Building Overall Resiliency – Part 1

PART 1: MENTAL RESILIENCY

“Let me tell you something you already know. The world ain’t all sunshine and rainbows. It’s a very mean and nasty place and I don’t care how tough you are it will beat you to your knees and keep you there permanently if you let it. You, me, or nobody is gonna hit as hard as life. But it ain’t about how hard ya hit. It’s about how hard you can get hit and keep moving forward. How much you can take and keep moving forward. That’s how winning is done!”

– Rocky Balboa

This quote resonates with most adults as we all have faced life’s wrath at times. This quote appropriately summarizes the importance of resiliency, which the online Merriam-Webster Dictionary defines as “an ability to recover from or adjust easily to adversity or change”. Basically, it’s not about avoiding conflict and challenge but being able to bounce back afterward. Though the above Rocky quote applies to mental and emotional resiliency, it is certainly applicable to physical resiliency. Unfortunately, like an athlete lacking in certain aspects of general fitness, many individuals do not have all the resiliency components necessary to successfully withstand life’s punches. The goal of the next two articles is to discuss the importance of mental and physical resilience and provide some tips on how to strengthen both. This article will focus on mental resilience and the next will be geared towards physical.

DISCLAIMER: I am not a mental and behavioral health expert. The information I provide in this article is from a combination of courses during my physical therapy education, experience as a healthcare provider, my own personal life experiences, and the mental/emotional resiliency training I received while serving in the Army. I encourage those with mental and behavioral health concerns to seek further assistance from a specialized licensed professional.

Mentally and emotionally, being resilient is crucial to withstand the stresses and emotional challenges of life. As a dad of two young girls, I see the need to build resiliency early in life. Though their “life problems” are not the same stressors as adults, they face their own challenges including rejection (“no, you can’t have cookies for dinner”) and having to do something they don’t want to (“you need to stop playing and do your homework”). These challenges may seem small compared to an adult’s, but they are big to them. A child’s ability to face these struggles will build their resiliency so they can withstand the harder challenges that naturally come with age.

One way to build resiliency is through exposure. Every punch you take and recover from, the tougher you get. Every time you get back up after falling, the stronger you become. Each and every successful rebound increases overall resiliency, better preparing you to handle larger challenges in the future. The caveat is that these blows must be enough to stress you emotionally and mentally but not be complete knockouts. A knockout event may be too much to overcome and create secondary adverse effects (depression, anxiety, social withdrawal, avoidance behaviors, etc.) while a life without stress does not challenge a person’s resiliency, resulting in a weakened ability to rebound. Like Goldilocks looking for the right porridge, we need the “right” amount of stress to build resiliency: not too much, not too little.

There are other ways to build mental and emotional resilience than through just exposure. Research has shown time and time again expressing gratitude consistently can be very impactful. The most common method of doing so is by keeping a daily gratitude log identifying three to five specific items you are grateful for that day. The more specific the better, and it’s more impactful to reflect on why you are grateful for it. I recommend keeping a notebook next to your bed and either start or end the day completing your gratitude log.

If you find yourself not handling a stressor well, there are other tactics to assist in the heat of the moment. Think of these as spotters for your emotional and mental resilience. First, identify if you are catastrophizing and making it worse than it truly is. It’s common to spiral downward when faced with an obstacle or stressor  (ex: doing a task wrong at work leads to thoughts of getting fired which leads to financial problems then marital issues followed by losing the house then winding up alone living in a ditch). Stopping these thoughts immediately and recognizing the spiral can be challenging, and success depends on being able to accurately identify the most likely outcome (ex: doing a task incorrectly at work likely will result in a verbal warning from a supervisor). The goal is to put the stressor into perspective, acknowledging that it’s not great but also not fatal.

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Pillars of Rehab Success

Turns out pain is very complicated (see previous blog about pain science). The medical world has come a long way in understanding and treating pain, but we still haven’t found that magic pill for resolving pain. However, we do know pain is much more than just the body part involved and impacts (and is impacted by) other body systems. The goal of this post is to identify and discuss a few key lifestyle behaviors that can greatly impact the recovery process. Addressing these “Pillars of Rehab Success” along with following the guidance from medical providers will greatly increase your chances of overcoming or better managing whatever physically ails you. There are many lifestyle choices that can impact recovery, but the pillars we will be discussing in this article are sleep, diet, stress, and exercise.

