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Bluegrass Doctors of

Physical Therapy, PLLC



What we do in the spine and extremities affects our brain.

Posted on July 7, 2016 at 9:35 AM

Manipulation of Dysfunctional Spinal Joints Affects Sensorimotor Integration in the Prefrontal Cortex: A Brain Source Localization Study


Above is a title of a new article looking at what happens we apply joint manipulation in the spine, on the brain. Amazing. Again, this is yet another article that shows interventions that are applied to the spine and extremitieis affect our BRAIN. This in time could induce neuroplastic changes. Good stuff! 

Wellness Programs

Posted on June 29, 2016 at 11:10 AM

Employee Satisfaction Linked to Wellness Programs

The prevalence of wellness programs in today’s work environment was examined in the 2012 Aflac WorkForces Report, an online survey of more than 1,800 benefits decision-makers and more than 6,100 U.S. workers. The study included findings about the impact of wellness programs on employee satisfaction, well-being and productivity. Compared to workers who are not offered wellness programs, employees who are offered wellness programs and participate in them are more likely to have a higher level of job satisfaction, feel happier with their employer, and be more satisfied with their overall benefits.  

The bottom line is that companies can help increase employee satisfaction by focusing on the well-being of their workforce. For example, 28 percent of workers said they would feel more satisfied and more loyal to their employer if their company offered more options to improve their health and lifestyle. Workers also recognize the fact that they need to take an active role in workplace wellness. Thirty-five percent of employees were willing to change their lifestyle habits if it meant they could lower their health insurance premiums.


Financial Benefits of Implementing Wellness Programs

While companies certainly care about the well-being of their employees, benefits decision-makers admit that a primary reason their company maintains a wellness program is to help curb health care costs, and 59 percent of companies agree that wellness programs can help reduce these costs.


Despite the benefits of wellness program, nearly a quarter (22 percent) of companies do not offer them for their workforce due to the difficulty in quantifying the return-on-investment (ROI). However, a comprehensive analysis of 42 published studies of worksite health promotion programs showed that companies that implemented an effective wellness program realized significant cost reductions and financial gains, including:


· An average of 28 percent reduction in sick days

· An average of 26 percent reduction in health costs

· An average of 30 percent reduction in workers’ compensation and disability management claims

· An average $5.93 to $1 savings-to-cost ratio.


The 2012 Aflac WorkForces Report found similar results. Nearly all (92 percent) of the companies with a wellness program in place agreed that these programs are effective, and 47 percent reported the programs are very or extremely effective. In addition, 44 percent of employers agree they are able to offer lower health insurance premiums as a result of their wellness program, and six in 10 (61 percent) agree they have a healthier workforce as a result of having a wellness program in place.


Recognizing the Role Financial Stress Plays in Overall Health

Creating a healthy workforce requires more than physical health. Financial security is another factor that influences overall wellness. Many American workers today are facing financial predicaments and high debt as a result of the current economy and a lack of education about financial principles. These situations can lead workers to enormous amounts of stress which in turn can lessen overall wellness.


For instance, only eight percent of workers strongly agree that their family will be financially prepared in the event of an unexpected emergency, while 51 percent are trying to reduce debt. Nearly six in 10 workers (58 percent) don’t have a financial plan in place to handle the unexpected, and the same amount either don’t consider health insurance a part of their financial plan or consider it a minor part. Clearly, many Americans are in a difficult financial position and that often means turning to their employer for help.


Workers facing debt and unstable financial situations reported their stress has caused occurrences of ulcers, digestive problems, migraines, anxiety and depression. Results even showed heart attacks occurred at rates between two and three times the national average for these overstressed workers.


As a result, employers are also feeling the effects of their employees’ anxiety, beyond higher health care costs. One in five (20 percent) workers have experienced a health issue that has affected their ability to get their work done, which can result in higher productivity losses for companies. Additionally, nearly half of companies (43 percent) surveyed estimated their average productivity loss stemming from employees’ concern over personal issues is between 11 and 30 percent, and productivity losses related to personal and family health problems cost U.S. employers $1,685 per employee, per year, or $225.8 billion annually.


These statistics show the negative impact companies face if their workers are not adequately protected by their current benefits coverage. Voluntary benefits options are beneficial because they allow businesses to add coverage options at no direct cost to their company and, at the same time, help protect workers.

By making voluntary plans available to workers, companies can help alleviate financial concern and help employees feel more protected in case of an unexpected health event. Workers have more positive feelings about their benefits options when they are offered or enrolled in voluntary plans. For instance, 70 percent of employees whose benefit packages include voluntary options feel that a comprehensive benefits package safeguards their health and wellness

How all your medical professionals get paid.

Posted on May 15, 2016 at 7:10 PM

Great post about our system in general. This is exactly why my employers are MY PATIENTS and I will continue to achieve greater results for THEM. 

Thanks to all my patients!!!!

Dr. B. 

Imagine going to your favorite restaurant. You are greeted at the door by the hostess, who seats you and takes your drink order. You order through your favorite waiter, Andrew, who recommends the special of the day: prime rib with a dinner salad and a chocolate torte for dessert. Soon after, the food is brought out and it is delicious! You have time to enjoy your food. You then receive the bill and pay for your meal, returning to your home satisfied, all your dining needs met. Let’s say, for simplicity's sake, you paid $75 for this meal: $50 for the steak, $10 for the salad and $15 for the dessert.


A change then occurs in the restaurant industry. A new form of eating out has been adopted. Your favorite restaurant has now contracted with over 30 ”different restaurant insurance companies.”


Anticipating another pleasant dining experience, your return to the restaurant with your new “subscribers card.” You pay your $5 “copay.” You sit in the foyer of the restaurant. You wait an hour, even though you made reservations. A harried Andrew greets you and quickly takes your order after you briefly glance at the menu. The food arrives at your table. As you take your second bite, Andrew informs you that “your time is up” and the table is reserved for another party. You are escorted outside with your hastily boxed left-overs.


