Isn't swimming the safest kind of cardio? Not as safe as you may think...

I get this question often. As a triathlete, I can tell you from experience that any kind of repetitive physical activity produces wear-and-tear on the joint involved...and for swimming, there are a lot of joints involved and lots of potential for wear-and-tear.

Susceptible joints:

Shoulder- swimmers with poor technique (crossing arms midline during the pull, e.g.) can acquire shoulder problems like impingment syndrome, rotator cuff tears, and labral tears. Keeping one's hands/arms in line with the shoulder can prevent these types of problems as well as dry-land strengthening and conditioning aimed at improving muscular endurance.

Knee- meniscus tears are potentially high for the breastroke- that whipping frog kick can wreak havoc on the menisci, which are susceptible to twisting-type injuries.

Back- I've treated a number of swimmers in the past with back problems. Disc herniations, bakc strain and spasms are among the few. In fact, there are some types of back disorders where specific strokes should be avoided. For example- spinal stenosis (which usually occurs in the >50 crowd) sufferers should limit or avoid butterfly, freestyle or breastroke because lumbar extension is what worsens their symptoms in the first place. When I get a patient who tells me that their physician recommend swimming, I'm very careful about what exactly they'll be doing in the pool.

So, while swimming is an awesome calorie burning and cardiovascular activity, it is not as safe as people may think of it to be!

Do I need a prescription to start physical therapy? What's Direct Access?

"Oh, I want to start physical therapy, but don't I need to get a prescription first?" This is a common question that we receive from patients. The quick answer is....mostly no.

In nearly 40 states, Direct Access legislation has been passed, allowing doctors of physical therapy varying degrees of autonomy. For example, in the state of New Jersey, physical therapists are permitted to evaluate and treat patients without an MD prescription for most commercial insurance plans (BC/BS, United Healthcare, etc). However, Medicare, workers' compensation, and no-fault patients do require a prescription.

The advantage to you as the consumer is that your musculoskeletal pain (neck, back, shoulder, knee, etc) can be addressed far more quickly instead of the weeks of waiting that can occur when trying to see a physician. Also, while family/primary care physicians, and internists are adept in utilizing their knowledge of medicine and systemic diseases, physical therapists are trained in evaluating and treating musculoskeletal injuries and can usually arrive at a movement impairment diagnosis without the use of diagnostic studies such as MRI, X-ray. Physical therapists are also educated on medical screening and will send patients to the appropriate physician when a medical yellow or red flag may be present.

Don't I need to get an MRI or xray before I see a physical therapist?

Seeing is not always believing-

I will venture out and say that 95% of the cases I've treated- whether it be neck, low back, shoulder, knee, or ankle pain have not required a diagnostic study (MRI, X-ray) for a patient to be treated successfully. Any orthopedist, neurologist, or physical therapist will tell you that most of the time, musculoskeletal and neurological pain follow specific pain patterns and with a good history taken and thorough clinical neuromusculoskeletal examination, a diagnosis can be determined without a diagnostic study.

Case in point- We have had a number of patients who have had a "torn meniscus" show up on their MRI study only to have surgeons go into the knee arthroscopically and finding no tear.

Another case in point- MRIs demonstrate a 30% FALSE positive in determining the presence of a disc herniation. What does that mean? 30% of the time the MRI study will read that a disc herniation is present when in fact, a herniation is not even there. AND, even if a disc herniation is present, unless the patient reports very specific kinds of pain patterns (worse with sitting or bending forward, and sciatic pain down the back of the thigh, e.g), the disc herniation is probably NOT the cause of the patient's back pain.

When pain does not follow the typical pain patterns or if pain is constant, if there's night pain, or if conservative care does not bring about significant change in a few weeks, then a diagnostic study may be ordered by your physician.

I strained my quads yesterday after squatting. Should I stretch them out?

The intuitive answer for most people facing this question would be, yes. Perhaps, you figured
that you injured your quads in the first place because you haven't stretched them out enough in the past, so you should start stretching now. Bad idea. what?! but, why?

If you've strained your quads (or any muscle for that matter), then at the micro-level,
you've torn some of your muscle fibers; essentially, a strain is equated to damage to a muscle because it was either overloaded or overstretched during activity. Stretching the muscle right after an injury can actually worsen the strained muscle.

