Do we have medical treatments and cures that will accelerate your body’s ability to heal faster than scientifically possible? We regularly get questions about certain new and novel treatments that are supposed to “have me back running in half the time” or “have me skiing after ligament injury weeks or months before the doctors told me to”. To answer the question simply, NO, we don’t have that. Unfortunately none of us can radically accelerate the body’s ability to heal, but we do have scientifically based techniques and systems for optimizing healing. Let’s look at what really can be done with physical therapy or other interventions. First we can address swelling and edema which tend to limit the body’s ability to heal. When you have a backlog of fluid surrounding a joint blood flow may be restricted. Blood flow is the only way healing occurs. Next, it is vital to optimize mechanics. We are experts at assessing how a joint moves and the forces involved in any activity whether it is walking, running, skiing, cycling, throwing, etc. There are many factors to consider when assessing mechanics, in short, this involves the joints surrounding the area injured, muscular control throughout the entire limb and trunk muscular control. It is also vitally important to alter a person’s habits. What someone does day in and day out including how they sit, how they stand, how they sleep, what they eat, or whether or not they smoke all play a role in how fast someone heals. By bringing these factors to light individuals are able to see what the contributions of their daily habits are to their overall healing. The person is then able to choose what is done in an effort to optimize healing. A fourth component is hands-on or manual therapy. This is one of the most vital components in healing. Most research shows that a combination of manual therapy, exercise and postural changes make the biggest difference in optimizing healing. Hands-on treatment can be anything from soft tissue mobilization for swelling, manual stretching of the joint, joint manipulation and mobilization of scar or stiff connective tissue you. Other things may include hands on guided movement of a joint through a range of motion. Often times the joint has pain with motion when used in a normal manner, but when a particular force is imparted into it a pain pattern changes or goes away.
Simply put, when tissue is placed in an optimum environment it heals at the fastest rate possible. Things we do or don’t do take that tissue into or out of the optimum environment. The more we realize there are no magic bullets or secret techniques that only a few select people possess the more we will realize that healing is under our own control.
I frequently analyze and consider the structure and activity of my treatments. The first analysis that I make is “am I doing the right thing at the right time?” Total knee replacement is one condition that makes this question vital and important. In 22 years of treating this condition, I have found that therapy can greatly help or hinder someone’s outcome. My approach is to work in order on several things that are keys to success. First, I spend a long period of time addressing the edema and pain that occurs with this type of surgery. I work hard on reducing swelling with various techniques including massage, elevation and body movements. Only after we have begun reducing pain and edema do we move on.
The second step is to begin working on motion in the knee. The old images of someone being stretched on the rack are completely outdated and wrong. The approach needed for successful total knee outcomes is gentle stretching performed for a longer duration. Strong and aggressive stretching almost always results in increased inflammation, pain and setbacks.
If we can encourage a person stretch regularly at home and then attend therapy for a regular period of time after surgery they almost always have a good outcome. Once someone has obtained good range of motion it is vital to restore strength.
Several excellent studies show that people with a total knee that did not receive physical therapy had significant leg weakness and overall decreased function. Performing strengthening and range of motion activity is a delicate balance. The knee has only a certain capacity for activity each day. Too much work on strengthening can result in a knee that is inflamed and swollen. By following these steps we see continued success with total knee replacement.
Type in “iliotibial band” or “IT band” on Google. No, seriously, go ahead and Google it. What did you find? I can tell you. The vast majority of websites state that treatment for IT band issues is stretching. Why is that an issue? It seems logical. If it’s tight, then stretch it. The problem lies in that fact that the IT band becomes tight because of faulty mechanics in the lower extremity, not by simply being tight. A quick review of anatomy shows that two key muscles are responsible for moving the leg out to the side into what is termed abduction.
Abduction is vitally important not only for moving your leg to the side, but for stabilizing your leg when you’re standing on one leg with activities such as running or walking. The two main muscles that abduct the hip are called the gluteus medius (GMe), the second one is called the tensor fascia latta (TFL). The TFL is the muscle that inserts into the IT band. This muscle originates on the front outside portion of the pelvis and tapers to the band. The band then continues down the side of the leg and inserts just past the knee. There are two sites that are common for IT band issues. One is at the hip on a bony prominence called the trochanter. The other site is at the side of the knee. When a person does not have good strength in the gluteus medius (GMe) the TFL takes over and acts to stabilize the hip. When this situation occurs the IT band is tensioned. With this tension we see pressure on the trochanter and the lateral knee. This is also the feeling the leads people to believe that the IT band is tight. It is not tight, it is just reacting to the load applied to it by the TFL.
Treatment of this condition includes specific exercises to restore strength of the gluteus medius. The result is significant and dramatic improvements in all IT band issues. The initial exercises for the (GMe) are performed in a position that optimizes the contraction of the gluteus medius. They are performed lightly in an effort to eliminate old patterns of movement and substitution of the TFL. Once this muscle has restored some strength and the ability to contract normally, the exercise load is increased. The final step is to return to dynamic activities such as running or landing from jumping.
I drove by Home Depot the other day and wondered what it would be like to own all the tools in the store. A thought then hit me: If I owned every tool in the store I still wouldn’t be a craftsman. I began to think about healthcare professionals who have or say that they have every technique, device or tool in the world. They acquire every new thing that comes around. Are they really craftsmen? Do they have the ability to use those tools? Do they have a sense of the tissue and what is the right application of force, technique, etc.
I was taught a long time ago when working with tools to master the simplest tools first and then progressively move on to more complex tools. I believe that having a solid foundation in science and evidence-based practice is the first essential step to becoming good as a physical therapist. It is not stuffing your belt full of every tool under the sun. It is about mastering the tools you have.
When I go to a course I tend to find that I learned one or two essential things that help me in my practice. I rarely find the one thing that revolutionizes my practice. I do question others who, every six months, come up with the latest and greatest intervention. Is it really better? What happened to the old “greatest thing”? Is it marketing or is it the truth? I think these are questions that we need to ask ourselves any time we’re about to embark on something, whether it is having a bookcase built, having your car worked on or getting something done with our body. Is the person we see a craftsman or a tool collector?