Why is Physical Therapy a Group Activity?

Well, my running is still curtailed by this pesky hip problem which has now become a literal pain in the butt..some sort of piriformis/sacroliliac/who-knows-what syndrome  (that’s HKWS) that’s causing pain in my, um, derriere and halfway down my leg on one side.  But enough about that..what I really want to whine about in this post is PT.   I’ve been thinking a lot about why I dislike PT so much.  Sure, there are the usual intellectual reasons..the huge amount of time it takes, the fact that each visit costs me the same as a doctor visit but there are 8 or 12 times as many of them; the fact that it often amounts to nothing more than supervised exercise..but lately I’ve been noticing that it’s not just the rational objections that make me dread it.  There is something sort of unpleasant and stress-indusing about the whole experience, and I think I’ve figured out part of it.  It’s the togetherness.  When I go to a doctor, it’s pretty much a private 1-1 experience.  But when I go to the PT, I’m there in a room  with a bunch of total  strangers , all bring treated at one time, usually by the same practitioners.  That’s weird, isn’t it?  I mean, imagine going to the doctor and sharing your time slot with three other people in the same exam room?  And yeah, I  go to group exercise at the gym with people I don’t know, but PT is not like going to Zumba, where you’re basically doing a group activity and there’s music playing and it’s all happy happy.  It’s more like being in a stranger’s hospital room, where no one is having fun and you’re trying hard to ignore one another.

At my most recent therapy  session I had to do my exercises on a table about 2 feet from a guy with back trouble and try as I might, I couldn’t avoid hearing him telling the therapist all about how much pain he was in.  It felt intrusive.  And then I had to listen to the therapist having a long detailed and loud conversation with the woman on the table to my right, all about her wedding plans,  for at least 15 minutes while she performed some manual therapy.  (Believe me, there is nothing less interesting than someone else’s wedding plans. )   The therapist was, I guess, quadruple booked, so I can see how it was convenient to have everyone close together but from my standpoint, it wasn’t much fun.

I don’t know.  I suppose that PT couldn’t make economic sense if it were always 1-1 but for me it’s just one more reason to avoid it.  Anyway, I only lasted 1 session at that particular PT, and I am switching to one where, for whatever reason, there seem to be only 1 or 2 patients there at a time usually.  And if that doesn’t work out, I guess I’ll have to take the last resort and go to the ortho, which I doubt will be productive.  I suspect that what I really need is a good trigger point therapist but my insurance doesn’t cover that. That’s probably ironic, right?

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Finally a question the internet can’t answer?

So, finally, I’ve reached the point where my trochanteric pain syndrome-slash-hip bursitis-slash- IT band syndrome has made me stop running.  I’ve promised myself I’m not going to run until I can run 5 miles pain-free, and also walk and sleep pain free.  The sleeping part has been the hardest so far.  No matter how I start out sleeping, I always end up  rolling onto my affected side (the left side) which causes pressure on the affected hip and eventually an intense pain that wakes me up.  So then I roll over onto my right side and somehow that causes the same left side pain as sleeping on the left side..I’m assuming that the IT band or some other structure in there is compressing the inflamed bursa  in that position.  But  my body really, really wants to curl up on my side to sleep, even though my brain knows it’s gonna hurt.  Back-sleeping is just wrong!   Of course, it goes without saying that I asked the Internet how to keep from rolling onto my side, but all I got was advice on how to keep a baby from rolling over.  Apparently side-sleeping is bad for babies?    Anyway, unless I figure out how to somehow affix my back to the mattress,  or construct some sort of bumpers to hold me in place, I think it’s going to be a while before I can get through the night.  But meanwhile, (thanks to the internet  of course), I’ve learned that sleeping on my side is actually good for my brain.  So, there’s that.