WWJD (What Would Jerry Do)? From a nutritional standpoint- Focus on getting the injured muscle healthier by drinking plenty of water, upping your protein intake (I would focus on whey and egg whites due to their high absorption rate into muscle), and
active rest. What's active rest? Avoiding activities that caused the injury in the first place.

Seeing a physical therapist can accelerate your recovery with a combination of modalities,
taping techniques to calm the muscle, and professional guidance. Stretching can be implemented after 10 days (past the acute stage of an injury) in a slow and gradual manner. After the acute stage, I recommend holding your stretches for at least 1 minute and perform the stretch for 3-5 times, several times a day because lengthening is best achieved with longer duration stretches performed throughout the day. There should be no pain when you stretch.
At the same time, if you're doing a pre-game warm-up, then shorter duration (10-30 seconds) is the way to go, because you don't want your muscles to lose their game-ready tone!

Is Surgery Needed to Treat a Rotator Cuff Tear?

Is rotator cuff surgery always necessary to treat a tear? The quick answer is no. One must distinguish a full-thickness tear from a partial-thickness tear before arriving at a more accurate decision. Full-thickness tears typically result in a patient unable to lift his/her arm and is associated with significant weakness during muscle testing; partial-thickness tears, on the other hand, vary in their presentation and may require an MRI study (see below).

Clinical evaluation is necessary in ruling in or ruling out a tear and more importantly, as to whether or not surgery is absolutely indicated. A thorough review of the patient's history is necessary to begin shedding some light on the prognosis. The examination performed by a physician (usually, orthopedist or sports medicine) or physical therapist provides valuable information about the patient's movement restrictions and limitations via range of motion testing, special clinical tests, and muscle/joint testing.

Is an MRI necessary? In some cases, yes. Partial-thickness tears, determined by clinical examination, may warrant the need for an MRI study, especially if the patient's signs and symptoms do not improve after a few weeks of physical therapy. Again, a good clinical examination will usually reveal the severity of a tear based on the functional limitations and impairments noted. If I see a patient for a diagnosis of "rotator cuff tear", and the patient is able to perform movements and tests without restriction, I usually tell the patient to rehab (or "prehab") the shoulder, and if the symptoms don't dramatically improve in 2-3 weeks, then I'll go ahead and refer the patient to the appropriate physician for further testing.

Can a rotator cuff tear "heal" on its own? Again, it depends on the size the tear. Full-thickness tears will not heal on their own. Partial thickness tears may scar down with time.
Gender, age, activity level, lifestyle, occupation, and diet are all factors that can influence general tissue healing and post-surgery recovery.

why is a meniscus tear hard to treat?

The causes of knee pain are many- consider diagnoses like meniscus tears, ITB syndrome, patellofemoral syndrome, ACL, PCL tears, tendonitis, and you get an idea for what needs to be teased out of that pack.

To properly diagnose a meniscus tear through clinical examination, the pain symptoms and signs must be further qualified- Did the injury occur during a twisting type activity? Is there pain at the joint line? Does the pain occur during knee bending and/or the very end of knee bending? Is there associated knee buckling or a "giving way" sensation? Is there clicking or "catching" sensation? Most likely a meniscus tear may be the culprit.

Is an MRI absolutely necessary in diagnosing a meniscus tear? Usually not. A thorough clinical examination by an orthopedist or physical therapist is usually sufficient. People often wonder, "how do you diagnose a tear without being to see it?" I can attest that a good examination not only quickens access to necessary care, but also is may be more accurate at times than an MRI (seeing isn't always believing, since MRIs can produce a false positive- ask any radiologist!).

Meniscus tears are particularly a problem for athletes since the cutting, pivoting, rapid stop and go movements can cause these tears to occur. Menisci lesions may or may not heal on their own due to the fact that the meniscus (lateral and medial) are particularly avascular (less blood supply to the area). The menisci rely on joint movement and some compression to receive nourishment for repair and general health.

Physical therapy can be effective in treating menisci lesions through specific manual techniques and activities, and many athletes and non-athletes are able to return to their activities unhampered. In cases where symptoms become more constant, surgery is generally recommended and then resumption of physical therapy is needed for proper return to sports and activities of daily living.

