Listen in to hear my story, and learn more about the mobile physical therapy movement! A Health and wellness studio that comes to you where you are! A true physical therapy clinic on wheels.
Plus the link to my book below: The Pioneer PT Prototype - The Ultimate Guide to Building Your Mobile Health & Wellness Studio so you too can serve rockstar clients!
Ankle Sprain 101 - What to do 1st
Hey, what's going on everyone! It is James Dulkerian, doctor of physical therapy and the owner of Pioneer PT, the first mobile physical therapy clinic.
Today, lets go ahead and discuss ankle sprains. We will discuss what they are, the different grades of sprains, the different types of ankle sprains, and then how to deal with it. That is the most important part.
What is an ankle sprain? An ankle sprain occurs when you stretch the foot a little bit too far, more than the normal range of motion. The most common, is when you land on your foot, your foot turns in and your ankle turns out. That is the most common, with between 70-85% being these lateral ankle sprains or it is called an inversion ankle sprain. The inside of the ankle is a little bit more rare so we are not going to spend much time with that.
In these sprains, what happens is that you stretch the ligaments (ligaments connect bone to bone) too far causing damage. You may also have some tissue damage to the muscle/tendon (tendon attaches muscle to bone).
Grades: Grade 1 is just a stretch of the ligaments. You stretched them a little bit more than their normal maximum range of motion, causing some irritation. Grade 2: that means that you overstretched the ligaments, and this time you have had some failing. Some of those fibers tore. Just some. Lastly, Grade 3. In this case, the ligament had gone beyond it length of support and it has failed causing it to tear completely. Grade 3, definitely takes the longest for recovery time.
With grades the recover time varies. You can be down 1-2 weeks with a minor Grade 1 sprain, but up to about 12 weeks or so with a Grade 3 sprain. Unfortunately, ligaments they due not have as good of a blood supply compared to other tissues in out bodies. Even bone can feel faster than ligaments. Be patient, and hang in there, it will get better.
Now, we covered grades, and approximate recovery times for return to sport. Again, about 2-12 weeks depending on the severity. Then, types, we talking about the inversion sprain being the most common, when the foot turns in and the ankle rolls out. This often occurs walking on uneven ground and your ankle rolls out, you are wearing high heels stepping on an uneven sidewalk and twist it (Think Fells Point in Baltimore). Then most commonly it occurs in sports when running and cutting or in basketball, this happened to me in high school. I sprained it once, and then sprained it again. (The doctor never sent me to physical therapy at that time to strengthen the ankle). I went up for a rebound and come down on another players foot, causing the ankle to twist.
Research shows that the most common cause of injury is a previous injury. Make sure you get it taken care of so it is not a reoccurring issue.
Most ankle sprains are low ankle sprains. High ankle sprains can also occur, but this is more rare. A high ankle sprain occurs with the tissue between the two lower leg bones, the Tibia and Fibula.
What do you want to do when you have an ankle sprain? When you have an ankle sprain the easiest acronym to remember is called P.R.I.C.E. What does P.R.I.C.E. stand for?
First, you want to protect it. You want to protect it from further damage. Depending on the severity the doctor may prescribe you crutches to unweight the ankle. You can also consider wearing a brace/tape so you do not twist it again. Something to protect that ankle. That is P.
R stands for rest. With a sprained ankle you want to rest it, meaning you want to get off of it early on to protect it from positions that irritate it or be angry. An angry sprained ankle is when it is Warm, Swollen, Red, and Painful. When it is angry you do not want to do things that aggravate it. Therefore, R stand for rest.
Next, one of the most common things that you want to do is Ice. Ice initially after an ankle sprain for at least the first 3 days. Ice helps to bring swelling down by constricting your blood vessels so it does not get more and more swollen, and more painful causing further tissue damage. Use an ice pack on there at least 20 minutes per hour. I would recommend ice at least 3-5x a day at a minimum for at least the first 3 days. Also, for the ankle, I really like an ice bath. Fill a bucket full of ice water, and dunk your foot for 30-60 seconds and then take out for 30-60 seconds, then dunk it back in. It is tough, but I would try to repeat the process for about 5 minutes. Get the ice on there to control your inflammation.
Next, we are talking about C. C stands for compression. Please wear an athletic sock as it tends to have a little bit more compression down in the foot, and (It is easiest to get on in the morning first thing) wrapping your ankle. You can use an Ace bandage. It does not have to be super tight, because you do not want your toes turning purple or red. That means it is too tight cutting off the blood flow return by creating a tourniquet. Back off if that is the case. In general wrap from the toes to above the ankle, and grade it, meaning have a little bit more compression down in the foot and less compression above the ankle. Wrap tighter at the bottom and as you go up decrease the tension. That helps to pull the fluid back up. We want to get that fluid back up towards our hip.
That leads to the last one, E. E stands for elevation. Ideally you want to elevate your foot above your heart. Use at least 2 pillows one under the thigh and one under the lower leg. Lying back on your back this will help elevate the leg. That way we have the assistance of gravity to help pull that fluid back up towards the hip and towards the abdomen so our lymph nodes can recycle that fluid and get rid of it.
P.R.I.C.E. the easiest acronym to remember. Protection, Rest, Ice, Compression, Elevation. That is the best method for treatment of the ankle early on.
Hey, what's going on everyone! It is James, Doctor of Physical Therapy and the owner of Pioneer PT.
