Posts Tagged ‘physical therapy’

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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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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Previously in this blog I have chronicled my experiences with physical therapy and physical therapists.  I recently had a radial tear of the anterior horn of the lateral meniscus in my knee, along with a leaking popliteal cyst.  I started physiotherapy about 10 days post-injury, and I managed to stick with it for 6 sessions not counting my initial evaluation.  Each visit resulted in  a $40 co-pay, which is the same co-pay as a visit to my orthopedist or a surgeon or some other specialist, which means if I had continued on for six weeks at two visits per week, as prescribed, it would have cost $480.  That’s a lot for someone to watch you exercise, but more to the point, the system is broken.  Insurance companies treat PT as a specialist consultation, but therapists treat it as a long-term relationship  of weeks or months,  and that disconnect isn’t helpful to patients.  If a patient isn’t motivated or able to do their rehabilitation exercises at home, then an appropriate treatment plan may legitimately require biweekly therapist visits for 6 or eight weeks.  Insurance should treat it as one visit. With one co-pay.   For me, 6 weeks of therapy is never going to happen.  I show up for an eval, with the goal of getting back to my activity as soon as possible.  I want to minimize my visits and get the most benefit in the shortest period of time, and if my injury is chronic, I want to know why I’m injured and how I can prevent it.  But typically, I’m given a treatment that is gradual and incremental in nature, and predicated on the idea that I’m going to keep coming back until I am “discharged”,  giving the therapist constant feedback on how I feel after each treatment.  That’s unrealistic, and taxes my patience.

I believe that exercise is very beneficial in most injuries, and I welcome an expert prescribing a rehabilitation plan for me.  But, give it to me up front, let me do it at home, chart my progress on-line, and come back in a few weeks for a re-eval.  In fact, depending on the injury, it seems to me that four visits spread over 8 weeks could be more valuable than the same 4 visits crammed into the first two weeks, especially if the patient never comes back after the two weeks are over.   I wonder if anyone has done a study about that?

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I had my 6-week follow-up with the orthopedist.  She did a follow-up ultrasound and opined that the tendon was less heterogeneous in appearance..not as many “dark patches” as she called them.  OK.  That seems good, I guess.  And yet, I am in much more pain now, still, at 6-weeks post-procedure, than I was prior to the procedure.  So, it’s hard to think of this as a success.  In fact, it seems pretty clear to me that I made things worse by undergoing the needle tenotomy and I probably shouldn’t have done it.   The magic healing response hasn’t materialized. Did that ever make sense..the idea that inflicting more damage would stimulate a beneficial response in the tissues?  I have no idea.. Anyway, maybe it is the lack of endorphins talking but I’m not a happy camper.   I’ve started back on the nitro patch and am still not supposed to run.  So, I’ve decided to try an acupuncturist.  Clearly at this point, it can’t make things any worse.  I’ve found one right up the street, and made an appointment for two weeks from now.

In PT,  we started eccentric exercises.  Actually I started the a couple of days ago on my own.  We also tried a hop on one leg test, which I did OK with until she told me to land on my forefoot instead of my heel and then it got very hard very fast.  The PT and I discussed my latest theory (brought on by re-reading Jay Dicharry’s Anatomy for Runners), that inability to effectively recruit the glutes is a major contributor to my chronic Achilles tendon issues, and asked about exercises for that.    I have noticed, that when I do exercises purportedly for the glutes, like bridges for example, I never feel it in my glutes, I feel it in my quads or in my lower back, or somewhere in my calves.  So we tried a bunch of things until she hit upon something that I actually felt in my hips, and now I have standing hip abduction and standing kickbacks added to my exercise regimen.   I feel like the PT is helping me in a general way, but I don’t feel as though it is doing much for my AT pain.  But at least I like my PT this time, so I’ll stick it out for another couple of weeks.  I can feel my interest in it waning, though.

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To Kevin, whom I saw for IT Band Syndrome, and whose office was in the hospital.

Dear Kevin,

In case you are wondering why I stopped coming after two visits, I did not like going to the hospital.  As you’ve probably noticed, hospitals are full of sick people.  And germs.    I don’t care if you wipe down the table between patients,  I did not like lying on the table possibly occupied by sick person with  possibly-antibiotic-resistant bacteria.   I also did not like exercising with people in wheel chairs.  I am sorry about this, I know they have  a right to have PT too.  I think the hospital is a good place for them, but not for me.  I also did not like being in a windowless room with eery hospital lighting and, did I mention this? germs and sick people.  Also, everyone who worked in your office was sort of sullen, which is understandable when you have to work around so many sick people.

