Active Release Technique

Active Release Technique or ART is a patented and proven manual therapy technique that can speed recovery from injury or surgery.  ART can alleviate symptoms that have been unresponsive to other treatments. Certified practitioners for the NBA, NFL, PGA Tour, and Ironman events utilize Active Release Technique.  It is a hands-on system that allows the practitioner to diagnose and treat soft tissue injuries and peripheral nerve entrapments. ART uses the fundamentals of anatomy and biomechanics to determine and to treat dysfunction in the system.  The “touch” is developed through a comprehensive certification process.  At OrthoWell/Walkwell , we are certified in Active Release Technique for the lower extremity.

So how does it work?  As repetitive injury or cumulative stress occurs to soft tissue, the normal longitudinal arrangement of fibers can become disrupted via the haphazard and erratic formation of scar tissue.  Stretching a muscle with scar tissue only stretches the area above and below the “knot”.  Hence, more stress occurs at the point of dysfunction.  ART entails the application of specific pressure via one’s thumbs or hands on an area of fibrosis or adhesion as the patient actively or passively moves through a specific, guided range of motion.  The “knot” will release through the applied tension.

SO WHAT DO OUR PATIENTS THINK ABOUT ACTIVE RELEASE?

After 13 months of suffering through debilitating left hamstring pain, I had given up hope.  Two courses of PT and multiple trips to my primary and orthopedic specialist brought little relief.  WalkWell changed all that!  Throughout the entire process of evaluation and treatment, I believed from the start that I would one day be painfree.  Today, I have never felt better!”
Chad Konecky, Program Manager for ESPN

How do you get shoulder impingement syndrome?

The shoulder joint is called the glenohumeral joint.  It is the articulation of the top of the humerus bone with the glenoid fossa of the shoulder blade.  It is one of the most complex and most mobile joints in the body.  In fact, shoulder pain is the third most common musculoskeletal disorder, following low back and neck pain (Donatelli).   Because of the mechanical demands placed on the shoulder, it is susceptible to numerous soft-tissue injuries.   One of these injuries is called shoulder impingement syndrome.  It is the result of compression of the soft tissues between the top of the humerus and the undersurface of the acromion process of the shoulder blade.  The most commonly traumatized soft tissue is the rotator cuff tendon.  Impingement results from the cumulative stresses of repetitive shoulder motion such as pitching or sustained overhead activity such as painting a ceiling.  This repetitive stress can lead to tendonitis, rotator cuff tears, bone spurs, or bursitis.

Your physician may classify the syndrome as either a primary or secondary impingement.  A primary impingement is caused by the structural anatomy of the area below the acromial process.  Your physician may determine through X-ray that you have an abnormal variation in the shape of your acromion process.  A type 3 “hooked” acromion makes you more susceptible to impingement and this may require surgical intervention to correct.  On the other hand, a secondary impingement is mostly the result of dysfunctional biomechanics of the shoulder joint.  It may be due to weakness of the rotator cuff muscles, poor posture, shoulder joint stiffness, and/or incoordination/weakness of the scapular stabilizing muscles.  So how do we treat shoulder impingement syndrome at OrthoWell?   Click on the “How do we treat?” link, and click on shoulder impingement syndrome.

“I play tennis and developed pain in my shoulder so strong that I could not even sleep, let alone play!  After the very first treatment (ART combined with joint mobilization) 80% of my pain was gone!  I am practically pain free now after 4 visits.  Thank-you Chris!  Great job!” – DK

What are the BEST shoulder exercises?

Everything we do at OrthoWell is evidence-based!  Maximizing results in minimal time depends on the expertise of the clinician. As our knowledge of biomechanics and muscle function improves, more of an emphasis is placed on scientifically based rehabilitation protocols.  This is particularly true regarding the shoulder and scapulothoracic complex.  In the February 2009 volume of JOSPT, Mike Reinold, the Boston Red Sox team physical therapist, presented a thorough analysis of the shoulder and scapular stabilization exercise literature.  One of the most effective exercises for each muscle will be presented.