What has happened to the restaurant? Behind the scenes, the restaurant owner has learned some tough realities of the “new system.” During the first month of taking insurance, the owner sends a form to the insurance company requesting payment for the $75 steak dinner: $50 for the steak, $10 for the salad and $15 for the torte. The contract with the insurance company already states that they will only pay $45 for the $50 steak, but the owner decides that the extra customers brought to the restaurant by contracting with this insurance company will more than off-set this small loss.


The first attempt at collecting the $75 dollars for the full meal is returned unpaid with the note that it was rejected due to a “coding error.” The forms for payment from the insurance company require the owner to list the parts of the meal, not by name, but by the numerical codes. The owner had listed the salad by the wrong numerical code. No suggestions for the correct code are offered, so the restaurant owner purchases a series of books, at a cost of $500, to learn how to assign the correct code to the different parts of the meals. These books will need to be bought annually due to the constant changing of the code numbers. After 30 minutes of study, the owner realizes the dinner salad should be coded as a 723.13, not the723.1 the owner originally put on the form. The salad, it turns out, needed to have two digits after the decimal point, indicating that it was a dinner salad, and not a “main course” salad. The owner mails the corrected form.


In response to the second request for payment, the insurance company does not send a check, but a detailed questionnaire: Was garlic used in seasoning the steak? Was it necessary to use garlic for this particular recipe? Did the restaurant ask for permission to use garlic from the insurance company before serving the steak? Why was salt, a less expensive alternative, not used instead? The owner submits the answers, emphasizing that the garlic is part of a secret family recipe that made the restaurant famous.


The owner waits another week (it has now been 3 weeks since the dinner was served). The check arrives three and a half weeks after the meal was served. The check is for $20 and states that it is specifically for the steak. The check also comes with a letter stating that no billing of the patron may occur for the salad, but no other explanation is enclosed. No mention is made of the $15 dessert.


The now frustrated restaurant owner calls the provider service number listed in the contract. After five separate phone calls to five different numbers (The harried voice behind phone call number four explains that the insurance company has merged with another insurance company and the phone numbers had all changed last week, sorry for the inconvenience…), the owner gets to ask why, when the contract says the steak will be paid at $45, has the check only been written for $20? And what happened to the payment for the $10 salad and the $15 dessert?


As it turns out, this particular patron’s insurance contract only pays $45 when the patron has reached their deductible, which this patron has not at this time. The remaining portion of payment for the steak must now be billed by the restaurant to the patron directly.


The $10 for the salad would have been paid if the patron had ordered it on a different day, but, per page 35 in the contract, because it was billed on the same day as the steak, it is considered to be part of the payment for the steak and no extra money can be collected from the patron or the insurance company.


The dessert, the owner learns, should have had a “modifier” number put with its particular billing code when billed with the steak and the salad.


Realizing that the insurance billing is quite a bit harder than anticipated, the restaurant owner hires a company, who is paid 5% of any money collected to specifically make sure these coding errors do not occur again and follow up on payment rejections. For an additional $99 per month, the billing company will “scrub” the forms submitted for payment to make sure specific clerical errors will not cause future delays in payment.


The owner now must lay off the hostess and the bus boy to pay the billing company, so these duties are now added to the waiter’s other responsibilities.


In the meantime, the restaurant owner has also had the waiter take on the job of answering the phones due to the now high volume of phone calls from patrons questioning why they are receiving bills for meals they ate over two months ago, and why did their insurance company not pay for this portion of the meal? This extra work is now resulting in longer times patrons must wait to be seated, and grumblings from the waiters who “were not hired or trained to do this kind of work.”



The owner now realizes that, although the dinner originally cost $75 to make, only $25 has been paid. The remaining $30 billed to the patron is now in its third mailing, with the first two requests for payment going unanswered by the patron. The restaurant owner realizes a collection agency must be employed in order to have any hope of receiving any portion of payment from the patron.


Each meal served now costs at least an additional $20 due to the added overhead of the billing company, coding books, and the collection agency. These added expenses have nothing to do with cooking food or providing any direct service to the restaurant’s customers.


Service to the restaurant’s patrons has been compromised with these changes as well. The owner has now over-extended the waiter, who was an excellent waiter, but is now taking on the roles of host, phone answering and table bussing.


In order to even meet the costs of providing fine dining, the restaurant owner now must seat twice as many patrons in the same amount of time.


What was once an outstanding business that focused on fine dining and customer service has now been turned into a business in the business of trying to get paid.


Alas, I wish this were a fictional tale, but it is not. The only fictional portion is that this is not your favorite restaurant, but your favorite doctor’s office, which is responsible not for meeting your dining needs, but those of your health.

Summer is approaching!!!!

Posted on May 2, 2016 at 5:45 PM

With Summer around the corner, many people are taking up tennis, and even the relatively newer sport of pickleball. 

Here are a few common ailments that can sneak up on you if you dont keep things in check!!



1) The Infamous Tennis Elbow

What is it? Tennis Elbow is a condition where the outer forearm muscles become inflamed or have small tears which causes pain on the outer part of the elbow.

What are the symptoms? Pain and tenderness on the outside of the elbow, which may travel down towards your wrist. Pain when bending or lifting your arm, gripping your racket or twisting your forearm. Pain and stiffness when fully extending the elbow.

Why does tennis cause it? Players tend to overload the forearm muscles, particularly when new to the sport. Additional causes include a faulty backhand technique and a tendency to swing from the elbow, leading the racket.

How can you avoid it?

Check the string tension of your racket and reduce this if necessary, as less tension means less impact on your forearm muscles.

Talk to us about specific exercises to avoid having this sometimes complicated injruy. 

2) Tennis Shoulder (SAY WHHHAA???)

What is it? There are 4 rotator cuff muscles in the shoulder which help aid shoulder movement in all directions. Tennis shoulder (also known as rotator cuff tendinitis) occurs when the tendons of these muscles become inflamed and irritated.

Why does tennis cause it? Tennis shoulder is caused by the tremendous repetitive forces which occur when hitting the ball. Over time, this damages and inflames the tendons, causing tendinitis.

What are the symptoms? Weak shoulder movements, pain when putting your arm behind your back, pain when raising and lowering your arm, clicking or flicking sensation when raising your arm, swelling at front of your shoulder, stiff and restricted shoulder movement.

