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Bluegrass Doctors of

Physical Therapy, PLLC



Cupping our way to victory?

Posted on August 8, 2016 at 8:00 PM

If you have watched any of the Olympics as of late, the big buzz is Michael Phelps Circular bruises. Almost covered more intensly than the events themselves. He undergoes a procedure called Cupping. Cupping has been around for centuries. Used in various cultures around the world it is thought to improve blood flow (reducing stagnation), improve Chi, (energy) and liberate toxins from an area that is haing pain or dysfunction. There are many ways to utilize myofascial cups to aid in pain reduction and to improve tissue texture. We can lengthen fascia, and improve flexibility as well as reduce pain. The mechanisms that are truly happening are a bit ore enigmatic but are thought to involve actually causing a localized inflammatory response to allow a chronic injury to heal appropriately and thus pain can be alleviated. 

However, one does not have to come out looking like he/she had a hot date with an octopus to get benefit from this technque. At Bluegrass Doctors of PT we utilize cupping techniques that most often do NOT leave bruises. Unlike Dry Needling this technique is non invasive, completely safe with relatively no contraindications. It is a wonderful adjunctive therapy, to needling, Laser therapy, manipulation and exercises. It however, in my opinion is not a stand alone technique.

Follow us on Twitter, and Facebook. #OlympicCupping. 

To all female athletes!

Posted on July 20, 2016 at 9:50 AM

Wearable Reduces ACL Injuries in Female Study Subjects

Published on July 11, 2016

Technology may offer a way to control the significantly higher occurrences of ACL injury among young women who play soccer. A new report shows that using a wearable neuromuscular (WNM) as part of a training protocol helped substantially reduce ACL injuries in recent testing.


According to the study, presented recently at the American Orthopaedic Society for Sports Medicine’s (AOSSM) Annual Meeting in Colorado Springs, Colo, athletes who used the devices in combination with a regular training program showed functional improvements.


“Our study showed that training with a wearable neuromuscular (WNM) device improved postural control in athletes, without limiting performance,” says Michael John Decker, PhD, from the University of Denver in Denver, in a media release from AOSSM. “Moreover, no athletes in the study experienced an ACL injury during training or over the course of the following season.”


In the study involving 79 elite youth and collegiate female soccer players (ages 12 to 25), participants trained with a WNM device that applied bilateral, topical pressure to the medial quadriceps and hamstring muscles. The preseason training program with the device lasted 7 to 9 weeks, and consisted of strength and conditioning exercises and on-field team practices.


“Research has shown female soccer players have a three times greater risk of ACL injury compared to males, yet only a small portion of soccer coaches are currently utilizing ACL injury risk reduction programs,” Decker states in the release. “We hope these devices offer coaches a practical means to overcome participation barriers, opening the door for more organizations and teams to implement similar programs.”


[Source(s): American Orthopaedic Society for Sports Medicine, Science Daily]

Can't Sleep?? Come in and see us.

Posted on July 16, 2016 at 8:40 AM

In the past 10 years, computers and cellphones have become one of the most important factors in our lives, and one which has a tremendously negative impact on our muscles. Muscle tension may be one of the causes of sleep disturbance. Tension in the shoulders and neck can affect blood circulation to the muscles. This research uses a dry needling treatment to reduce muscle tension in order to determine if the strain in the head and shoulders can influence sleep duration. All 38 patients taking part in the testing suffered from tinnitus and have been experiencing disturbed sleep for at least one to five years. Even after undergoing drug therapy treatments and traditional acupuncture therapies, their sleep disturbances have not shown any improvement. After five to 10 dry needling treatments, 24 of the patients reported an improvement in their sleep duration. Five patients considered themselves to be completely recovered, while 12 patients experienced no improvement. This study investigated these pathogenic and therapeutic problems. The standard treatment for sleep disturbances is drug-based therapy; the results of most standard treatments are unfortunately negative. The result of this clinical research has demonstrated that: The possible cause of sleep disturbance for a lot of patients is the result of tensions in the neck and shoulder muscles. Blood circulation to those muscles is also influenced by the duration of sleep. Hypertonic neck and shoulder muscles are considered to impact sleeping patterns and lead to disturbed sleep. Poor posture, often adopted while speaking on the phone, is one of the main causes of hypertonic neck and shoulder muscle problems. The dry needling treatment specifically focuses on the release of muscle tension.