Supraspinatus
*Full Can Exercise
*Enhances scapular position>
*Decreased deltoid compared to empty can
*Minimizes superior humeral translation

Infraspinatus/Teres Minor
*Side-lying ER
*Minimal capsular strain
*25% increased EMG using towel roll
*Highest EMG for infraspinatus

Subscapularis
*IR at 90 deg abd
*Position of shoulder stability
*Enhanced scapular postion
*Less pectoralis activity than 0 deg abd

Serratus Anterior
*Push-up with plus
*Easy position to resist protraction
*High EMG activity
*Also activates subscapularis

Lower Trapezius
*Prone full can at 135 deg abd
*Full can = horiz abd with ER(thumbs up)
*High EMG activity
*Also activates infraspinatus, teres minor, Mid traps, supraspinatus

Middle Trapezius
*Prone Full Can at 90 deg abd
*High EMG activity
*Also activates infraspinatus, teres minor, Mid traps, supraspinatus

Rhomboids
*Prone Row
*Below 90 deg abduction
*High EMG activity
*Good ratio of upper, mid, low traps

Combo Exercise
*Bilateral T-band ER
*25% increased EMG ER’s with towel roll
*Good ratio upper:lower traps per McCabe
*Emphasize scapula retraction and post tilting

In addition, it is clinically imperative to ensure proper technique during all therapeutic exercises especially as you progress to other exercises such as plyometrics, closed chain UE exercises, and sport- specific exercise training. Proper exercise TECHNIQUE and proper exercise CHOICE is required to effectively treat the muscular imbalances seen in most shoulder pathologies.

OUCH!!…My shoulder hurts!!

Shoulder pain is the third most common musculoskeletal disorder, following low back and neck pain (Donatelli). Because of the mechanical demands placed on the shoulder, it is susceptible to numerous soft-tissue injuries. One of these injuries is called shoulder impingement syndrome. It is the result of compression of the soft tissues i.e. most typically, the rotator cuff tendon, within the sub-acromial space. Impingement results from the cumulative stresses of repetitive shoulder motion such as pitching or sustained overhead activity such as painting. This repetitive stress can lead to tendonitis, rotator cuff tears, bone spurs, or bursitis.

Impingement syndrome can be classified in two ways – external vs. internal and primary vs. secondary. An external impingement affects the superior surface of the humeral soft tissues in the sub-acromial or coraco-acromial region. Applicable clinical tests include the Neer and Hawkin’s/Kennedy tests. An internal impingement may affect the undersurface of the rotator cuff, the posterior labrum, and is, more specifically, a post/sup impingement. Clinical exam may produce post/sup shoulder pain with passive ER which can be alleviated with a passive posterior humeral glide. A primary impingement is caused by the structural anatomy of the sub-acromial region. X-Rays can determine an abnormal variation in the shape of the acromion process. A type 3 “hooked” acromion may require surgical intervention to correct. On the other hand, a secondary impingement is the result of dysfunctional biomechanics of the shoulder joint. It may be due to weakness of the rotator cuff muscles, poor posture, gleno-humeral joint stiffness, thoracic hypomobility, and/or in-coordination/weakness of the scapular stabilizing muscles. And that is what WE treat at OrthoWell?

“I play tennis and developed pain in my shoulder so strong that I could not even sleep, let alone play! After the very first treatment (ART combined with joint mobilization) 80% of my pain was gone! I am practically pain free now after 4 visits. Thank-you Chris! Great job!” – DK

The Missing Link – SCAR TISSUE

 

Scar Tissue

All physical therapy is NOT created equal. As a physical therapist with 2 decades of hands-on care, I have tried many approaches in treating soft tissue dysfunction. Tissue stress can be identified objectively through a comprehensive biomechanical evaluation and well as subjectively through a thorough interview with the patient. Patient compliance and therapist experience is paramount in achieving maximum results in minimum time. I strongly feel that the “missing link” in achieving permanent, maximum results is inadequate treatment of soft tissue fibrosis i.e. scar tissue throughout the kinetic chain. Let me explain!