How can you avoid it?

Work on strengthening your shoulder muscles so they can cope with the repeated motion of swinging the racket to the ball.

Stretch your shoulders thoroughly before playing, Tight muscles restrict movement and are more likely to inflame due to friction.

If you need specifics please give us a call. 

3) Wrist Strain

What is it? A wrist strain occurs when the tendons of your wrist muscles become damaged.

What are the symptoms? Pain around the wrist, swelling and perhaps bruising in the area, spasms in your wrist muscles, some loss of movement and flexibility in the wrist.

Why does tennis cause it? A wrist strain is caused when tendons in the area are over stretched in a forceful nature. In tennis players often go to strike the ball with the racket and misses, they yank their wrist which damages the tendons. It can also be caused during return shots, when the ball travels with force and causes both your racket and wrist to bend backwards.

How can you avoid it?

Make sure your racket is the correct weight with the correct handle size to suit your individual grip and swing, and use the “hand shake grip” with the arm in an L shape position.

It’s also a good idea to invest in wrist supports and shoes with strong grip, to prevent unnecessary injuries when tripping over.

4) Lower Back Pain

What is it? Lower back pain is a very common tennis ailment and the pain can come in all different forms, from sharp sudden pains to dull and long lasting aches.

What are the symptoms? Sudden, sharp persistent pain that may be worse after prolonged standing, sitting or running, muscle spasms in the area, pain that radiates down to your glutes and even hamstrings.

Why does tennis cause it? During service strokes, players exaggerate the arch in their back to increase power, which puts pressure on the tissues and joints of the spine. Overuse is a frequent cause, due to repeatedly rotating, flexing and extending the spine when serving.

How can you avoid it?

Wear shoes with plenty of cushioning to help absorb the impact caused by running around the court when playing tennis.

Strengthen your abdominal and lower back muscles so they are as prepared as possible, also remembering to stretch your lower back and hamstrings thoroughly.

Lower back mobility exercises are also important, so rotate from side to side before a match.

5) Ankle Sprains

What is it? An ankle sprain, also known as a twisted ankle, occurs when the ligaments within the ankle become overstretched and damage.

What are the symptoms? Swelling, bruising, tenderness, pain in the area, stiffness and trouble weight bearing.

Why does tennis cause it? The most common cause of an ankle sprain in tennis is twisting, rolling over on the ankle or landing on the outside part of the ankle. Most injuries occur towards the end of the match when the player is tired and less alert.

How can you avoid it?

Ensure your shoes are supportive and consider wearing an ankle support. It’s worth taping your ankle if you’ve sprained it before, to help avoid a repeat injury.

Focus on conditioning and stamina when working out off the court, so that you don’t get tired towards the end of matches.

Use balance and coordination exercises to improve the proprioception of the ankles. One legged exercises and wobble board programs are ideal for this. Don't forget those glute strengthening exercises!!!!!!

Remember, have a great safe and FUN summer!!!!

Simple preparation can also help, so remove all balls from the court to avoid tripping hazards!

Direct Care Lowers Health Costs

Posted on March 25, 2016 at 7:40 PM

Direct Physical Therapy Access Could Reduce Healthcare Costs



A policy brief from the Health Care Cost Institute reports that Individuals with lower back pain who received physical therapy had reduced healthcare costs.

When it comes to healthcare costs, the federal government, medical providers, and payers are attempting to reduce rising spending and adopt value-based care reimbursement.  A number of different strategies have been implemented including bundled payment models and accountable care organizations. In the realm of physical therapy, patients with lower back pain could benefit from reduced healthcare costs.


A policy brief from the Health Care Cost Institute reports that Individuals with lower back pain who received physical therapy had reduced healthcare costs when compared to patients who visited with another provider first. Patients who visited a physical therapist at the beginning of their treatment were less likely to end up in an emergency room. A lower likelihood of emergency department visits also produces hospitalization costs.


Since low back pain is a very common occurrence in the healthcare setting and a likely contribution to disability, these findings are key to reducing medical spending across the industry. In fact, $90.6 billion in direct healthcare costs are spent on treating back pain throughout the United States.

The study authors focused on analyzing beneficiary claims data from six states including Oregon, Washington, Wyoming, Alaska, Idaho, and Montana. The researchers  looked at claims data  showing three different groups of people including those who never saw a physical therapist, those who saw a physical therapist later in their treatment, and those who immediately received physical therapy.


The study found that patients who saw a physical therapist first were also less likely to be prescribed a painkiller when compared to others who saw a different type of clinician. The policy brief emphasizes that visiting with a physical therapist first will reduce the use of costly healthcare services and thereby cut spending across the board.

Researchers from the University of Washington and the George Washington University also found that taking away state restrictions on physical therapy could improve health outcomes among those on opioid prescriptions as well as enhance imaging. Individual states should consider addressing restrictions on direct physical therapy access, according to the policy brief.

State restrictions on physical therapy access could affect overall healthcare costs by impacting the use of differing medical services. Essentially, in order to reduce healthcare costs, state policymakers should allow patients direct access to physical therapy without physician referral, according to the study.

“The findings from this study suggest that seeing a physical therapist as the first point of care compared to seeing a physical therapist at a later point in time (or not seeing a PT) reduces utilization of potentially costly services,” the study from the Health Care Cost Institute stated.

“Of particular interest was the significant decrease in opioid prescription, ED visits, and imaging for those patients receiving PT first. The potential reduction in opioid prescriptions is notable given the increasing awareness on the overprescription of opioids and the high risk of substance abuse. These findings suggest that having access to PT could have an impact on healthcare costs including out-of-pocket costs across all settings.”

While reducing healthcare costs is an imperative within the medical industry, quality care and patient needs come first. However, a study from the American Physical Therapy Association shows that patient needs may not come first in a referral-for-profit environment.

The study illustrates that patients who obtained physical therapy services from a clinic owned by their original physician received twice as many PT visits as compared to patients who were referred to physical therapy not affiliated with the referring surgeon. The therapy was also less customized and less intensive, the researchers found.