A few people reached out after my last post and asked, "How do I know if I have enough mid back mobility?"
Well, here is a quick and easy test that you can do to find out!
You just need 2 things. You need some type of stick or dowel, and a chair without arm rests.
We are going to be sitting on the very, very corner of the chair looking at both straight lines of the chair for this test.
-Sit on that corner.
-We will go left first, so cross your left foot over your right ankle.
-Place the stick behind your neck
-& rotate left as far as you can comfortably
For adequate range of motion you should be going past the straight line on the chair for your mobility of your mid back.
Repeat on the other side, and if you do not have symmetry, or you cannot go past that straight line, then you know there is an issue and it should be addressed.
Without proper mid back mobility, you must move more elsewhere throughout the spine and this often leads to neck or lower back problems. Please reach out to Pioneer PT with any further questions.
Let's talk about the importance of Mid Back Mobility or Thoracic Spine Health:
We want good rotation and extension through the mid back, so we can take some pressure off both the neck and shoulders as well as the lumbar spine, or your lower back.
A couple quick exercises that you can do are the Cat-Cow. First, drop your head down, round your back, tuck your tail, take a big deep breath at end range....and as your blow out, bring your head up, drop your belly down towards the floor, and again big deep breath at end range. About 10-15 repetitions.
Then, you can drop back, butt to heels, and lead with your head, reach up towards the sky. Do this on both arms, again between 10-15 repetitions. It will help you to loosen up and feel good through your mid back.
Try it out and comment in the section below as to how it's helped.
Desk Jockey Back Stiffness 101
Are you a weekend warrior who works as hard as you play, or do you simply enjoy getting outside for a walk after a long week at work? If you are stuck behind the desk or in the car for prolonged periods, you have probably felt back stiffness and difficulty when first standing up. You are not alone as many desk jockeys feel these symptoms.
First, I will tell you why you experience this stiffness, and then we will address it with simple exercises that can be performed while at your desk and during your work day.
Why is it that you feel really stiff when first standing after a prolonged period of being hunched over your desk or computer? In short, it is the dreaded HIP FLEXORS! In the image below the Psoas Major and Iliacus are the primary hip flexors. Hip flexion is the motion of bringing your knee closer to your trunk. This muscle becomes shortened when in a sitting position. If you are stuck seated for a prolonged period, the hip flexor becomes shortened, and it is difficult to stand tall when first getting up. Tension of the hip flexors is coupled with tension in the small of the back.
When the hip flexor on the front side of the hip becomes shortened, that means the opposite is likely true on the backside, causing the hamstrings to become weak and long. Coupled with long and weak hamstrings are long and weak lower abdominals.
Both short and tense or long and weak are not ideal, as muscles function best at mid range. Mid range also creates balance that is necessary around the spine.
Now that you have a better understanding of the effects of prolonged sitting and the havoc it can cause to the lower back, let's get to how to reduce back stiffness with exercise that can be performed at your desk.
See the video below for a quick routine that can be done at your desk to help reduce lower back stiffness. Both static stretches and re-education exercises are included to first improve mobility and then lock in these gains.
Ideally we should all change position every 30 minutes by getting up to stand or walk at least a short distance, but at many jobs this is very difficult. Many people do not have the flexibility or time. Standing desks can be great option to help accomplish this, keeping employees healthy.
Please complete this routine every day you are stuck at your desk for an hour or more. Initially focus on the portion of the routine that you feel the most. Comment or share with a friend who may be in need of the same knowledge to reduce back stiffness. Knowledge can be very powerful, and empower us all to live a happier, and more mobile lifestyle.
Pioneer PT's goal is to help those with a busy lifestyle to get the treatment they deserve to live without pain pills or unnecessary surgeries so they can continue to be strong, mobile, and on-the-go. Visit www.pioneerptmd.com for more details.
See How To Video Below
Diaphragmatic or deep breathing is essential to our well-being. It is a normal way of breathing that utilizes the diaphragm to increase oxygenation to the rest of our bodies. The diaphragm is a muscle that runs horizontally across our midsection that separates the chest from the abdomen, and it's sole purpose is for respiration.
There are many positive effects from this type of breathing as it helps to shut off the fight or flight response and promote relaxation. Health benefits include decreased stress, anxiety, depression, high blood pressure, and headaches. It helps to reduce breathlessness in people with COPD or asthma. It is also utilized by many singers and musicians. This is crucial as summer is drawing to a close and the busy time of the year begins to ramp up with increased demands from work, school, and the holidays.
You may be thinking, how does this work? I want you to think of a time you have been stress or have even seen a person on TV hyperventilate. What happens? The rate of respiration increases, which increases oxygen levels, but also decreases carbon-dioxide in the bloodstream. This causes increased agitation, and why you may see people breathing into a bag on TV. Carbon-dioxide is actually a benefit as it helps to calm you down. This is one way that deep breathing works by creating an optimal balance of oxygen and carbon-dioxide in the blood stream to help with the calming effect. It is also why I recommend breathing OUT for 1 more second than breathing in during a stressful time. It also works because secondary muscles from the neck and chest do not get involved with respiration. These muscles are not meant to have the type of endurance it takes to breath 24-7 and often get tense and sore from the inability to keep up. Tension in the neck does not feel good and can often lead to even greater anxiety.
How do I perform deep breathing?