What can I do to protect my ACL?

ACL tears are rampant, especially among our youth. Why? There are a multitude of reasons. Let me list a few-

"Sport-Specialist Syndrome"- Is your child the type of athlete who plays the same sport in multiple leagues, all year round? Your child fits the mold! I have treated many young soccer players with blossoming talent, playing in not one or two different leagues, but maybe three to four different leagues, seven days a week- school team, town team, traveling team, regional team. Whew! Parents and coaches, where's the needed rest?! In sports like soccer, volleyball, basketball, football, lacrosse, the same type of rapid cutting and pivoting can set your child's ACL up for injury over time. It's no wonder that so many kids each year end up with career-ending injuries, like ACL tears. Coming from one parent to another, your child will perform better and be much happier rotating through different sports throughout the year.

Gender? Female athletes, particularly in soccer, are eight times more likely to tear their ACL than their male counterparts. Why? It may have to do with the hip width-to-knee ratio- Females tend to have wider hips, which causes their knees to buckle inward ("knock-knees") when they bear weight abruptly. Females also use their quads and hamstrings differently during activity than males. The hamstrings provide effective dynamic assistance to the ACL during activity, and males tend to contract their hamstrings more than their quads as compared to females.

The hip hype? More and more research over the last 5 years or so has pointed to gluteal muscles having a protective effect on the knees and ankles. Why? Your booty is the largest muscle in your body. Strengthening the glutes increases shock absorption of your legs during activity and can help direct your knee to be in a better position overall as you cut and run, keeping your ACL safer and more sound!

Proprio-who? Joint proprioception is the ability of your joints to know where they are in space and particularly during movement. Many athletes simply don't know how to position their knees for protection and can set themselves up for ACL injury. By re-training your knees to move in patterns that are protective during activity, you can reduce the potential for knee injury up to four times.

As you can, there are many tools out there to help prevent ACL tears. Feel free to contact Dr. Jerry Yoo at jerry@mavenpt.com.

How to Choose the Right Physical Therapist

Ok, so you got injured doing...something. Maybe you hurt your knee while playing some pick up basketball, maybe it was lifting your child the wrong way, or perhaps you were just innocently twisting your body while getting out of the car. You go to see your physician because it's been over a week, and as you "wait it out" you notice your pain isn't getting any better. The physician gives you a script for physical therapy. Often times, physicians will give you a few recommendations, but how do you really know who's good?

Well, there are handful of questions you should be asking the physical therapy office BEFORE you begin receiving care there.

1) How many patients is each physical therapist scheduled to see per hour? If you've ever been to a "mill" type physical therapy setting (see below) where there are 4-5 patients every hour, you're not gonna get the best care. The practices that are more quality-oriented will schedule one to two patients per hour.

2) Will I receive 1:1 supervision by the physical therapist or support staff during my visit? It's common for physical therapy assistants and aides to supervise clinical exercises during your visit. Just make sure you're not left all by yourself in a room full of patients (which happens quite frequently) and expected to do your exercises without any guidance.

3) Will I be seeing the same physical therapist every visit? Continuity of care is critical in keeping you moving forward and in the right direction. While the occasional switch is acceptable, many practices out there will swap physical therapists left and right, day-to-day. You really want one doctor to know you and your body.

4) Is the practice physician-owned or PT-owned? Typically speaking, physician-owned practices are "mills." Great business model, if you really think about. How can you beat self-referring patients to your own practice? However, since volume is key in these types of practices, the quality often suffers tremendously- I can't tell you how many patients I've spoken to who spoke with the physical therapist for 5 minutes and then was left to do "exercises". Years ago, a friend of mine sent his dad to a physician-owned practice for his shoulder; he was given electrical stimulation by the physical therapist, then was directed to ride a stationary bike for 30 minutes and received a bill for >$300. I don't know about other physical therapists out there, but I've never treated a shoulder injury by using a stationary bike (it was even one of those arm bikes for cryin' out loud!).

At Maven Sports Medicine, we focus our practice on providing quality care to our patients. After all, the best referral source is a content patient.