“When there is referral-for-profit, and from this data as related to group therapy and an extended number of visits, it stands to reason there is increased risk that the patient’s individual needs are of secondary importance to revenue. This has long been the concern here at the American Physical Therapy Association (APTA) and it is why we have fought so hard, alongside our partners in the AIM Coalition, against physician-owned physical therapy services (POPTS),” American Physical Therapy Association President Sharon Dunn, PT, PhD, OCS, stated in a press release.

“This study provides further evidence that when the bottom line takes precedence in healthcare, the patient loses. A patient’s welfare and recovery should always be the primary focus of treatment.”

The researchers looked at more than 3,000 patients who underwent total knee replacement surgery. Out of all of these, nearly 19 percent were found to be completed through a physician self-referral process while 72.3 percent of cases did not have a doctor who had “ownership interest in physical therapy services.”

The findings show that treatment in a physician-owned physical therapy setting lasted a week longer than services not affiliated with the referring physician. About twice as many visits were seen in physical therapy offices in which the referring doctor had a financial stake.

The issue seems to be that, in physician self-referral cases, patients were more likely to receive group therapy instead of individual, one-on-one care, which tends to extend the amount of visits needed to complete treatment.

This type of physician self-referral practice may improve revenue for an individual physical therapy clinic, but it only increases overall healthcare spending and negatively impacts patient care, the researchers wrote. In order to meet the Triple Aim of Healthcare, providers will need to look beyond their own revenue cycle and consider patient needs first.

When to Choose PT over Opioids

Posted on March 25, 2016 at 7:30 PM

Physical Therapy vs Opioids: When to Choose Physical Therapy for Pain Management



According to the Centers for Disease Control and Prevention (CDC), sales of prescription opioids have quadrupled in the United States, even though "there has not been an overall change in the amount of pain that Americans report."


In response to a growing opioid epidemic, the CDC released opioid prescription guidelines in March 2016. The guidelines recognize that prescription opioids are appropriate in certain cases, including cancer treatment, palliative care, and end-of-life care, and also in certain acute care situations, if properly dosed.


But for other pain management, the CDC recommends nonopioid approaches including physical therapy.


Patients should choose physical therapy when ...


... Patients are concerned about the risks of opioid use.

"Given the substantial evidence gaps on opioids, uncertain benefits of long-term use, and potential for serious harms, patient education and discussion before starting opioid therapy are critical so that patient preferences and values can be understood and used to inform clinical decisions," the CDC states. Physical therapists can play a valuable role in the patient education process, including setting realistic expectations for recovery with or without opioids. As the CDC guidelines note, even in cases when evidence on the long-term benefits of nonopioid therapies is limited, "risks are much lower" with nonopioid treatment plans.

... Pain or function problems are related to low back pain, hip or knee osteoarthritis, or fibromyalgia.

The CDC cited "high-quality evidence" supporting exercise as part of a physical therapy treatment plan for those familiar conditions.

... Opioids are prescribed for pain.

Even in situations when opioids are prescribed, the CDC recommends that patients should receive "the lowest effective dosage," and opioids "should be combined" with nonopioid therapies, such as physical therapy.

... Pain lasts 90 days.

At this point, the pain is considered "chronic," and the risks for continued opioid use increase. An estimated 116 million Americans have chronic pain each year. The CDC guidelines note that nonopioid therapies are "preferred" for chronic pain and that "clinicians should consider opioid therapy only if expected benefits for both pain and function are anticipated to outweigh risks to the patient."

Before you agree to a prescription for opioids, consult with a physical therapist to discuss options for nonopioid treatment.




Posted on February 23, 2016 at 11:40 AM

For any years we have thought anatomy as a completed science. Aparrently NOT! Researchers have found a new muscle! 


Introducing The Tensor Vastus Intermedius!

Introducing a new muscle almost as elusive as the legendary Bigfoot. In 2014 it was the anterolateral ligament this year it is the tensor vastus intermedius I wonder what will come next!


This is a New Muscle.

A research paper release in the Journal Clinical Anatomy details a newly described muscle as part of the quadriceps. This muscle lies between the vastus lateralis and the vastus intermedius, and is named the tensor vastus intermedius.


Found on All 26 Bodies

Researchers were able to identify this muscles on all 26 of the cadavers in the study; it was also determined that the tensor vastus intermedius is supplied by independent muscular and vascular branches of the femoral nerve and lateral circumflex femoral artery.


What are the Implications?

As an anatomy nerd this new scientific discovery caught my eye. Even though the implications for therapists will likely be minimal due to the relative size of the muscle. This new discovery serves as a reminder that our knowledge of the human form and function is constantly evolving.

Truth behind PT

Posted on January 28, 2016 at 10:05 AM

Common Misconceptions about Physical Therapy


You Can Choose! It is a common misconception that you have to go where your doctor refers you. In Kentucky you do not have to obtain a referral to see a Physical Therapist, but there are some insurance plans that require you to have such. However, you are still able to go to a facility of your choice. Bluegrass Doctors of Physical Therapy receives the majority of our patient referrals from Friends & Family spreading the word. Not all physicians refer based on where they think you will get the best care, there may be other reasons for why they send you to a certain clinic. Take the time to do your research. We have many local community physicians that refer to us as well our past & current patients. If we are not the best clinic to receive treatment from for your condition we will be sure to refer you to a specialty clinic that is. Now that's real care!


Hospitals cost you more! Often times physicians will refer a patient to a hospital or physician owned therapy practice. What they don't tell you is that this often cost the patient more. Hospitals and physician owned practices often have higher negotiated rates with insurance companies than private practices typical do, and that means the higher the rate the more you pay.


In-Network Providers are not always best! Most insurance companies require providers to drastically reduce their rates in order to join the insurance companies network or be considered an In-Network provider. Lowering fees means that the providers have to find creative ways to keep quality up but at the same time keep treatments affordable for the business which can be difficult. We currently have patients who have most major insurances but refuse to allow those insurance companies to dictate the care our patients receive. so if it will not financially allow us to provide our patients with the best care we can offer. Our patients getting well is our number one priority and we will do all we can to continue to offer that care while remaining affordable.


Don't Just Trust Your Body To Anyone, or Your Recovery!