Remember to "SMELL THE ROSES & BLOW OUT THE CANDLES"
With March Madness now, spring almost here, and lacrosse season upon us, lets talk about lacrosse and basketball. How do you get into shape for lacrosse? Do you lift weights, do you run, do you play a different sport? I believe that a combination of training techniques should be considered, however, basketball is a great sport in combination with lacrosse. Minus indoor lacrosse, basketball season and lacrosse season do no coincide, making them an ideal match. With basketball season prior to lacrosse season this could be the perfect set up.
What is the best sport to play in the off-season before lacrosse? I believe that basketball is the best cross-training for lacrosse. It helps improve cardiovascular fitness, increase quickness, increase toughness, and is also similar with game movement. What do I mean by game movement? I am referring to team sliding on defense when someone gets beat. I am talking about offensive cutting and movement with the ball. Team riding/pressing and clearing is also very similar. Everything down to body position to protect the ball are comparable in each sport.
Size is now beginning to matter in lacrosse more than ever as attackman are as big or bigger than defenseman. Basketball players just so happen to be the largest most nimble athletes. However, being quicker and faster than the opponent still has its place in any sport. There are always exceptions, but attackman and guards generally work in a similar fashion, as do defensemen and forwards. Middies are a a combination of both. Could you imagine Lebron James with a lacrosse stick? Could he have been a new school Jim Brown? That would be tough to beat, but is a great example of how playing multiple sports is key to performance. Performing the same sport all year around is not advised due repetitive stress and increased likelihood of over-use injury.
I loved running midfield as you had the chance to play both offense and defense. Middies, you have got to be in shape and have the ability to run up and down the field with explosive bursts. A well executed fast break ending in a goal might be one of the sweetest feelings in team sport. Endurance training or even playing soccer in the offseason may help you in this area. You must also be strong and explosive. Lacrosse is the fastest game on two feet, and you are the ones who set the pace. Be explosive when powering through a ground ball. Exercises like squats, lunges, deadlifts, and basketball can help in this regard when staying low, stable and balanced. The face dodge is similar in quickness and cutting pattern as a cross over, and one of the most satisfying moves as you blow by and overpower your opponent. Allen Iverson did it best, but Paul Rabil is pretty nice too.
Attackman, you don't have to run as much, but while the ball is on the offensive side of the field you better be running 110% until that ball crosses midfield. You must be some of the quickest guys on the field. Strength training for a stable base of support and footwork drills are important for you to beat your man to the spot. Going to the hole is like going to the goal. You are the point guard from behind the cage or off the dodge looking to pass or make something happen by getting a step on your man.
Defenseman, you are some of the strongest guys on the team, and hold the fort down for the lonely Goalie. Strength or hypertrophy training is advisable to help keep the offense in check. Again, a balanced and stable base is essential with the inclusion of deadlifts, squats, and lunges into training. Good footwork and stable base is essential, which sounds eerily similar to a basketball player. Team defensive movement and positioning or sliding are almost identical in both basketball and lacrosse. But, do not forget defenseman still need to be able to run not only to keep up with attackman, but also to help clear the ball. Basketball players must run up and down the court too help with cardiovascular fitness.
Indoor lacrosse takes the fastest game on two feet to the next level allowing the game to be even more like basketball due to size of the field and quickness necessary. The take home message is to play different sports. Being a multi-sport athlete promotes different training patterns that help improve body control, with an added bonus of decreasing chance of injury.
Baltimore - Reduce Lower Back Pain Today
Hi, this is James with Pioneer PT. Day in and day out I get asked about lower back pain. It is the most common thing that people get. About 80% of people get debilitating lower back pain at least once in their lives. So, I wanted to come out with a video to show a few of the easiest exercises that people can start with. These are universal and most anyone with lower back pain can benefit from these. One of the hardest ones to teach is called a pelvic tilt. I want to go into more detail on that first.
While lying on your back, I want you to pull your pelvis up. I want you to think about pulling your belly button up and in and flattening your back to the bed. Think about your tailbone, your tailbone should be dropping towards your feet while your belly button pulls up. If you want feedback, with your hands wrapped around your hips; when you tighten up pulling your belly button up and in you should feel the abdominal muscles right underneath your fingers become tense. Hold this one for a good 10 second count and get at least 10 of those to help strengthen your core.
Next one, a nice easy stretch you can do is called a lower trunk rotation. Stretch from side to side, nice and easy, helping to gap the lower back. Get a good hold as you go side to side (10-30 seconds)
Lastly, I would recommend a piriformis stretch, to stretch out those tight glutes. With your ankle resting on your opposite knee, grab your knee (closest to the joint), and pull up and across getting a good stretch through your glutes. If you prefer more of an intense stretch, you can grab under your opposite leg and pull up. This will also target down on the glute. in the piriformis. Try to hold a good 30 seconds to a minute, and relax.
To review, the 3 universal exercises you can do for lower back pain include, pelvic tilts, lower trunk rotations, and piriformis stretching. If you have any severe aches or pains, especially burning, tingling, or numbness increasing, please contact your physical therapist. Take care, and best of luck!
How Pioneer PT helps get you back to the active lifestyle you deserve without pain medication, injections, or surgery.
Pioneer PT is revolutionizing the delivery of physical therapy to active individuals assuring the most convenient and highest quality care through one-on-one visits at your doorstep by:
Are you experiencing lower back pain, neck pain, or headaches? Maybe it is shoulder pain, knee pain, or hip pain?