Questions? Contact us at info@mavenpt.com.

Help, my baby only turns her head to one side!

So, you just had a baby, (we'll call him, "Jimmy")...say 3-4 months ago, but being that he was your first, you're busy with the daily stresses of being a new parent. One day, a friend of yours comes to visit you and see the new baby. After the "oh, how cute" conversation, she looks at Jimmy with an eyebrow raised and mentions, "hey, why is Jimmy's head stuck to the left like that?" Then, you notice it yourself, and a surge of panic...and guilt comes on. "How could I have not seen this?!" In a single swoop of the arm, you rush out the door while grabbing li'l Jimmy, throw him in the car seat, leave your friend behind, and manage, somehow, to speak to your pediatrician en route to his office. "My God, Dr. Smith, I have an emergency! Jimmy's head is stuck on his left shoulder!" You get to the office, and in tears tell Dr. Smith about li'l Jimmy's head. He take a glance and dispassionately says, "oh, looks like torticollis". More tears stream down your face as you consider the worst case scenario- Jimmy is gonna be wheelchair-bound, live in a bubble, or be stuck with needles day-in/day-out. "Doesn't look too bad, he says. Let's send him to physical therapy."


You arrive at the physical therapist's office 10 minutes later. The physical therapist, with his trained eye, says," Yeah, definitely a left muscular torticollis." You finally gather the courage to ask, "What exactly is torticollis?"

Torticollis, or "wry neck" is a problem that affects the SCM muscles of the neck (see image above). Often times, infants with torticollis demonstrate limitations in turning their head in one direction as well as presenting with their head tilted to one side. Along with torticollis, often times infants will present with "plagiocephaly", which is a flattening of one side of the the head.

So, what causes torticollis and how is it diagnosed? The answers are not clear. Some incidences may be related to larger babies in utero who have less room to maneuver their bodies during the third trimester, in particular. Other incidences of torticollis may be a result of favoring one side, leading to a flattened side of the head (plagiocephaly), making it easier for the child continue preferring one side, especially when on his/her back. The formal diagnosis usually comes from the pediatrician or pediatric physical therapist, though parents, friends and fam may also point out the odd tilt to one side.

How is torticollis treated? The first step is ruling out other possible diagnoses (superior oblique nerve palsy, Sandifer's Syndrome, hemarthrosis, e.g.). The next step is extinguishing the harmful behavior- positioning activities and strategies are simple interventions, but VITAL in diminishing your child's tendency to one side. Stretching exercises, often performed by physical therapists, are reviewed with parents to be performed with their children at home.

Does it go away? Does it ever come back? 80-90% of the time, after 2-3 months of treatment and monitoring, torticollis will full resolve. The key point is getting infants earlier in the game than later!

More questions on torticollis? Contact Dr. Jerry Yoo at 201-977-4441 or via email: info@mavenpt.com

Tri season cut short?!?!

Oh man, my knee has been hurting. Sorry to say that unlike my business partner, Dr. Taylor Lee, who had a 24 hour "miraculous recovery" from his debilitating shoulder pain a few weeks back (check out Taylor's blog- www.jatofitness.blogspot.com), I am still suffering...3 months later. Oh, Lordyyyy.

Yes, even the most invincible and careful DPTs may succumb to injuries. During my first 15k last November, I felt a little stiffness/pain in my knee during the last 3 miles of the race, but of course, I was stubborn and decided to bite the bullet and persevere....well, I was rewarded for my tenacity; let's just say that my L knee has not been the same since. I'm my own best patient.

My symptoms? Pain on the outside of the knee when I run...and only when I run! I can skip, jump off of a plyo box, perform deep squats, jump in place on one leg, do knee extensions, heel raises, BUT, running more than 1/2 a mile causes my knee to really, really hurt. Yeah, I guess Runner's knee (IT band syndrome) may be the working diagnosis, but I'm not so convinced that it is. I'm gonna have my associate, Dr. Murphy, and my graduate student Bhairvi, take a closer look. As good as I am a physical therapist, I can't always treat my own body!

Knee injuries are rampant among runners. Meniscus injuries, patellofemoral syndrome, muscle strains, Achilles tendonitis and tears are just a few of my favorite things to treat. Most of these are biomechanically-driven, ie., the way you run is causing stress to structures over time.