Not all Providers are the same. In fact many professionals that are not even licensed in physical therapy say they offer physical therapy services. These providers usually will just offer exercises without even looking at what may be CAUSING your pain or condition. Physical Therapists are specialist in movement and the neuro-musculoskeletal system, meaning they are experts in how all of the components of your nerves, muscles and bones interact with each other and how they may cause dysfunction and pain. This is why it can be very disadvantageous to receive services from someone that does not specialize in physical therapy or from a physical therapist that does not specialize in your specific condition. With many surgical repairs there is a small window of opportunity for optimal recovery and if you are not receiving top notch care during that time frame it can negatively affect the recovery permanently. Some important questions to ask when choosing a therapist would be:


1.) What type of patients or cases do you see most?


2.) Am I going to receive one-on-one care?


3.) Are you familiar with my condition and symptoms?


Don't let your provider eat up your visits!


Depending on your rehabilitation needs some episodes will take just a few visits to recover while others will require an extended amount. However, there is typically a norm for how many visits it will take to recover. If you feel that you are not seeing much improvement it never hurts to obtain a second opinion. Often times, people wait until all of their yearly visits have been used up or they have utilized all of their funds before they realize the provider they were seeing may not have been the best provider for that particular case.


At Bluegrass Doctors of Physical Therapy our mission is to provide you with excellent care and fast results. We recognize everyone is different and that is why on your first visit we will perform a thorough evaluation with you to find out what is causing your specific issue and design an unique treatment plan based off of your specific needs and goals for your therapy. And as always treatment starts DAY ONE!


Kind Regards,



Needling and Patellar Tendinosis

Posted on January 22, 2016 at 12:40 AM

Great Article on Needling with patellar tendinosis. 

ORIGINAL ARTICLE Ultrasound guided dry needling and autologous blood injection for patellar tendinosis Steven L J James, Kaline Ali, Chris Pocock, Claire Robertson, Joy Walter, Jonathan Bell, David Connell ................................................................................................................................... See end of article for authors’ affiliations ........................ Correspondence to: David Connell, The Royal National Orthopaedic Hospital, Stanmore, Middlesex HA7 4LP, UK; [email protected] Accepted 21 February 2007 Published Online First 26 March 2007 ........................ Br J Sports Med 2007;41:518–522. doi: 10.1136/bjsm.2006.034686 Objective: To evaluate the efficacy of ultrasound guided dry needling and autologous blood injection for the treatment of patellar tendinosis. Design: Prospective cohort study. Setting: Hospital/clinic based. Patients: 47 knees in 44 patients (40 men, 7 women, mean age 34.5 years, age range 17 to 54 years) with refractory tendinosis underwent sonographic examination of the patellar tendon following referral with a clinical diagnosis of patellar tendinosis (mean symptom duration 12.9 months). Interventions: Ultrasound guided dry needling and injection of autologous blood into the site of patellar tendinosis was performed on two occasions four weeks apart. Main outcome measures: Pre- and post-procedure Victorian Institute of Sport Assessment scores (VISA) were collected to assess patient response to treatment. Follow up ultrasound examination was done in 21 patients (22 knees). Results: Therapeutic intervention led to a significant improvement in VISA score: mean pre-procedure score = 39.8 (range 8 to 72) v mean post procedure score = 74.3 (range 29 to 100), p,0.001; mean follow up 14.8 months (range 6 to 22 months). Patients were able to return to their sporting interests. Follow up sonographic assessment showed a reduction in overall tendon thickness and in the size of the area of tendinosis (hypoechoic/anechoic areas within the proximal patellar tendon). A reduction was identified in interstitial tears within the tendon substance. Neovascularity did not reduce significantly or even increased. Conclusions: Dry needling and autologous blood injection under ultrasound guidance shows promise as a treatment for patients with patellar tendinosis. Patellar tendinosis or jumper’s knee refers to a clinical syndrome characterised by anterior knee pain and tender- ness at the inferior pole of the patella. It is recognised that this represents a phenomenon of myxoid degeneration and tearing of collagen fibres rather than being secondary to inflammation.1–3 This condition often causes morbidity in sport and may be refractory to treatment. Various techniques have been adopted for the treatment of patellar tendinosis, including physiotherapy,4 sclerosant injection,5 steroid injection,6 extra- corporeal shock wave therapy,7 and surgical decompression with resection of the affected tendon and open stimulation techniques.7–9 Autologous blood injection has been evaluated as a treatment for lateral epicondylitis in humans,10 11 and in vitro studies have been carried out in rabbit patellar tendons.12 Our aim in the current study was to assess the efficacy of ultrasound guided dry needling and injection of autologous blood into the patellar tendon as a treatment for proximal patellar tendinosis. Following treatment, the patient adopts a standardised physiotherapy protocol to aid rehabilitation before re-starting full sporting activity. METHODS Patients Forty seven knees in 44 consecutive patients were included in the study, which involved sonographic assessment of the patellar tendon and autologous blood injection. Informed consent of the patients and institutional review board approval were obtained before recruitment. There were 40 men and seven women (mean age 34.5 years, range 17 to 54 years) with 22 left and 25 right knees treated. The mean duration of symptoms was 12.9 months (range 1 to 48 months). Forty patients described sport as a precipitating factor. These included football (17), running (11), tennis (4), rugby (3), boxing (1), triathlon (1), dancing (1), golf (1), and martial arts (1). Only patients with proximal patellar tendinosis were included in the study. Three patients were excluded as ultrasound showed the presence of multiple focal areas of calcification within the proximal tendon. It was felt that this might be an adverse factor in tendon healing. Two patients who had undergone previous surgery for anterior cruciate ligament reconstruction were also excluded. Pre-procedure Victorian Institute of Sport Assessment scores (VISA)13 were obtained in all patients to allow quantification of the symptoms and follow up assessment of the efficacy of treatment. Sonographic technique Sonography of the patellar tendon was carried out with the patient lying supine on an examination couch. The patient was positioned with the knee partially flexed by placing a pillow behind it. During sonography the patellar tendon was therefore under a degree of tension and the wavy configuration that is evident with the knee in full extension was abolished. Patients underwent diagnostic examination and therapeutic interven- tion at several institutions where the senior author practices. Ultrasound machines from two manufacturers were used: Siemens (Acuson) Sequoia (Siemens Medical Solutions, Abbreviation: VISA, Victorian Institute of Sport assessment score