Do these aches or pains cause trouble with daily activities, or even worse, cause you to miss out on moments that make you happy?
Have you been told that you need surgery, are tired of taking pain medicine, or want a second opinion for a conservative treatment approach?
Have you received treatment and were frustrated with the amount of time you spent with the specialist? Do you prefer an honest, caring, and professional relationship with your provider?
Do you want the ability to have "tune ups" to maintain a healthy lifestyle?
Is your day-to-day schedule busy? Would you like the ease of your own personal physical therapist come to you?
If you answered YES to any of the above questions don't wait, Call (410) 929-3532 and get back to the active lifestyle you deserve.
For most distance runners foot strike is irrelevant to performance (1). Naturally foot strike occurs through a continuum, depending on speed. Sprinters benefit from forefoot running to maintain explosive quick movements. Frequent short strides are taken to get moving quicker and propel forward faster. However, healthy long distance runners show no clear benefit from the type of initial contact, and most runners have a rear foot strike (1). It is normal to have a heel strike as stride length increases.
When would mid-forefoot strike be beneficial? One study suggests that a 6:25 pace per mile is the transition point where mid/forefoot striking may be more efficient (2). However, this may be best for elite runners that choose a mid foot initial contact and are biomechanically sound. The majority of long distance runners chose heel strike, and it is not necessarily wrong (3). As with any type of training it is not recommended to suddenly increase or change training habits. Changing habits too quickly can result in injury.
Force with each running style is almost identical, however it is spread differently to the body. Forefoot runners absorb more vertical force in their foot and ankle, while heel strike runners absorb more force up the chain specifically in their knees (4).
In a 2017 study, Hamill suggests that changing style of contact is not beneficial for most runners, as it can result in injury, however changing style of running may be beneficial for some (1).
Chronic lower extremity pain including achilles tendonitis, plantar fasciitis, and patellofemoral pain may be taken into consideration. Runners with chronic anterior knee pain and clicking at the patellofemoral joint may benefit from slowly transitioning to more of a mid foot style running to decrease knee joint forces. This should be done gradually. Other biomechanics should be considered as well, such as achilles flexibility and arch type. Decreased ankle dorsiflexion and high arches may result in achilles tendonitis, plantar fasciitis, or metatarsal stress fractures, especially if the transition occurs too quickly. Individuals with high arches may also be succeptible to ankle sprains with this running style. On the other hand if you are an elite runner who typically runs with mid foot strike, transition towards heel strike may be beneficial if you are struggling with achilles tendonitis.
Bottom line, for most, heel strike running is sufficient. However, the above considerations may be beneficial with certain conditions. It is best to consult with a professional to help answer these questions as everyone is unique and if your body is in pain, it is telling you to back off.
1.) Hamill J, Allison G. Is changing foot strike pattern beneficial to runners. Journal of Sprite and Health Science. Vol. 6, issue 2, June 2017, Pages 146-153
2.) Ogueta-Alday A, Rodriguez-Marroyo JA, Garcia-Lopez J. Rearfoot Striking Runners Are More Economical than Midfoot Strikers. Med Sci-Fi Sports Exerc. 2013 Aug 30
3.) M.O. de Almeida, B.T. Saragiotto, T.P. Yamato, A.D. Lopes. Is the rearfoot pattern the most frequently foot strike pattern among recreational shod distance runners? Phys Ther Sport, 16 (2015), pp. 29-33
4.) Hamill J, Allison H. Derrick G, et al. Lower extremity joint stiffness characteristics during running with different footfall patterns. European J Sports Sci. Oct 15, 2012.
Baltimore- How to walk on ice
Hey Baltimore this is James with Pioneer PT. I wanted to talk with you guys about walking on the ice. We have some slippery conditions coming this evening. Unfortunately we are in the area of the country where we are at the rain, snow, sleet line. You have to be careful when you are out and about walking in the winter.
When you are walking on the ice, first thing I would recommend is some good shoes. Good shoes with good tread, with nice raised bumps on the bottom of the shoe is ideal. With a flat soled shoe you will end up slipping and falling. As for body mechanics there are quite a few things you can do. First off, you want to think about widening your base of support a little bit more than usual when you are walking, that way you are wider and more stable. Also, when you are walking, try not to land with your heel. If you land with your heel first, you tend to slip back and fall on your rear. Instead, I recommend landing flat footed or slightly towards your toe first. That way you are landing soft and you are not going to tend to slip backwards. So wide base of support, land with a flat foot, and lower your center of gravity by bending your knees and hips bringing you closer to the ground. You are a little bit more stable. You can also use your arms a little bit wider to maintain nice center of gravity. So you are walking a little bit more gingerly on the ice. Be careful out there, enjoy the winter, and take care!
Why Knee Pain affects Runners?
Why runners? It is due to the repetitive nature and high forces involved with running. Release techniques and strengthening exercises for treatment are available, however there are other factors to consider.
Runner's knee is a common condition that is caused by decreased mobility of the knee cap (patella) on the thigh bone (femur). If lacking proper movement the patella can be compressed into the joint causing irritation and pain in the front of the knee. Sometimes people even feel an ache that extends down into their shin. This is called Patellofemoral Pain Syndrome. Clicking or popping is often reported, especially with squatting or stairs. Some clicking here and there is fine, but the knee should not be clicking repeatedly. Pain often occurs when first moving after a period of rest, or can also occur with prolonged activity towards the end of a run. If this is the case, do not wait, call your physical therapist to do something about it. Otherwise, the cartilage under the patella can be worn down over time causing lifelong effects.