 

Sleep is arguably the most impactful modifiable lifestyle behavior as sleep plays a role in nearly every bodily system and function. Regarding pain and recovery, our naturally produced growth hormone spikes in the deep sleep cycles. This hormone is responsible for rebuilding and growth. Additionally, our stress hormone cortisol is lowest while we sleep. This flip in hormone levels is one reason why sleep is considered restorative. The less quality sleep we get, the less restoration we achieve. Additionally, since the mental, emotional, and cognitive effects of sleep deprivation are processed in the brain alongside pain processing, there can be some crosstalk between them. It’s very common to have increased pain symptoms after a night or two of poor sleep. For most adults, we should aim for at least seven hours of sleep but try for eight or more, if possible. This typically requires being more mindful of when we need to be in bed and practicing good sleep hygiene before bedtime (avoiding stimulants, dimming lights, reducing screen time, etc.).

We know food is certainly good for the soul and the way to anyone’s heart; however, the quality of food consumed can impact pain and the recovery process. Most importantly, we need to remember the original purpose of food is to provide the appropriate nutrition to fuel our bodies. What we put into our bodies will be what our body uses to provide energy, grow, and recover. Simply put, crappy nutrition will lead to crappy fuel. Additionally, highly processed “unhealthy” foods can irritate the gastrointestinal system, generating local inflammation than can have a systemic effect. This effect can then be like fuel to a fire for someone already in pain and dealing with an injury. Ideally, we would eat a 100% healthy diet full of veggies, fruits, lean meats, fish, seeds, nuts, healthy fats, and whole grain carbs. However, going on a fulltime strict for most of us eventually leads to mental irritability and eventually caving in. If this is you, my recommendation is to aim to eat “healthy” 85-90% of the time each week. This still allows for some splurge meals/snacks while maintaining the overall fairly healthy diet for proper fueling.

Research has shown a link between persistent pain and sympathetic nervous system (SNS) overdrive. The SNS is the “fight or flight” part of our autonomic nervous system responsible for priming our bodies in threatening and extremely stressful moments. A heightening SNS is good when in that moment (facing a bear, in a battle, etc.); however, we ideally only want to spend a small portion of time in this state. Unfortunately, our SNS cannot differentiate between the stress from an actual threat or the stress of our day-to-day lives. Therefore, due to stress, many of us live each day with an amped up SNS, reducing our ability to relax, restore, and recover. If you find yourself in this category, there are several ways to help reduce stress. These include, but are not limited to, finding an appropriate outlet (ex: hobbies, exercising), talking/counseling, gratitude logs, journaling, and meditating.

It’s common to avoid all physical activity when injured or in pain. However, general exercise is very therapeutic and aids greatly in recovery. Actively moving the joints and muscles can reduce swelling better than ice and medication by mechanically pumping the fluid into the lymphatic system. Additionally, the more we move a joint, the more synovial fluid the joint will produce, which is the body’s natural WD40 lubricant. Exercising increases blood flow, bringing in oxygen and nutrition to aid in recovery while flushing out inflammation and other metabolites. Hormonally, exercise has been shown to increase endorphins, growth hormone, and protein synthesis, all of which assist in pain reduction and recovery. Now, I’m not saying to ignore the pain and injury and to train as if 100%. When hurt, it may be advised to rest a healing joint or muscle, but there are usually other ways to exercise without physically aggravating the injury. For example, if one shoulder is injured, the lower body, trunk, and the other arm can be worked. If high impact activities are bothersome, try low-impact machines or get into a pool. If one limb hurts, don’t avoid exercising the other in fear of creating imbalances. Working the non-injured side will actually assist in the injured side’s recovery. It’s important to continue cardiovascular and strength training while hurt, unless advised otherwise by a medical professional.

The above four pillars discussed are only some of the many lifestyle behaviors that can be modified and optimized to improve recovery and pain management. These recommendations are general based on my experience with orthopedic pain and injuries. It’s always recommended to see a medical provider for further evaluation, treatment, and guidance when appropriate. However, regardless of the presence of pain or injury, following the above recommendations will certainly lead to a healthier life!