Check out the full article here!

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!

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! 

Central Components of Peripheral Pain

Posted on December 30, 2015 at 9:55 AM

My patients and I have had coutnless discussion of how even something as "tendonitis" can have central (IE central nervous system) effects in our body which can cause these ailments to perpetuate. This is often the case of my inteventions. I am trying to change processes that are in the CNS to then reduce pain in the periphery. Here is the abstract of an article that demonstrates just that with regrds to Achilles Tendonitis.



Central pain processing is altered in people with Achilles tendinopathy



Background Tendinopathy is often a chronic condition. The mechanisms behind persistent tendon pain are not yet fully understood. It is unknown whether, similar to other persistent pain states, central pain mechanisms contribute to ongoing tendon pain.

Aim We investigated the presence of altered central pain processing in Achilles tendinopathy by assessing the conditioned pain modulation (CPM) effect in people with and without Achilles tendinopathy.

Methods 20 people with Achilles tendinopathy and 23 healthy volunteers participated in this cross-sectional study. CPM was assessed by the cold pressor test. The pressure pain threshold (PPT) was recorded over the Achilles tendon before and during immersion of the participant's hand into cold water. The CPM effect was quantified as the absolute difference in PPT before and during the cold pressor test.

Results An increase in PPT was observed in the Achilles tendinopathy and control group during the cold pressor test (p<0.001). However, the CPM effect was stronger in the control group (mean difference=160.5 kPa, SD=84.9 kPa) compared to the Achilles tendinopathy group (mean difference=36.4 kPa, SD=68.1 kPa; p<0.001).

Summary We report a reduced conditioned pain modulation effect in people with Achilles tendinopathy compared to people without Achilles tendinopathy. A reduced conditioned pain modulation effect reflects altered central pain processing which is believed to contribute to the persistence of pain in other conditions. Altered central pain processing may also be an important factor in persistent tendon pain that has traditionally been regarded to be dominated by peripheral mechanisms.

Why we should see a PT once a year for yearly check up.

Posted on August 28, 2015 at 1:15 PM

Rethinking Movement: Why You Should See a Physical Therapist Every Year


Why is it that superbly fit athletes can find themselves in as much back, knee, or neck pain as their flabby fans, who sit at desks all day long then watch sports from overstuffed sofas?


“When you do an activity over and over again, your body adapts to that activity,” warns Dr. Shirley Sahrmann, professor emerita of physical therapy at Washington University School of Medicine. “If you play tennis, your arm gets bigger on that side; if you do karate you get adaptations in your hip and leg. Even if you just sit, you lean, you slump, your neck goes forward.” Either your body fails to build up musculature to support itself, or it overbuilds certain muscles and throws off the symmetry your skeleton craves.


That’s why Sahrmann wants to see an annual physical therapy exam become as routine as a dental checkup. “We go to the dentist twice a year and spend thousands to straighten our teeth, and all we do with them is eat and talk. Meanwhile the rest of our body’s just hanging out there.”


People think of p.t. as something generic their doctor orders after an injury, she says. But by analyzing the way you walk, bend, sit, and carry yourself, physical therapists can prevent injuries and head off future surgeries and chronic pain.


“Kids don’t sit correctly, they slump, so they wind up sitting on the middle of their back,” she says. “We have these little bones on our bottom where we are supposed to sit and keep our spine erect. When you slump, the muscles get stretched out, and they’re not going to function optimally.”


A temporary phase? Maybe. But “bones adapt to the alignment that you keep them in,” Sahrmann points out, “and your spine becomes shaped like that.”