Weakness of the core, hips, and inner thigh, cause increased stress and formation of muscle imbalances. Muscle imbalance is one of the likely causes of increased tension . Muscle tension then builds up along the outer portion of the thigh down to the knee. These connections to the patella cause it to tilt compressing it into the joint. A physical therapist can diagnosis this condition and begin treatment to both release the areas of tension, and provide proper strengthening exercises to keep knee pain from coming back. One of my favorite techniques for release with quick results is myofascial decompression. This helps to lift the tissue increasing circulation and promoting proper mobility of muscle fibers. Self treatment tools can be valuable as well.
Runner's knee can also occur due to lack of control of the foot during initial contact to the ground, causing "over pronation" or when the arch of the foot collapses too fast. This is where it is important to replace your running shoes every 300-500 miles, because the foam is no longer supportive. It is also important to have the proper shoe for your body and is recommended that you go to a running specialty store for proper shoe fit. Holabird Sports or Charm City Run are good examples in Baltimore. Some people have high arches, while others have flat feet. High arches cause increased force translating up the chain to other joints especially if you are a heel strike runner. On the other hand people that roll over too quickly may develop discomfort too due to lack of control (too much side to side motion). Repetitive stress in this manner will also increase compression of the patella. If strengthening alone isn't enough, lack of control of the foot and ankle may be remedied with motion controlled shoes or orthotics. When running the lower leg should be stable and controlled when your foot is in contact with the ground without excessive rotational or side to side motion.
Exercise is the fountain of youth, but proper body maintenance is required to continue to lead a happy and active lifestyle. Stay moving my friends.
Hey whats up guys? It's James with Pioneer PT, and I wanted to talk with you today about self release. Specifically for cyclists and runners. Both involve a lot of repetitive stress. For cyclists revolutions per minute (RPM) are about 60-80 revolutions, runners you hit the ground 80-100 times per minute when you are running, and all that repetitive stress can lead to patellofemoral pain or IT band syndrome.
Lets go over how to self release properly. We are going to start with a foam roll. Foam rolling is one of the most common methods for self release. For self releasing with a foam roll you want to target more on the muscle. You do not want to hit the IT band itself. The IT band itself is about the consistency of a leather belt. It is very hard connective tissue that runs down the side of your leg and attaches to the lateral (outer) portion of your knee. Instead, try to focus on your lateral quad. (outer thigh), and your gluts. Specifically your TFL (tensor fascia lata).
Many of you have seen, the foam roll here, you cross your upper leg on top and roll that back and forth. Target at the top of the hip first. Specifically more towards that front half, so you can hit that TFL, which is the muscular portion that leads into the IT band. You can make a much bigger difference on the muscle than you can on the tendon. As you go down focus more on the front part of your leg on the quads, on that lateral (outer) aspect. Back and forth there, if you find a specific spot that is tender. Hold pressure to it. Hold it until you feel it release. It may be a minute, 90 seconds, or even a few minutes. To target that a little bit better, I prefer a lacrosse ball. A lacrosse ball is much more specific and you can hit those "knots" better. So you can start in the gluts again here, right around the hip. Don't go directly over the bone, but you want to go adjacent to it. Find those "knots" in the side of the hip. They are often a little bit more to the front. That will be the TFL that leads into the IT band. When you find an area of tension, hold pressure to it until you feel it relax. You can also target down by the knee. Try to get more quad (thigh). Again, hold until you feel it release.
And that is it for self release today. Please remember target your lateral quad and the outside of your hip. If you continue to have these symptoms and you cannot maintain a healthy leg, come see your physical therapist. We can target specific strengthening exercises that will prevent that from happening again in the future. Take care, bye bye.
Video Into and Tour of Pioneer PT
"Hi my name is James Dulkerian, doctor of physical therapy, and owner of Pioneer PT. I have been a physical therapist for about the past 10 years, and I always wanted better for the patients. So I came up with a mobile clinic. A mobile clinic has a lot of advantages. A couple main things, it is much more convenient, and it is also patient-centered. I can see each client one-on-one for a full hour, all with a doctor of physical therapy. You will not be passed off to another person. You will not be seen at the same time as another person. That's a huge advantage, that way I can focus on getting to the true source of the discomfort. Also being mobile, I can see you at the local park, I can see you at your home, and I can see you at your office, or anywhere we deem fit. That way it takes the stress out of commuting to physical therapy when you are not feeling well, because I show up to you.
I would also like to give you a look inside today to see what the mobile clinic is like. Inside I have a private treatment room, with a bed that I can take inside your home or office if you feel more comfortable. In the back, we've got all the equipment you need for strengthening purposes, and extra equipment in the cabinets. The van also has plenty height. I am over 6'2" and can still reach overhead. That way, if the weather is bad, we can keep the work inside, but we also have the advantage of going outside when the weather is great.
If you have any questions or concerns please feel free to reach out. I can be reached at (410) 929-3532 and I can help answer any questions you may have. I want to see you pursue your passions to the fullest! Take care."
Marathon Season Recovery
Congratulations and special shout out to everyone who participated in the Baltimore Running Festival! It is marathon season and you have just completed 26.2 miles! It is a lifetime achievement to be proud of and something that not many people can dream of accomplishing. The amount of preparation, hard work, and determination it takes to complete a marathon has paid off.
