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.