Watching teenagers walk makes her crazy: “They are not using what we consider a normal gait. They walk without bending at the hip and knee and pushing off. They shuffle. And they sway back—their shoulders are behind their hips—so their gluteal muscles don’t work as much as they should. All of these little cultural changes in sitting posture, what’s considered cool—even the clothing.” For a while there, she says, “the new waistline was the gluteal fold! And how do you walk when your legs are strapped together with a belt? Their knees get caught in the crotch of their pants—it’s hysterical. But it’s also not good.”


In years past, there was little appreciation of how lifestyle affected your health. “My family thought they just got diabetes or hypertension; it had nothing to do with the cans of Crisco my grandmother cooked with.” The way we move and align ourselves is just as important as what we eat, she says. “There is complexity to movement, and you can do it right or wrong.”


I bring up ergonomics—surely that’s helped? “It’s not just whether the setup is right,” she points out. “It’s what you bring to that setup and what you do when you’re not there.” We’re designed to keep changing position, not sit frozen in the perfect chair. Even working out requires real knowledge, if you want to lift weights or do aerobic training without compromising the performance of all your other joints.


Sahrmann’s one of the nation’s pioneers in pushing the concept of a movement system, emphasizing the subtle, necessary interconnections of muscles and bones and nerves but also heart, lungs, and the endocrine system. Her career has spanned more than half a century, and its twists and turns led her to see the body whole. She began work at the end of the polio era and spent nine years taking care of patients who’d suffered head injuries or strokes. In order to understand the disordered motor control of patients with central nervous system lesions, she left clinical practice to earn a Ph.D. in neurobiology. Then serendipity sent her a different kind of patient: athletes who had musculoskeletal pain.


“I started teaching them to move differently, and they got better for reasons I didn’t understand,” she says. “I’ve spent a good many years with my colleagues at Wash.U. working to analyze these relationships between movement and musculoskeletal pain.”


She’s written two books and talked herself hoarse, urging people to see the body’s movement as systemic. Now that approach is finally catching hold, not just here but nationally and internationally. But she’ll know she’s really succeeded when p.t. evaluations are annual, and there are formal diagnoses based on movement patterns that consistently cause pain: flexion syndrome, when the back bows out; extension syndrome when it bows in and hunches you over; tibiofemoral rotation that can lead to knee problems.


“We all move differently,” she says. “I’ve seen patients whose feet are so callused I don’t know how they put their shoes on, and I’ve seen marathon runners with no calluses at all.


“You need to have an exam by a body expert at least once a year,” she finishes crisply. “Even if insurance doesn’t cover it, the cost is no more than you’d pay a personal trainer. I think we could substantially reduce the number of injuries and slow the process of osteoarthritis as people age.” She’s not saying arthritis can be eliminated altogether—but it can be delayed and its effects minimized. “There’s evidence that if a joint is lax, or you have injury, or your muscles are weak, you can get these arthritic changes.” Move right, and you lower the chance of injury—whether you’re an Olympian or a couch potato.



Somewhat personal touch on my blog

Posted on August 14, 2015 at 11:20 AM

As I sit recovering from abdominal surgery, I can't help but understand the relationsip between the myofascial abdominal wall referral and underlying organ dysfunction. For years I had been plagued with stomach pain, and some still. Likely a myofascial perpetuator?


Myofascial Dysfunction and Its Relationship to Laparoscopy John Jarrell University of Calgary, Calgary, AB, Canada

Check the link out to see relationship between muscle and visceral pain in regards to laprosocpy.

OK City Surgery Center

Posted on May 2, 2015 at 9:35 PM

OKLAHOMA CITY – Taking a “cash only” free market approach, the Surgery Center of Oklahoma City is causing a stir locally, and attracting nationwide attention.


What the company calls “price transparency” with guaranteed rates for procedures is even triggering a home-grown version of medical tourism.


A company in the Dallas metroplex has designated Surgery Center a partner for employee health care. Savings from procedures performed at the center, even with lodging and travel covered, yield lower costs for the employer.


Admirers laud physician-founder Dr. Keith Smith, who founded the center in 1997, for “lighting a candle, rather than cursing the darkness.”


At a state Capitol event, Dr. Smith explained the center’s up-front pricing of medical procedures in diverse areas of practice, including orthopedics, ear/nose/throat, general surgery, urology, ophthalmology, foot and ankle, and reconstructive plastics.