But now what? More than likely you never trained for the whole 26.2 miles, but rather only about 20 miles for your longest run and then relied on adrenaline and determination to get you to the finish line. By that 20 mile marker you could start to feel it deep in your muscles and joints. Asymmetries are bound to form as one calf tightens, you start to cramp in a hamstring, or your IT band becomes irritated as you push your body to its limits to reach the finish line. The soreness is from over-stressed muscles, which have caused micro tears within the muscle. Don't worry, this is a normal occurrence and your body will work to rebuild and become stronger. It does not change the fact that you may be sore.
Initially a hot/cold alternating shower to improve circulation, then refueling your body with proper fluids and protein should be taken into consideration. Starting the second day, a combination of rest with non-stressful movements to promote blood flow to sore muscles will be important to decrease tension. Try an easy walk, swim, stretching routine, or easy yin style yoga. You hope these areas of tension go away on their own with rest, but they often hang around feeling restrictions even with daily activities. After the initial rest period when you begin back training these muscle imbalances can hinder your body from performing at its peak ability and can lead to more serious injury.
It is advised that you follow up with a knowledgable physical therapist who can work these imbalances out through deep tissue work or even myofascial decompression. They will also teach you strengthening exercises to improve your running form by targeting the specific areas of weakness that lack the necessary endurance for such a long distance. If treated early you will often only need 2-3 sessions to get back to your baseline, plus you will have greater knowledge to maintain your body in the future. This is all at a relatively low cost considering registration fees, running shoes, hotel room, and your desire to continue your lifestyle in a worry free manner.
Pioneer PT has the ability to come directly to you via a mobile clinic and provide one-on-one care with a doctor of physical therapy for a full hour. Service is direct care meaning you will not need to waste crucial time going to your doctor or a specialist for a prescription. Pioneer PT is your musculoskeletal expert and direct point of access for heath related needs.
Meniscus surgery is wack
The meniscus acts as a cushion in the joint between the thigh and shin bone as well as providing extra stability at the knee. It naturally moves forward and backward in the joint depending on the knee position.
Arthroscopic surgery usually involves meniscectomy, which means to cut out or remove a portion of the meniscus. Why would you want to cut out the cushion in your joint? Could this possibly contribute to more "bone on bone"or joint irritation and degeneration? The failure rate of meniscus surgery is fairly high (1), and often leads to total knee replacement.
To top it off, research at the highest level is showing that there is no difference between groups for surgery verses no repair in 35-65 year olds (2).
Here are my suggestions:
1.)Majeed H, Karuppiah S, Sigamoney KV, Geutjens G, Straw RG. All-inside meniscal repair surgery: factors affecting the outcome. Journal of Orthopaedics and Traumatology : Official Journal of the Italian Society of Orthopaedics and Traumatology. 2015;16(3):245-249. doi:10.1007/s10195-015-0342-2.
2.) Sihvonen R, Paavola M, Malmivaara A The FIDELITY (Finnish Degenerative Meniscal Lesion Study) Investigators, et al
Arthroscopic partial meniscectomy versus placebo surgery for a degenerative meniscus tear: a 2-year follow-up of the randomised controlled trial
Annals of the Rheumatic Diseases 2018;77:188-195.
Fall Mountain Biking Tips:
Fall is my favorite time of the year in the Mid Atlantic. The colors, the smells, the weather, the food, and family are all amazing. It is the perfect time to get outside to take it all in and enjoy a nice trail ride.
The leaves are now falling and they sure look nice, but this is the time of year to be careful on the trail. Freshly fallen leaves are slick and act just like ice. They also hold moisture longer, which adds to a slippery ride. These tips will not only benefit you now, but can help you to become a better rider when conditions are ideal. Here are some tips to enjoy the fall mountain biking season.
First thing is first, know the trail if you are planning to get after it. Knowing the trail does not make it boring, it makes it more fun. Riding new trails are exciting, but it is not as enjoyable not knowing where you are going or the typical conditions. Your "home trail" is more fun, because you learn where you need to carry momentum to make it up a hill more easily, or hit off a log or rock to catch some air. You also learn where to slow down so you do not take a spill in sections of the trail that are technical or wet. Lessons are often learned the hard way and you remember them.
Second, always keep your eyes down the trail picking a line of attack. This will help you to avoid obstacles that slow you down and decrease the chance of pedal strikes. Sometimes with the added leaves and sticks that have fallen it will actually smooth out the trail in certain sections. Maintaining speed and keeping your eyes up allows you to hop obstacles that may be obstructive and help you to maintain a more direct line of attack on the trail. Always stay on the attack with the most direct route.
Third, stay light on your bike. This includes your hands and feet. There is no need to give your handle bars the death grip, it will just increase fatigue. Staying light on your bike allows you to roll over obstacles easier. For example helping to pull your bike or hop over an obstacle by first pulling up on your handle bars and then lifting your bike with your feet will decrease hard hits that slow you down. Use your legs to absorb the hits rather than holding your body stiff, and you will last longer on the trail.
Fourth, you must understand center of gravity and not be afraid to move around on your bike! Riding in a straight line it is definitely more efficient to keep your body still, but how often is your trail straight?