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New problem, new PT, new weird

I went to a new PT last week, and he did an evaluation in response to my lateral hip pain.  He did that thing where you lie on the side and raise your top leg laterally and try to resist when the evaluator pushes down on it.  He said that my right hip was rock solid , super-strong and he could “do push-ups on it” if he wanted to, which I think was a poor choice of words and I’m not exactly sure how that would work, but OK, so I’m strong on that side.  He also said that my left side abductors were “profoundly weak.’  But the right side is the one that seems to usually be out of whack with the weird rotation and the tendinopathy pronation and torn meniscus and whatnot.  So I’m not sure why it would be so much stronger, unless I’ve just been focusing on it more in my exercises.  Interestingly, this is the exact opposite result of a previous evaluation in 2013.   Then it was my right side that was weaker.  So either physical therapist evaluations have non-reprodicible results or I am slowly oscillating between being  weak on the right side and weak on the left side.  I imagine most people have a stronger side, but I can’t quite figure out why there would be such a dramatic difference.  It just get weirder and weirder.

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More answers = more questions.. my running gait analysis

They say a picture is worth a thousand words, and a video is worth a million words. This week I had a video analysis of my running gait. Here’s what I learned.

• I’m a forefoot striker. (Mildly surprising..I would have said I’m a mid-foot striker)
• I have pretty good foot and ankle control. Slight supination on the left; more pronation on the right..apparently nothing too earth-shattering.
• My right foot toes out but my left one points straight ahead. (I’m surprised I don’t end up just running in endless clockwise circles!)
• My pelvis isn’t as level as it wants to be. (Not unexpected, and confirms what I thought from looking at still photos)
• I don’t overstride and I have a decent amount of forward lean.
• According to the guy who went over my results with me, most of the bad stuff that’s happening is around my hips and upward.
• The more I look at it, the more I think my whole right leg is sort of rotated at the hip, which would help to explain the knee injury and the achilles tendinopathy on that side.

So, not a million words, but still a lot of information from a 15 minute exercise.  The question is, what to do about it?

 

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Ho hum, another training epiphany

I know, I know, I’m always having epiphanies about this or that.  Shoes, cross-training, heart rate training, cadence, form, exercises, blah-blah-blah, and every time, I think my running life will be miraculously made better, and it hardly ever is.  Nevertheless, I persist in having epiphanies.  It’s fun.

So this time, I was finally reading Ben Greenfield’s book, Beyond Training, which I’ve had on my Kindle but had forgotten about until I had nothing else to read on the train, and right there in Chapter 1, he described me almost perfectly..older athlete,  slightly driven, constantly injured, often tired, overtraining in a sort of dysfunctional way.  Long story short, I decided I need to stop the medium length, medium effort, death-march runs, do my easy runs as an easier pace, and add in some High Intensity Interval Training.  I’ve always found it hard to push myself to run at maximum effort unless I’m  in a race and sprinting for the finish line.  But I downloaded Tribal Tabata from Podrunner, and now I’m doing 20 minute Tabata runs on my 2 short-run days, and slowing down on my long-slow-distance run days.  The routine is 20 second going full-out, 10 second (though it seems shorter) rest, for 8 rounds, 4 sets.  So far, I like it, because it allows me to cover more distance in a shorter time on my Tabata days, while not feeling as much wear and tear on my body.  And I don’t get that exhaustion feeling.. as long as I keep the high intensity to 20 seconds.  I’ve tried it twice with running, and once on the elliptical at the gym so far, so it’s too early to tell if I’m getting any faster.  We’ll see how it goes.   I haven’t gotten to Chapter Two in the book yet, so I’m sure there will be more epiphanies coming up.

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Saved by a podcast (Lateral Hip Pain Exercises)

How did we runners ever survive before podcasts?  Not only do they help me run 10 or more miles without dropping over from boredom, but I’ve learned so many very useful things about fitness and running from them. (Thanks, Trailrunner!  Thanks Ben Greenfield!)   Recently I found Physioedge, which has the added bonus of being Australian.  There is just something about an Australian accent.  I find  Aussies all sound somehow  ruggedly sporty and capable of wrestling alligators and sharks, and therefore more credible.  So, I’m pretty sure this interview with  Dr. Alison Grimaldi about lateral hip pain  is going to help me fix my pesky hip enthesopathy/IT Band Stuff  once and for all.  Yes, I know, I always get excited about some new treatment, which typically fails to magically fix everything, but this one is not about a new treatment, it’s more just a really precise synthesis of what is known about this condition and how to treat it.