One of the most contentious debates that I have had with physicians as well as physical therapists is the inflammation versus fibrosis debate. Many health care practitioners feel that inflammation is the main source of pain in chronic conditions (greater than 3 weeks). This is evidenced through their long-term use of anti-inflammatory meds, cortisone shots, and the over-use of anti-inflammatory modalities in physical therapy such as iontophoresis and phonophoresis. My main adage as a physical therapist is “there better be a good reason for everything you do!” Evidence-based or research-based treatment is fundamental to our professional growth. I feel that using anti-inflammatory procedures is a very effective strategy in the short-term. It is true that we are our own worst enemies during our hectic lives. Intermittent, acute inflammation can certainly occur. However, what underlying dysfunction is present that predisposes us to this chronic, intermittent pain? What does the research tell us?

Karim Khan,MD in “Time to abandon the “tendonitis” myth”, BMJ, 2002, 324(7338):626-7 reports that “animal studies conclusively demonstrate that, within 2-3 weeks of insult to tendon tissue, inflammatory cells are not present.”

Karim Khan,MD in “Histopathology of common tendinopathies”, SportsMed 1999;27(6):393-408 states that “We conclude that effective treatment of athletes with tendinopathies must target the most common underlying histopathology, TENDINOSIS, a non-inflammatory condition.”

Harvey Lemont,DPM in “Plantar fasciitis”, JAPMA 2003;93(3):234-237 states that, after analyzing tissue samples from 50 plantar fascia surgeries, “Histologic findings are presented to support the thesis that “plantar fasciitis” is a degenerative fasciosis WITHOUT inflammation, not a fasciitis.”

Although the literature states that inflammation is not present in chronic soft tissue lesions, many practitioners continue to get positive results with anti-inflammatory procedures. Why? Steroids have been shown to inhibit the early stages as well as the later manifestations of the inflammatory process. (Fredberg 96) Ultrasound guided peritendinous injections of achilles and patella tendonitis have shown a significant reduction in the average diameter of the affected tendons (Fredberg 04) as well as a disappearance of neovascularization. (Koenig 04) What this last statement means is that steroids have the ability to “shrink” pathological tissue. This “shrinking” has been associated with a decrease in pain, but it does not stimulate tissue regeneration and strengthening of the pathological tissue. As a result, the patient is susceptible to chronic reinjury. So how does the therapist stimulate tissue regeneration?

The first step in the process is to identify tissue texture abnormalities. Microscopically, healthy tissue is smooth, longitudinal, and symmetrical in presentation. Scar tissue i.e. fibrosis is laid down by our bodies in a very haphazard and erratic fashion. During palpation, both the clinician and the patient can detect areas of grittiness, nodules, and “knots”. A partial tear in the Achilles tendon is thicker, harder, and gritty compared to the healthy side. Fibrosis in the plantar fascia can be felt and heard as you stroke the edge of a coffee mug along the central band of the fascia. Once a lesion is detected, I utilize patented and proven techniques such as instrument assisted soft tissue mobilization(IASTM) and Active Release Technique to “break up” cross-links, adhesions, and/or restrictions in the tissue. Please read my links for Graston’s New IASTM and Active Release Technique for more information.

As a result of 2 decades of asking questions and critically appraising my successes and failures, I have become convinced that the “missing link” in the treatment of chronic pain is the release of scar tissue adhesions. In conjunction with IASTM and Active Release Technique, rehabilitation is accomplished through the functional integration of strengthening, stretching, joint mobilization, cardiovascular exercise, and compliance with a home exercise program. Correcting biomechanical deficiencies with foot orthotics is also a consideration. Most physical therapists do an adequate job of treating pain. Acute pain usually resolves with the most innocuous of therapy interventions. However, the only way to prevent reoccurrence of symptoms is to ensure that every aspect of the dysfunction is being treated in the most comprehensive manner. At OrthoWell/WalkWell, we do just that!