Keep your weight over your rear wheel the majority of the time. This will assist descending and even more so ascending. Keeping your weight over your rear wheel and maintaining a seated position will ensure that all the power you put out goes directly into forward momentum. If your weight shifts too far forward to your front wheel, then those difficult ascents will turn into hike a bike because your back wheel will lose traction and spin out especially on the leaves. On descents keeping your center of gravity low by either hanging off the back of your seat or hitting the dropper post will allow you to have greater control. The front wheel will float over obstacles and have less chance of hanging up causing you to go over the bars.
Watch the camber of the trail. For example, if the trail is on an angle from left to right with the left being the high side, DO NOT lay your bike on edge to left in attempt to turn left. These extremes cause decrease tire to ground contact area and with the slick conditions make you prone to slipping out. Instead shift your weight on the bike by moving your body to the LEFT with gentle handle bar turn to the left. Try to keep the bike more upright, which increases tire to ground contact area and helps to maintain traction.
Fifth, we just touched on: maintain maximum tire to ground contact area. This can also be achieved by running lower air pressure in your tires, which increases surface area of tire to ground contact. This can be achieved best tubeless, or with plus sized tires. 29 inch wheels have more contact area than 27.5, but fat bikes rule when conditions are not at the best.
Enjoy, stay safe out there, and see you on the trails!
Ice or heat? R.I.C.E or M.E.A.T?
One of the most common questions asked by clients is what to use for their injury, ice or heat? Both have their place, both are beneficial for pain relief, but one may be better than the other. Ice constricts your vessels helping to limit swelling, and heat increases circulation helping the healing process by bringing beneficial nutrients and flushing out the waste. Both heat and ice also assist in reducing pain because they give our bodies another sensation to contend with. When ice or heat are applied, our larger sensory pathways kick in and help to overshadow the smaller pain pathways; therefore dulling the effects of pain.
Traditionally ice is used 20 minutes on, 20 minutes off for the first 2-3 days after an injury. This is where RICE comes into play. RICE stands for Rest, Ice, Compression, and Elevation. RICE along with NSAIDs or non-steroidal anti-inflammatory drugs such as Advil are often utilized. However, please consult with your doctor before taking over-the-counter medication, because NSAIDs have been shown to limit long-term bone and tendon healing. Swelling is at its peak at this point and it should be reduced, or should it? Reducing swelling will reduce pain short-term, but our bodies produce this for a reason. Swelling acts as a natural "splint" causing us to protect the painful area and promote healing when it is most crucial.
Now, the next step depends on the extent of injury and you should consult with your doctor or physical therapist before beginning. Here, MEAT, another method of dealing with injury comes into play. Timing can range from the day of with a minor muscle injury to 1-2 months for severe ligament or bone damage. MEAT stands for Movement, Exercise, Analgesics, and Treatment. I am a huge fan of early mobilization as long as there is no fracture or surgery requiring a lengthened rest period. Nothing crazy, but movement targeting gentle range of motion should be initiated early on after injury. Heat applied for 10 minutes prior to motion can promote circulation and allow greater ease of motion. Exercise should begin next, starting to strengthen the muscles surrounding the injury site. The easiest type of exercise is an isometric where you tighten a muscle without moving, like when power lifters pose by tightening their muscles or some of you may know Charles Atlas. Concentric exercises, followed by eccentric, and finally progressing to full body functional movements with the goal to return to activity. A is for Analgesic, which means dulling the pain like Tylenol or Acetaminophen. Tylenol helps to dull the pain without limiting circulation like NSAIDS. Pain relief promotes improved movement, but Tylenol too can have side effects. Those with liver problems may want to stick to ice and heat if pain is tolerable. Again with medication please consult with your physician or pharmacist if you are unsure. Finally, Treatment that involves mobilization and releases by a skilled practitioner such as a physical therapist, who is an expert in movement will help you return to full function and the activities you desire.
Unfortunately there is no straightforward answer, but I will try to clarify. I prefer a combination, as pieces of both RICE and MEAT have their benefits. Swelling acts like a natural "splint" for a reason during the initial healing process. At a micro level our bodies need this crucial rest period to heal. However, do not wait too long because humans are the best at compensating and will often find other ways to function, which is not always the best. Ice can and should be used early on for the first 2-3 days after injury then a combination of heat and ice can be used to promote circulation during the rehab process.
5 Benefits of Physical Therapy
1.) Improved mobility : You will have greater flexibility and freedom to move as you like through targeted mobilizations and stretches that are catered specifically to you and your problem.
2.). Strength gains: You will have improved strength and control during simple and complex functional tasks by addressing the correct muscle groups.
3.) Decreased Pain and discomfort: With an increase in range of motion and strength, you will have less inflammation of tissues and decreased pain. This decreases the need for long term pain medication use and it's potential side effects.
4.) Have tools to manage symptoms: Physical therapy is unlike chiropractic work or massage therapy, because we encourage active participation in wellness through education. Education of posture, a specific home exercise program catered to you, and information on how to best deal with your condition.
5.) Do what you love to do without restriction: Improving flexibility and strength, as well as decreasing pain and providing intentional education allows for you to return to activities that you love with decreased discomfort and fear.
The vision statement for the American Physical therapy Association is "Transforming society by optimizing movement to improve the human experience." That is my role and my wish to share with society. We are only here for so long, so why not enjoy the treasures that life can offer?