I feel thwarted, and frankly, a bit frustrated, as even with active rest, I have not been able to run without pain...I hope it's not a sign that I'm actually getting...OLDer or WORSE yet, that I won't be able to complete, let alone just compete in my triathlons this year. = (

What a way to start of the new year.....Stay tuned.

Medicare or MediCUT?

Maybe you're still under the age of 65 and things regarding Medicare are an afterthought and don't really concern you...yet. Maybe you ARE a bonafide senior and have Medicare and wondering how Mr. Obama and his administration have been "reforming" our healthcare system....or, perhaps you have a parent or grandparent who has Medicare and may need a medical service, like physical therapy. How does the Medicare CAP affect you and your loved ones?
Well, for starters, $1,860/year (regardless of how many body parts need to be treated at any given time) is simply NOT ENOUGH. You really can't expect the best quality care or enough of the best care to be covered under less than $2,000 per year!

Case in point, I knew of a Medicare patient with a knee replacement who was discharged (though he needed the therapy) from out-patient physical therapy because his CAP amount was met for the year. Unfortunately, this poor chap, a few months later, fell and broke both his wrists and needed rehab...but guess what, because his CAP ran out, he was unable to afford rehab for this new problem(s). Sad, but true.

"APTA is discouraged and disappointed that Congress is allowing an arbitrary annual cap on outpatient rehabilitation services to be placed on Medicare beneficiaries on January 1, 2010. This is clearly inconsistent with efforts by President Obama's administration and the Democratic majority to reform health care by eliminating arbitrary limits imposed by private insurance companies. (www.apta.org)"

Need I say more? Well, ok, maybe just one more question to pose- Can someone explain to me why our beloved senators, congresspeople, etc are not subject to the same restrictions for their own healthcare?!?! For cryin' out loud, Mr. Obama, gimme THAT plan!

Jan 9, 2010- Back to Tri-training!

In a previous blog, I wrote that I would be setting my goal of completing a 1/2 Ironman and several other triathlon races this year, and I intend on doing so. So, how's my training going? Well, I had a shoulder injury from swimming in late November, which proved to be a longer-than-expected set-back to my training (yeah, can you believe it?! The irony....), then I hurt my left knee (IT band pain, if you're curious) last month. I felt somewhat defeated, and searched for a good divine reason as to why my joints were falling apart when I've been injury-free for the past few years. I decided to listen to my body and rested (at the expense of my formerly trim waistline).

FINALLY, last week, I started up in the pool, I fixed up my knee and shoulder during the rest time, and now I'm getting back on my training schedule.

So far, I'm scheduled for a 1/2 marathon in Asbury Park this coming April. Wyckoff is coming up again in June as well as the NJ State olympic distance triathlons. Hoping to get into the Eagleman 1/2 Ironman as a charity participant, but not guaranteed. Thankfully, the sport is growing and more and more races are popping up each year.

More on tri-training next time....

"Always keep in mind what's really important"

Of all the things I could do on Christmas morn', the Yoo clan decided to check out, "The Princess and the Frog". Man, what a heart-felt flick. Didn't expect the Adam's apple flutter while watching a cartoon! Anyway, the one line that moved me was when Tiana's (the heroine) late father emphasized in a loving way to "always keep in mind what's really important." It was obvious that he was alluding to the fact that while life may be busy as we pursue our all-consuming ambitious endeavors, we cannot and must not discount the relationships we have in our lives and, of course, love. The last three years were truly a blur for me when I think out my family life.

Working part-time jobs to make ends meet in the first year of business and doing my best to accommodate patients at wee-early and way-late hours were trying times back then. Fast forward two years and here I am, two practices later, working on getting the patient to get our two locations flowing and growing, yet not seeing my kids and wife for days at a time had become a source of conflict in my personal life- wanting the professional and financial success, but sacrificing the quality life with the fam, is not a path I desire to take any further. 2010 is starting off on the right foot. Learning to be more efficient at work while making a conscious effort to be present (mentally, physically, spiritually) at home is the plan for this year.

Now, how exactly do we fit in triathlon training?!?!