Ultrasound guided needling for patellar tendinosis 519 Longitudinal image of the proximal patellar tendon. Colour Doppler shows marked neovascularity in the hypoechoic segment of the proximal patellar tendon. Mountain View, California, USA) with a 15L8W transducer and a Toshiba 5500. Sonographic image interpretation The patellar tendon was examined in both the transverse and longitudinal planes to confirm the imaging findings. The diagnosis of patellar tendinosis was based on the presence of four characteristic sonographic features. These included tendon size, focal alteration in tendon echotexture, interstitial clefts or tears (fibrillar disruption), and neovascularity (fig 1). All patients included in the study had a hypoechoic tendon with loss of the normal fibrillar architecture in the affected tendon segment. A focal increase in proximal patellar tendon thickness was also universally apparent. Discreet interstitial tears were present in 31 patients (66%), with no intrasubstance tear identified in the remainder. Neovascularity was present in 39 patients (83%) (23 mild, 13 moderate, and three severe). Procedure Three millilitres of autologous blood were obtained from the antecubital fossa. Under aseptic technique and sonographic guidance, 3 ml of 0.5% bupivicaine was infiltrated along the superficial and deep aspects of the patellar tendon at the site of tendinosis. Once the local anaesthetic had been given sufficient time to act, the needle tip was positioned centrally within the site of tendinosis (fig 2). Following this the tendon was ‘‘dry needled’’, passing the needle repeatedly through the abnormal tendon substance for a one minute period. The local anaesthetic syringe was then removed from the needle and the autologous blood filled syringe was attached, followed by slow injection of the blood. If areas of interstitial tears were evident on sonography, these were targeted for injection of the blood. Filling of these clefts can be directly visualised as fluid permeating between the abnormal hypoechoic clefts. Follow up and physiotherapy protocol Following the initial treatment, patients were advised to cease the sporting activities that precipitated their symptoms but to continue their activities of daily living. If they had been undergoing physiotherapy before autologous blood injection this was postponed until the treatment course was completed. A second injection was then scheduled at an interval of four weeks following the initial injection. At this time, a repeat sonographic assessment was undertaken, followed by dry needling and autologous blood injection using the same technique as at the initial visit. After the second injection, the patients were referred for a standardised physiotherapy programme specifically designed for the study. At the outset of treatment all patients are advised that the treatment consists of both injection and physiotherapy, and they should expect a three month healing period before they resume their previous levels of sporting activity. All patients were asked to complete post-procedure VISA scores to allow assessment of the efficacy of the treatment. Twenty one patients (24 knees) were invited back for a repeat ultrasound examination to assess the changes in the patellar tendon following treatment. Statistical analysis Comparison was made between the pre- and post-procedure VISA score. Normality of the difference between the pre- and post-procedural VISA scores was assessed using the Kolmogorov–Smirnov test. The data did not show evidence of non-normality and were analysed using the paired sample t test. All statistical analysis was carried out using SPSS for Windows, version 14.0 (Chicago, Illinois, USA) and probability (p) values ,0.05 were considered significant. RESULTS Clinical outcome The mean (SD) pre-procedural VISA score was 39.8 (16.3), range 8 to 72. It increased significantly to 74.3 (17.5), range 29 to 100, on post-procedure follow up (t = 13.770, df = 43, p,0.001). The mean follow up period was 14.8 months, range 6 to 22. There were three treatment failures among the initial 47 patients. These patients failed to achieve symptomatic improve- ment. At follow up all three had undergone surgical decom- pression and so a follow up VISA score could not be recorded. One of these patients had two autologous blood injections but did not follow the physiotherapy protocol and returned immediately to sporting activity. The further two cases under- went routine injection and physiotherapy as per protocol. Ultrasound outcome Follow up ultrasound examination was undertaken using the same technique, knee position, and machine as in the pre- treatment examination. The ultrasound features that were used to diagnose patellar tendinosis were reassessed for interval change. These included overall tendon thickness, focal altera- tion in tendon echotexture, interstitial clefts or tears (fibrillar disruption), and neovascularity. In all, 21 patients (24 knees) returned for ultrasound follow up examination. In 22 cases, a reduction in proximal tendon thickness was observed, with no difference in the remaining Figure 1 Longitudinal image of the proximal patellar tendon. The needle (arrow) has been inserted into the hypoechoic area before dry needling and autologous blood injection. Figure 2