What does a physical therapist (PT) do? I wanted to address this, because I am not sure enough people know exactly what PTs can do to help. Our job is to reduce a client's pain and improve or restore full mobility through hands-on techniques, individualized exercise programs, and education to prevent or manage their condition. We work on everything from head to toe that is musculoskeletal in origin. Some of the most common problems include rotator cuff issues, and neck or back pain. Both acute, or chronic issues can both benefit from a proper treatment plan. Treatment often allows clients to avoid costly surgery or the need for prolonged use and side effects from pain medication. We promote life-long health benefits by promoting fitness or wellness oriented programs that allow you to be more active.
How do we do all of this? First off, we are highly-educated and licensed health care professionals. I went to Ithaca College for both undergraduate and graduate degrees, graduating with a Doctorate of physical therapy. Graduating from an accredited university is a prerequisite prior to sitting for an intensive state licensure exam that you must pass in order to practice. Then, one of the most important parts, we evaluate each client as an individual, gathering a history of their health and current symptoms. Evaluations typically start out similar to an interview delving into what is going on, how long it has been going on, what makes symptoms better or worse, etc.. We will then proceed to a systems review, palpate tissues and joints, screen strength, range of motion, and functional mobility. If problems are apparent, special tests can be performed, which allow a physical therapist to be able to confirm a diagnosis. For example tenderness to lateral or outer joint line of the knee alone has been shown to be very accurate in diagnosing meniscal injuries. Between the history and evaluation we are able to have a really good idea of the diagnosis without the need for MRI. After the area of dysfunction is determined then our education on tissues and their healing processes as well as medical conditions sets us apart in prescribing a specific and appropriate plan of care for each individual. Goals are set for each client's needs and desires so we can get them back to doing what they want. To stay on top of our game, it is required that physical therapists take continuing education classes every year, not only to maintain our license but to stay most current with new techniques and research.
Until now, physical therapists typically work in the hospital, nursing home, rehabilitation settings, in schools with children, outpatient clinics and with home health agencies. Pioneer PT introduces a new delivery of treatment via a mobile "outpatient" clinic that makes treatment easier and more private for the client, all while giving the best one-on-one care possible. No longer will you have to have the extra hassle to find a ride when you are unable to drive or take the extra time out of your day to travel to an outpatient setting. Pioneer PT travels to you whether your home, office, or wherever we deem fit. You also won't be crammed into an outpatient setting where you spend very little time with the actual physical therapist before being passed off to a technician who solely trained on the job. Clients will receive a full hour of one-on-one care with a doctor of physical therapy. Pioneer PT will fill the gaps where traditional delivery of care is lacking.
Hope to see some of you soon, so we can restore your movement and fuel your passions!
How Pioneer PT Began
I know some of you may be wondering, "What the heck is that picture, and how does it relate to physical therapy?" In short, this is a picture from my once in a lifetime trip that got the wheels spinning. However, after contemplating the question a bit longer, everything in my life has brought me to this point of launching the first of it's kind on-demand physical therapy clinic with a doctor of physical therapy that travels directly to the client.
Years before I knew I wanted to be a physical therapist, I had a sense of small business instilled into me ever since I was a kid. Both my mother's and father's parents owned small businesses. My grandmom on my mom's side owned both a flower shop in OCMD, and a clothing store in Towson, while my grandfather owned a successful door manufacturing business. However, my father's family business, Dulkerian's Persian Rug Co., dulkerianspersianrugco.com, made the largest impact on my life as I helped my dad every summer growing up while school was out. My grandmother repaired rugs for years, while my dad took over for my grandfather. Getting up and commuting an hour into Baltimore every day to wash dirty rugs for a living will definitely make you humble. However, it was something I was proud of. Dad worked so hard to support his family and to help people out. He has always made it more convenient for customers with pick ups, deliveries, and sales directly to his customers out of his blue work van.
I found physical therapy in my junior year of high school, and I knew it was what I wanted to do for my career. I also knew that this career would allow me a chance to one day own my own business. I worked hard and ended up going to Ithaca College to study physical therapy. This was when I met the most influential person in my young career: my professor Ernie Nalette. He always talked about the profession of physical therapy and how it truly was in the real world. He became a mentor influencing me to question the status quo, and to want better for my patients. Physical therapy should not be an assembly line, packing as many people as possible into a day. I took his advice to heart, but worked on honing my skills for just about the past 10 years, becoming very proficient in hands-on techniques.
I have continually seen decreases in reimbursement from insurance companies forcing physical therapists to see more people, and increasing deductibles or co-pays for clients. I wanted something better. This was about the time I took a once in a lifetime trip along the California coastline camping, surfing, and hiking along the way via a 1984 Volkswagen Vanagon named Lone Star from Vintage Surfari Wagons, www.vwsurfari.com. Thank goodness we were not there during the mudslide this past year, because that was the same stretch of road in the Big Sur that we boondocked for the night to watch the sunset over the cliffs. I would highly recommend this drive at least once in your lifetime. Anyway, this was the time I began to realize that it may be possible to create a mobile clinic that I could take directly to clients, with everything I need inside to provide the best quality physical therapy. I made it my mission, putting in a lot of hard work preparing the business, even traveling all the way to the Lone Star State to purchase my big blue van. From scratch, I built out my van into a physical therapy office on wheels thanks to a lot of help from my family. Pioneer PT was born, and now I hope to help as many folks as I can by providing the best possible care directly to you!
James Dulkerian, DPT
Active outdoorsman with an honest soul and a passion for health.