This is something I’ve had two or three times over the past 20 years.  I finally got rid of it a few years back with an intense regimen of exercises, but of course, I stopped doing the exercises when the pain stopped, and then other injuries happened, and I had to focus on rehabbing from them.  And now it’s back.  So, what I really need is just a couple of things I can do to target this condition that are sustainable for the kong-term.  I need to listen to this podcast again, but one thing I learned that made me really happy was that I can stop doing clam shells!  They aren’t that great for targeting the glute med and they provoke pain.  Yay!  I have alway hated clamshells.  So apparently I can stick with my lateral leg raises and bridges and single leg stands on a pillow.  Two of those I can even do at my office while working at my standing desk.   So, if I can do 3 exercises three times a day, rather than 20 exercises a couple of times a week, I think that’s a win.

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Getting to 10

Yesterday I ran 9.5 miles, the farthest I’ve run since my injury last October.  Actually, I had planned to run 9, but accidentally ran 9.5.  I blame it on Strava.

My system has been to add one mile per week.  So, next Saturday I’ll run 10.  Beyond that is anyone’s guess.  I just want to hit 10.  For no particular reason other than 10 miles is a respectable distance, and a nice round number.

I don’t have the sense that the meniscus is healing.  I have just as much pain and inflammation as before.  I just think I’m getting much better at compensating.  Or ignoring pain.  One or the other.

A coolish humid morning in the Wissahickon.  5 miles on the bridle path with Shawmont club, and 2.5 miles on the white trail, over Fingerspan bridge, then 2 back.  There was a race being run, going in the opposite direction.  I miss racing.

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One month post-PRP

My PRP injection was a month ago, and I have no idea whether it helped at all.  It may be too soon to tell.  I had my follow-up visit with the doc last week.  I explained that the pain was worse than before and he said he was not disheartened yet, (good!) but that he definitely wouldn’t do another injection at this point (I agree).  He gave me a bunch of PT exercises..the usual lying-down single-leg raises  in all directions, (more on that in a minute), the ubiquitous ITB stretch,  and also VMO exercises..for my Vastus Medialis Obscuram..no wait, that’s not right..Vastus Medialis Oblique, that’s it.  It’s the muscle that causes that weird little bulge atop my knee in some pictures I was looking at from a couple of years ago when I was not injured.    I realize I don’t have that little bulge so much anymore, so I guess that is what the doc meant by “quad wasting.”  Apparently I must build the quads up again so they can stabilize the knee, and apparently this is the part of the quad that is suspected of failing in its knee stabilizing role.   So, I do these twice a day now, because, you know, I don’t have enough to do and need more exercises to add to my list of daily tasks.   I think I have 22 exercises per day now.  30 reps each.

But back to the lying-down leg raises.  Why do PTs and doctors always tell you to do leg raises lying down?  Because, I don’t generally run lying down, and it seems pretty easy to do leg raises standing up, in all directions, so I would think that would be even more effective.  For one thing, you’d be adding a balance component to the exercise.  And for another thing, it is much easier to find a comfortable place to stand to excercise than to find a hard surface to lie on..at least at my house and my office.  (Yes, I have a floor, but it’s not really so super sparkly clean all the time and  also whenever I lie down on it the cats come and stand on me.) I don’t know..I’m thinking I will try doing them standing up..in front of the mirror, paying attention to form…because I think that it’s better than not getting them done.

Today I ran/walked 7 miles on trail sin the Wissahickon.  Because it was a nice day.