520 James, Ali, Pocock, et al Longitudinal image of the proximal patellar tendon pre- treatment and 6 months post-treatment in the same patient. The post- treatment image shows near complete resolution of the hypoechoic segment in the proximal patellar tendon. There has been return of the normal echogenic fibrillar pattern in the tendon. There is a tiny residual hypoechoic segment at the insertion. two cases. Furthermore, the size of the focal alteration in tendon echotexture reduced in 22 cases (fig 3), with one case remaining unchanged and one case showing an increase in length of the abnormally hypoechoic segment. In only a single case, however, was the tendon appearance classed as com- pletely normal—that is, a return to the normal fibrillar pattern of the proximal patellar tendon. Two patients had tiny foci of calcification at the previous site of tendinosis (2 mm). Residual interstitial fissures/tears were identified in three cases but had resolved in 14. Neovascularity remained in 23 cases. The degree of neovascularity remained unchanged in nine cases, had lessened in five, and was more florid in nine. DISCUSSION Patellar tendinosis or jumper’s knee is an extremely common knee disorder with an estimated incidence of between 13% and 20% in athletic populations.14–16 Various possible intrinsic aetiologies for this condition have been proposed in athletes, including abnormal patellar tracking,17 limb length discre- pancy,14 and reduced flexibility of the quadriceps and ham- string muscle groups.18 While patellar tendinosis is often diagnosed clinically, magnetic resonance imaging and ultra- sound are now well established.6 19–22 The sonographic features of tendinosis are well described in both the patellar tendon and elsewhere.10 20 23 24 We used four sonographic features for diagnosis and ultrasound follow up. These included tendon size, focal alteration in tendon echotexture, interstitial clefts or tears (fibrillar disruption), and neovascularity. The degree of neovascularity identified in patients with patellar tendinosis is affected by the position of the knee during sonographic assessment. In the extended position, neovascularity appears more florid and when tension is applied on the tendon in flexion, some of the neovascularity is abolished. For the purposes of the study and to ensure continuity, the knee was examined in a consistent position, resting on a pillow. This enabled an assessment to be made on follow up sonography of the degree of neovascularity. When the patient returned at four weeks for the second injection, we often observed that the hypoechoic focus in the proximal patellar tendon had become more echogenic. We postulate that this accumulation of echogenic material relates to the formation of immature scar tissue/granulation tissue, though we have no pathological evidence of this. Furthermore, there were changes in the neovascularity following the autologous blood injection. We anticipated that a decrease in tendon neovascularity would be observed; however, this only occurred in nine patients. An equal number of patients showed an increase in vascularity, which we cannot explain. This occurred despite resolution in symptoms and a return to sporting activity. We assessed the clinical outcome of patients using VISA. This assesses symptomatology, simple function, and the ability to undertake sporting activity, scored out of 100. It has been validated as a clinical method for assessing the severity of a patient’s symptoms in patellar tendinosis and has been shown to be a reliable and reproducible index.13 We were able to demonstrated a significant in improvement in symptoms using our technique. The injection of autologous blood into tendons has been evaluated in studies assessing the in vitro12 and in vivo10 11 effects on tendons. Taylor and co-workers assessed the effects of autologous blood injection on the strength of rabbit patellar tendons and found a significant increase in injected tendon strength when compared with the contralateral normal side.12 Connell and co-workers reported clinical and sonographic improvement in patients treated with autologous blood injections for lateral epicondylitis.10 In our study, the patellar tendon underwent barbotage or ‘‘dry needling’’ before autologous blood injection in all cases included in the study. This technique involves the repeated lancing of the area of abnormal tendon. It is done to stimulate an inflammatory response within the tendon. There is focal disruption of the collagen fibres within the area of tendinosis, so the process of dry needling is done to incite internal haemorrhage. It is then hypothesised that the inflammatory response induces the formation of granulation tissue which strengthens the tendon.11 Although our study design does not allow comment on the mechanism of action of this technique, several workers have postulated possible biological mechanisms that may contribute. Anitua and co-workers investigated the effects of platelet-rich clots on human tendon cells in culture. They found that autologous preparations rich in growth factors induce cell proliferation and promote synthesis of angiogenic factors during the healing process.25 Furthermore, it has been hypothesized that basic fibroblast growth factor and transform- ing growth factor b may act as humoral mediators in the induction of the healing cascade.26 We believe that it is essential that this procedure should be done under ultrasound guidance. Fredberg and co-workers found that the clinical suspicion of tendonitis could be confirmed by ultrasound evaluation in only one third of cases.6 Ultrasound therefore allows confirmation of the diagnosis and provides an imaging baseline under which the response can be assessed. It allows the area of tendon abnormality to be located precisely and interstitial tears to be identified and targeted for blood injection. Frequently, the abnormality can be quite focal and the injectate can be seen permeating the clefts within the tendon substance. In addition, physiotherapy plays a vital role in the ongoing treatment of patients following a period of rest and the series of injections. We used a standardised protocol based on the findings of Purdam et al.27 Loading of the patellar tendon was achieved by decline eccentric dips, with Figure 3

