

    C1-2 Thrust Manipulation

    GT to the Upper Trapezius

    Here is where that term – Regional Interdependence – comes into play.  In simple terms, regional interdependence is the interplay between different regions of the body.  In this case its easy to see how limitations in the neck can affect the shoulder since there are a number of muscles that run between the spine and shoulder girdle.  In other cases it could be dysfunction even further down the spine, the pelvis, hip, and beyond that could affect alignment and function at the shoulder.  Without the proper evaluation, it would be nearly impossible to find these relationships.

    Once her cervical mobility was restored, we immediately went to corrective exercises to improve motor control of the neck and shoulder girdle.  These were fairly simple non-painful exercises that allowed her to successfully work through her neck limitations in a more unloaded position (hands and knees in this case).

    Following that first treatment she could reach behind her back and nearly touch her opposite shoulder blade!

    When the patient returned for her next visit, she had maintained her neck mobility and behind the back reach without shoulder pain.  We progressed to kneeling and standing motor control exercises, and by the end of the treatment she could touch her opposite shoulder blade without difficulty.

    Half kneeling chops and lifts are a great way to improve stability and motor control through the spine and hips.

    Needless to say, this patient was quite happy with the results.  Sometimes it is as simple as being in the right place at the right time with your treatment.  We’ll see how the rest of her treatment goes but for now we’ve knocked out a major limitation in her shoulder function without directly targeting her sore shoulder.

    Part III coming soon

    If you have any questions, feel free to contact me:  joe@elitepttc.com