Bottom line, the institution’s operational structure and market-oriented billing methods provide an intriguing alternative to the third-party payer systems that now dominate American health care, including the highly centralized structure envisioned under the Affordable Care Act, or “ObamaCare.”


The center has avoided entanglement in Medicare and Medicaid, and only carefully engages with private health insurance plans.


This week, Brandon Dutcher and Tina Dzurisin of Oklahoma Council of Public Affairs hosted a seminar to tout Smith’s work, which has begun over the past few months to garner favorable attention in local news reports. Lobbyists for major health care institutions in the region were present, as well as association executives interested in the Center’s approach, either to support or oppose it.


That’s not all: Reasontv has taken notice, producing a mini-documentary on the price transparency, overall efficiency and affordability in the Surgery Center’s approach.


Three years ago, Dr. Smith, who describes himself as a libertarian, began to post prices for 112 common surgical procedures at the facility, which was established with his partner, Dr. Steve Lantier, in 1997.


The original founding of their health-care business was predicated on the confidence they could provide top-tier procedures at a fraction of the cost traditional hospitals charge. Their already-successful venture took off after the online price posting was implemented.


He recalls, “The first people who showed up at our door were Canadians. Then we heard from the heads of Human Resource departments at local and regional companies.”


The center works directly with several businesses that are self-insured, and which pay employee bills directly. Today, Smith reported, the vast majority of patients at the center are individuals drawn initially by lower prices, and retained by high-quality care.


The center lists a guaranteed price for procedures, including facility fee, surgeon’s fee and anesthesiologist’s fee. Prices listed include those for initial consultation and uncomplicated follow-up.


Not included in the listings are diagnostic studies prior to surgery, consultations, therapy and rehabilitation, hardware or implants. As Smith noted, hardware and implants are priced at cost with no mark-ups. Overnight stays at the facility are not included, nor are lodging and travel expenses.


As a practical matter, the center’s approach leads to patient bills that can be laid out, with all costs listed, on a single page. The actual cost of the center’s procedures is sometimes one-tenth, and often around one-sixth, of the price at a traditional hospital.


The Reasontv video, shown at the Capitol briefing, highlighted some of the most dramatic price differentials, including for a “complex bilateral sinus procedure.” At the Surgery Center, the all-inclusive price is $5,885. At nearby Integris Hospital the price in 2010 was $33,505 – but that did not include either the surgeon’s or the anesthesiologist’s fees.


In response to a question from CapitolBeatOK, Dr. Smith said there are presently no legal impediments to the Surgery Center’s approach embedded in the Affordable Care Act, widely deemed “Obamacare.” He said he hopes that remains the case, but pointed out that regulatory mandates are a moving target under the law.


The Surgery Center of Oklahoma City does not deal with Medicaid or Medicare systems, although some patients access those systems separate from the center’s work.


While making it clear he is no fan of big insurers, Dr. Smith said the potential key impediments to emergence of more systems like his are “The federal government, the federal government, and the federal government.” He said what he dubbed “the Unaffordable Care Act” is “driving out what’s left of markets in American health care.”


In dialogue with CapitolBeatOK, Dr. Smith said the center’s approach is helping to restore an old-fashioned medical ethic for provision of charity care. Many referrals to the hospital come from churches and other groups helping the poor. Patients are encouraged in those cases to pay what they can, while physicians and anesthesiologists can (and often do) waive their fees for individuals in need.


Surgery Center does work with insurance companies, but that triggers a separate pricing structure. Dr. Smith explained, “We take on a lot of risks when we file with insurance companies, so we have to charge for that risk.”


Oklahoma Commissioner of Labor Mark Costello, who attended the Capitol briefing, will be presenting an Entrepreneurial Excellence Award to Surgery Center next month.


Dutcher, vice president at OCPA, reflects, “The remarkable things Dr. Smith and his colleagues are doing deserve to be spotlighted. They are demonstrating that competition and price transparency can drive down costs in health care just as in every other sector of the economy.”