Ultrasound guided needling for patellar tendinosis 521 What is already known on this topic N Patellar tendinosis is a common problem causing morbidity in sport. It is often refractory to treatment. Autologous blood injection has been reported as showing promise in the treatment of this condition at other sites, for example in medial and lateral epicondy- litis. What this study adds N This study reports the technique of dry needling and autologous blood injection under sonographic guidance as a therapeutic option for patellar tendinosis. N Therapeutic intervention led to a significant improvement in VISA score as a measure of clinical outcome. incrementally increasing load over three to six months, until the subject had returned to sport. All subjects also received quadriceps, hamstring, and calf stretches. The programme was home based, with regular physiotherapy clinic visits to guide the subject’s progression. There are various limitations to our study. We are, in essence, evaluating two therapies simultaneously. Autologous blood injection and dry needling is combined with physiotherapy as part of our treatment protocol. We therefore do not know the relative importance of the autologous blood injection and the dry needling in the therapeutic outcome of the group studied. Previous workers have identified good results with painful eccentric quadriceps training, with significant improvement in clinical outcome.4 However, most of our patients had under- gone a course of physiotherapy, and the tendinosis had proved refractory to this initial treatment. Second, although the VISA score provides an objective measure of clinical outcome in patients treated with this technique, we do not have any other objective measurement of tendon healing. The ultrasound findings are descriptive and rather subjective. It would be difficult to justify biopsy of the tendon to provide histological evidence of tendon healing. With this in mind, ultrasound was chosen as the method to monitor the ‘‘healing response’’ and to observe the sonographic appearances of tendons treated by this new technique. Further research is required with a randomised controlled trial of autologous blood injection/physiotherapy versus physiotherapy alone. CONCLUSIONS Dry needling and injection of autologous blood for patellar tendinosis shows promise as an alternative treatment for this chronic condition. It is important to carry out this technique under sonographic guidance so that the abnormal tendon can be targeted precisely for dry needling and injection of blood. The patient subsequently undergoes a course of physiotherapy following initial treatment before resuming sporting activity. ....................... Authors’ affiliations Steven L J James, The Royal Orthopaedic Hospital, Birmingham, UK Kaline Ali, David Connell, The Royal National Orthopaedic Hospital, Stanmore, UK Chris Pocock, Kingston Hospital, Kingston, UK Claire Robertson, Faculty of Health and Social Services, St George‘s University of London/Kingston University, UK Joy Walter, Joy Walter Clinic, Esher, UK Jonathan Bell, Wimbledon Clinics, Parkside Hospital, Wimbledon, London, UK REFERENCES 1 Khan KM, Cook JL, Bonar F, et al. Histopathology of common tendinopathies. Update and implications for clinical management. Sports Med 1999;27:393–408. 2 Alfredson H. The chronic painful Achilles and patellar tendon: research on basic biology and treatment. Scand J Med Sci Sports 2005;15:252–9. 3 Sharma P, Maffulli N. Tendon injury and tendinopathy: healing and repair. J Bone Joint Surg Am 2005;87:187–202. 4 Jonsson P, Alfredson H. Superior results with eccentric compared to concentric quadriceps training in patients with jumper’s knee: a prospective randomized study. Br J Sports Med 2005;39:847–50. 5 Alfredson H, Ohberg L. Neovascularisation in chronic painful patellar tendinosis-promising results after sclerosing neovessels outside the tendon challenge the need for surgery. Knee Surg Sports Traumatol Arthrosc 2005;13:74–80. 6 Fredberg U, Bolvig L, Pfeiffer-Jensen M, et al. Ultrasonography as a tool for diagnosis, guidance of local steroid injection and, together with pressure algometry, monitoring of the treatment of athletes with chronic jumper’s knee and Achilles tendinitis: a randomized, double-blind, placebo-controlled study. Scand J Rheumatol 2004;33:94–101. 7 Peers KH, Lysens RJ, Brys P, et al. Cross-sectional outcome analysis of athletes with chronic patellar tendinopathy treated surgically and by extracorporeal shock wave therapy. Clin J Sport Med 2003;13:79–83. 8 Ferretti A, Conteduca F, Camerucci E, et al. Patellar tendinosis: a follow-up study of surgical treatment. J Bone Joint Surg Am 2002;84A:2179–85. 9 Shelbourne KD, Henne TD, Gray T. Recalcitrant patellar tendinosis in elite athletes: surgical treatment in conjunction with aggressive postoperative rehabilitation. Am J Sports Med 2006;34:1141–6. 10 Connell DA, Ali KE, Ahmad M, et al. Ultrasound-guided autologous blood injection for tennis elbow. Skel Radiol 2006;35:371–7. 11 Edwards SG, Calandruccio JH. Autologous blood injections for refractory lateral epicondylitis. J Hand Surg Am 2003;28:272–8. 12 Taylor MA, Norman TL, Clovis NB, et al. The response of rabbit tendons after autologous blood injection. Med Sci Sports Exerc 2002;34:70–3. 13 Visentini PJ, Khan KM, Cook JL, et al. The VISA score: an index of severity of symptoms in patients with jumper’s knee (patellar tendinosis). Victorian Institute of Sport Tendon Study Group. J Sci Med Sport 1998;1:22–8. 14 Kujala UM, Friberg O, Aalto T, et al. Lower limb asymmetry and patellofemoral joint incongruence in the aetiology of knee exertion injuries in athletes. Int J Sports Med 1987;8:214–20. 15 Kujala UM, Kvist M, Osterman K, et al. Factors predisposing army conscripts to knee exertion injuries incurred in a physical training programme. Clin Orthop 1986;210:203–12. 16 Jarvinen M. Epidemiology of tendon injuries in sports. Clin Sports Med 1992;11:493–504. 17 Allen GM, Tauro PG, Ostlere SJ. Proximal patella tendinosis and abnormalities of patellar tracking. Skel Radiol 1999;28:220–3. 18 Wityrouw E, Bellemans J, Lysens R, et al. Intrinsic risk factors for the development of patellar tendinitis in an athletic population. A two-year prospective study. Am J Sports Med 2001;29:190–5. 19 Weinberg EP, Adams MJ, Holledberg GM. Color doppler sonography of patellar tendinosis. Am J Roentgenol 1998;171:743–4. 20 Terslev L, Qvistgaard E, Torp-Pedersen S, et al. Ultrasound and power Doppler findings in jumper’s knee – preliminary observations. Eur J Ultrasound 2001;13:183–9. 21 Peers KH, Lysens RJ. Patellar tendinopathy in athletes: current diagnostic and therapeutic recommendations. Sports Med 2005;35:71–87. 22 Khan KM, Bonar F, Desmond PM, et al. Patellar tendinosis (jumper’s knee): findings at histopathologic examination, US, and MR imaging. Victorian Institute of Sport Tendon Study Group. Radiology 1996;200:821–7. 23 Ferretti A, Puddu G, Mariani PP, et al. Jumper’s knee: an epidemiological study of volleyball players. Physician Sportsmed 1984;12:97–103. 24 Richards PJ, Win T, Jones PW. The distribution of microvascular response in Achilles tendonopathy assessed by colour and power doppler. Skel Radiol 2005;34:336–42. 25 Anitua E, Andia I, Sanchez M, et al. Autologous preparations rich in growth factors promote proliferation and induce VEGF and HGF production by human tendon cells in culture. J Orthop Res 2005;23:281–6. 26 Iwasaki M, Nakahara H, Nakata K, et al. Regulation of proliferation and osteochondrogenic differentiation of periosteum-derived cells by transforming growth factor-b and basic fibroblast growth factor. J Bone Joint Surg Am 1995;77A:543–54. 27 Purdam CR, Johnsson P, Alfredson H, et al. A Pilot Study of the eccentric decline squat in the management of painful chronic patellar tendinopathy. Br J Sports Med 2004;38:395–7.

Information for all New Year revolutionists!

Posted on January 3, 2016 at 8:10 AM

Just a quick blog to wish everyone a HAPPY NEW YEAR and of course a HEALTHY NEW YEAR! 2015 was such a roller coaster eh? 

I wanted to just drop a thought and let all my New Year Resolutionist in a small tidbit before they go running a marathon or joining the crossfit gym across the street. Just remember to begin slow and methodically increase your intensity over time. Often times we go "gung ho" into something new because...well...its NEW and its EXCITING. But we often end up with injuries as a result. I am always here if that happens, however an ouce of prevention is TOTALLY worth a POUND of cure. 

If anyone who reads this wishes to have a consult PRIOR to starting a fitness regimen please don't heistate to contact us. I will even give you 10% off the price if you mention this article! 

Heres to a New Year and a Heathier YOU!