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Adventures in PRP Therapy

Well, after 5 months or so, having plateaued in my recovery, I decided to revert to my default behavior..casting about for some non-surgical treatment that sounded vaguely like it might have a scientific basis, and would be unlikely to make anything worse.  What I came up with was Platelet Rich Plasma Injection Therapy, aka, PRP.  The theory is that you centrifuge the person’s blood to produce a plasma that has a high concentration of platelets, and therefore various growth factors ..in other words..all the good stuff that promotes healing..you can then inject into the joint and it might initiate tissue repair.  It seemed to make sense, and since it was nothing but my own blood being injected, with a little tiny needle, I figured there wasn’t a lot that could go wrong.   The doctor suggested he should, at the same time, aspirate the popliteal cyst in the back of my knee, which apparently either never resolved at all, or has recurred as I’ve increased my activity level.  I hadn’t noticed it lately, but that seemed like a good idea.

So, here’s how it went.  The nurses/assistants (or whatever they were..no one ever tells you these things..) drew a bunch of blood really fast by using an anticoagulant and went off to spin it down.  Then, two doctors, a med student, and a nurse-type person assistant came in and, after numbing the area and visualizing the cyst on ultrasound, and planning their attack, stuck a needle in and aspirated the fluid, while pushing on the cyst to get it properly positioned.  The doctor told me it was dumbell-shaped and wrapped around the gastroc, but that this is not unusual.  This part produced a sudden  and very unusual-feeling pain that ran down the back of my calf,  which apparently was unexpected, but the whole thing wasn’t bad.

After that I got to flip on my back,while they injected the PRP, and I was able to watch the ultrasound.  It was interesting having a 5-person team all gathered around..it was like an episode of ‘House’.  Except that if it had been an episode of ‘House’, I would have had a seizure and the camera would have zoomed into my body to reveal that procedure accidentally released a giantic hookworm that had been living in the cyst in my knee and was now swimming directly to my heart..or brain..or both..and then they would have had to take time to randomly speculate on possible diagnoses for an hour..and well..I would have been there all day, so yeah..good thing it wasn’t House.  Anyway, the main doc warned me that it would hurt when the platelets went in, but it didn’t at all.  According to him, I am the only patient he’s had who didn’t say “Ow” at that point.   After that, they had me wait around to make sure I wouldn’t faint, and then I went home feeling fine, but with a scrip for 10 Vicodin, because doctors like to give you Vicodin for some reason.  It seemed like too much trouble to fill the prescription and go sell them on the street so I didn’t fill it.

So, the rest of the day my knee felt mildly unstable while walking, but I attribute that either to the anaesthetic or to fact that all that fluid they aspirated was exerting a stabilizing effect on my knee.  In any case, that sensation wore off  and I had no pain until today, which is 4 days post-procedure, and all I have is  soreness  below the joint line in the back and medially.        Somehow it seems sort of unrelated to the other things.  Oh well.  Anyway, I have a follow-up in roughly 3 weeks.

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Knee capsule injury..is that really a thing?

I recently saw a chiropractor for a second opinion on my knee injury, and his opinion was that my pain and effusion might not be from the meniscus tear but might be from injury or inflammation of the ‘capsule’.  I had never even heard of the capsule and I still am not really super-clear on what exactly it consists of.  My impression is that it’s a thin sleeve of connective tissue that encloses the knee joint somehow. He suggested that my knee capsule feels like it has a fold in it, and that may be at least contributing to the pain on the lateral aspect of the knee. So my question is:  “Huh?”

I’ve heard of plica syndrome, where a fold in, um, something, gets stuck, um, somewhere, and causes pain.  But there was no particular suggestion that this fold in the capsule is getting stuck, just that it is causing pain, and that this injury happened concurrently with my meniscus tear and is confusing the issue with regard to healing.  I’m happy to believe in this theory, because it seems more likely to heal if this is the case.  It’s just the first time I’ve ever heard of it.

The chiropractor points out that the pain can be readily reproduced by applying  pressure to the spot on the lateral surface of my knee that is tender, and he says that if it were the meniscus it wouldn’t be so sensitive to palpation since the meniscus is way deep inside there.  This sort of seems to make sense to me, as a layperson, but then again, lots of things about the human body seem to make sense but aren’t really true.  The body is complicated.  The knee seems especially complicated.  Referred pain can happen in weird places.  So, really, I have no idea id the “capsule injury’ theory is true, or likely.  Still, as a working hypothesis, I like it.

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