To Rick, who was very officious, and always triple booked.

Dear Rick,

In case you are wondering why I only came to see you twice, you may recall that you were overbooked, and your way of  coping was to give me a 5 minute exercise to do and then go and spend 15 minutes with your other patients while I sat there staring into space being bored.   You really shouldn’t do that, it’s just wrong.  Also, you were really not very encouraging.
To  Cara, who was recommended by a Sports Medicine Doctor for my recurring IT Band Syndrome

Dear Cara,

How old are you, anyway?  Because you looked and talked like you were about 16.  No one wants to be told what to do by a 16 year old, except maybe another 16 year old.  OK, let’s say you are 23 and just look 16.  I still don’t want to be told what to do by a 23 year old.  I have a son your age, and I can not in my wildest dreams imagine taking advice from him, except perhaps on how to play World of Warcraft.   Also, your office was way out in God-forsaken King of Prussia and the latest appointment you had was 6:00 PM, forcing me to drive there in the middle of rush hour just so you could watch me do planks and one-leg stands.  I can do those at home, Cara.  And it was really strange the way you kept calling me every day after I canceled my appointment, trying to get me to come back.  That was just weird.

To Steve, whom I saw for my Achilles tendinopathy.

Dear Steve.

You were my favorite.  You “got” me.  You didn’t treat me like a frail old lady who might suddenly fall over and break her hip at any moment, and you didn’t treat me like an idiot who needed everything explained in very short words.  I would have kept coming but I have to tell you, my co-pays are $40 and the therapy wasn’t really working, so, it just seemed like $40 for thirty minutes of affirmation was a lot.  And then there was that glowing review you got in the local paper, so that now you are so popular that you are booked for weeks and weeks in advance.  So, sadly, I think it’s over between us.  I have found a new therapist and I think it is going to work out.

And to all of you,
Can you please stop saying “hop up on the table for me”.  Really, why do all you say that?  Is it something they teach you in Physical Therapy School?  Because I have to tell you, it sounds sort of ridiculous.   I’m not a bunny rabbit, and I’m not 5 years old, and even if I were 5 years old, I still don’t think I could actually hop onto the table, and really, why would you want me to?  Doesn’t that seem dangerous for someone with an injured Achilles tendon?  So no more cutesy talk, OK?  Thank you.



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It’s week three post-procedure .  At week two,  I had my follow-up visit with the doctor.  She  seemed mildly surprised but happy that I had not had any significant pain, and wrote me an order for physical therapy, accompanied by stern reminder to do everything gently, gently, gently.   I did not tell her that I had been walking 4 miles a day; no reason to spoil her happy mood.   Both my old PTs were booked up for weeks, so I made an appointment with a new therapist who works out of the gym where I do my work outs.  She listened to my long rambling account of my long rambling injury odyssey, and decided not to put me through another evaluation, but to jump right into therapy.  She had me stand on one foot for her, stand on tiptoes, and twirl my feet around to demonstrate my range of motion, and pronounced me in pretty good shape.  She seemed optimistic, though she might jsut have been an optimistic type of person; it’s hard to say on the first meeting.  But anyway, I liked her better than the infamous “Rick”.  She gave me stretches and exercises with the stretchy-band to do at home.   So now, I have a colorful array of red, blue and green Thera-bands draped on my bedpost.  She told me to do 2 sets of stretches and one set of the resistance exercises daily and not to overdo it.  So of course, I overdid it.  Because that’s who I am.  And today I’m sore.  Lesson learned.

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Today is my follow-up visit with the Sports Medicine Doctor.  I know she will ask me if I am better so I consult my blog to find the answer.  Yes!  A month ago, my ankle was hurting when I ran to catch the train, and now it usually only hurts when I run uphill or run more than about 4 miles.  So that’s progress.  In fact, according to my faithful Garmin, I ran 8 miles without having to stop for pain last week.  So, while I don’t feel anywhere near normal, I can’t deny I am improved.

My appointment is before work.  I talk with the doc and she seems upbeat.  She pinches, er, palpates my tendon and it is still really sore,  but I think that problem can be solved by not pinching it.  It is also still enlarged compared to the other one, but I personally feel that symmetry is overrated.  She says  she doesn’t think we need to do to the thing where they stick needles in your tendon down to the bone until it bleeds.  She says she doesn’t think I need an MRI.  Neither do I.  She asks if I want to renew the nitro prescription and I think about it..hmmm…is there any reason I want to squirrel away some nitro patches for some illicit use?  I can’t actually think of any illicit use for nitro patches, because as far as I can tell they just give you a headache, so I say no.  The doctor thinks I should go back to the PT again and get more advanced exercises.  I agree to do this providing I can find a time when “Rick” isn’t triple booked.  And actually I want to go back,because I want validation that my self-prescribed exercise regime is beneficial.

I stop at the PT counter and ask for a copy of my evaluation from last time I was here.  I scan it hastily and determine that I will need to do lots of googling to get through it, as it is laced with more jargon and initialisms than anything I’ve ever seen before.  I see the term “inadequate flexibility” in about 12 places.  And lots of stuff about rotation and compensation.  In other words, I’m a mess!  But I knew that already. Then I spy a part that really perturbs me.  It’s  the section on ” factors impacting prognosis” and it says:  “low motivation”.  Low motivation!  Me?  Now I really want to go back..just to prove “Rick” wrong in his stinging assessment of my motivation.   In fact, I would say I am highly motivated to go back.  And I plan to demonstrate a stunning improvement in strength and stretchiness.  So there.

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“Rick” has triple-booked today, so he is working with three clients at the same time.  This means he gives me an exercise to do, and I do it, and then I have a 10 minute interval while waiting for him to come back to me, during which I  read my email on my phone and start thinking about other things.  Eventually he comes back and asks me about the exercise I’d just done and by this time I can’t remember how many reps I did or how it felt.  He has me run on the treadmill.  Yay, I get to run!  He tells me that my right knee is collapsing in and I need to strengthen my right hip.  I’m on it!

OK,  this is now my current nightly exercise routine:

back extensions


side-lying quad stretch

pigeon pose

some sort of back stretch thing that I can’t even describe (I’m not so sure this is good for my back anyway)

lateral leg raises against the wall




single leg stand

rear-elevated lunges

monster walks with theraband

hip hikes

figure 4 stretch

bendy foot exercises with the theraband (no idea what these are called)

concentric heel lifts

eccentric heel drops

calf stretches, gastroc

calf stretches, soleus

Sigh…this is a lot of stuff to do…

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Sigh.  Back to the never-ending story of my health-care odyssey: the quest for pain-free running.

March 27.  I see a new PT for my AT problem.  His name is Rick.

Rick’s assessment seems very thorough and takes about 45 minutes, counting all the typing.  He tells me to close my eyes and stand heel to toe and demonstrates that I will fall over.  He has me stand on one foot, and do a squat on one foot, and the usual strength tests.  He explains proprioception and implies that mine is pitifully inadequate.  He tells me I’m weak on the right side, and my muscles are way too tight, which he find surprising in someone who runs as much as I do, though I’m not sure I see the connection.  Also, my hip flexors are both tight and weak, my gastrocs are maybe OK but my soleus muscles are horribly tight, my pelvis is “a little off” and something, I forget what, is causing one leg to rotate and torque my tendon.  In other words, I’m a mess, biomechanically speaking.  This fails to surprise me.   In fact, I’m pretty sure the podiatrist said something similar. Right before he made me the $600 orthotics that were going to throw everything that was out of whack back into whack.  Or whatever.

Rick does not, of course, believe in the shoe theory, or the toe theory, or the stress theory, or any of the other theories proposed by the 11 previous practitioners that I have seen and all the interesting people out there on the interwebs.  Rick has his own theory and it seems to hinge on tight muscles.    The cure: stretch, stretch, stretch.  I tell him I’m not a big believer in stretching.  He tells me stretching isn’t a belief it’s a fact!  Rick is all about facts!  And research!  And studies! And science!  Silly woman!  I tell him it was just an expression, that I do actually believe that stretching exists, I just haven’t found it to be very helpful.

Anyway, as usual, it all sounds vaguely plausible so I resolve to get with the program and dutifully follow instructions.  For a little while, anyway.  Even though this is the 12th health care provider I have seen and many have said plausible things that have failed to solve the problem at hand.   I’m getting sort of tired of it though.  I leave with a printout of my assigned stretching exercises.

One of my colleagues at work today saw me sort of limping about, and gave me the name of his acupuncturist.  So, if this whole science thing doesn’t work out, there’s always that.

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