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To Heel Strike or Not?

If you were to sit and watch a mass of runners going by at the local 5k race, you will see all sorts of varying running forms, techniques, and movement strategies. Noticeable differences include varying head positions, arm swings, elbow angles, spinal postures, hip movements, knee drives, stride lengths, and step cadences. A largely debated topic is landing mechanics, specifically if it’s a running sin or not to heel strike (land heel first). My goal with this article is to discuss the differences in foot landing positions as well as give my opinion as a runner and physical therapist on the subject.

The heel strike landing pattern (also referred to as rearfoot strike (RFS)) became a more widely-accepted and adopted technique with the creation of the cushioned running shoe. Prior to shoe companies adding extra cushion under the heel, it was near impossible for someone to consistently heel strike for miles and miles without crushing their calcaneus (heel bone) into oblivion. Therefore, most (if not all) runners “back in the day” were midfoot or forefoot strikers, allowing the soft tissue structures of the feet and legs to absorb more of the load. Many advocate a midfoot or forefoot landing pattern now since it is more “natural” when not influenced by the modern advancement of the cushioned running shoe.

So what’s the big deal between strike patterns? Great question!

Heel striking is exactly as it sounds and occurs when the runner lands heel first (usually on the outer heel) with their ankle flexed and toes up. Most runners nowadays are heel strikers. The benefits of heel striking include the naturalness of it for most runners (especially novice) and the decreased soft tissue strain when compared to the other landing types. However, heel striking increases the amount of force experienced by the leg bones, hips, and knees because the foot and ankle is unable to absorb some of the load like with midfoot and forefoot runners. Though the max peak force experienced is similar between the different landing patterns, heel strikers typically experience more overall forces due to 1) an increased initial peak force with landing (see image below), and 2) increased contact time with the ground required to go from landing to push off. The increased force exposure and absorption may increase a heel strike runner’s risk for general joint pains and boney stress injuries compared to forefoot and midfoot runners.

Midfoot striking occurs when a runner lands flat footed with relatively equal distribution of weight throughout the foot while forefoot runners land more on the ball of their foot. These landing patterns are commonly described as more natural styles of running because running barefoot would likely require adopting one of these landing patterns to help distribute the landing forces. Unlike with heel striking, the foot and ankle are able to absorb much of the force, reducing the forces experienced in the leg bones and joints proximal to the ankle. Additionally, these landing patterns usually result in a quicker step cadence, resulting in an overall decreased contact time with the ground. Though there may be reduced stress to the leg bones and joint structures, there is oftentimes increased strain to the soft tissues, especially those in the foot and lower leg. This is why runners transitioning from heel striking to midfoot/forefoot landing are advised to transition slowly. These runners do not experience the same initial contact peak force as heel strikers do; however, the max experienced force is relatively the same.

Source: https://www.researchgate.net/publication/319104024_Common_Running_Overuse_Injuries_and_Prevention

So, is one landing pattern better than the others? Well, it depends on who you ask. Below is this runner’s and physical therapist’s opinion.

If you have ever tried changing your own landing pattern or tried teaching someone else, it is extremely challenging and frustrating for all parties involved. It can be awkward for the runner and can take months to master a new running technique while slowing ramping up mileage to avoid overuse injuries. Plus, many runners cannot accurately identify their own landing patterns (many think they are midfoot/forefoot runners but on video analysis are actually heel striking). Therefore, I do not believe changing the strike pattern is necessary for most runners as there are other components of the running that may be easier to modify with bigger results: foot placement and stride cadence.

A common issue associated with heel striking is overstriding, meaning the landing foot is hitting the ground ahead of the runner. It’s hard to do so when landing midfoot or forefoot. The further out front the foot lands, the harder the impact typically experienced through the leg. Additionally, the foot will spend more time in contact with the ground as it becomes the supporting post for the body transitioning over into the next step. In general, increased time with an external force can increase injury risk. Also, when the foot lands ahead of the body, it creates a temporary braking force. Newton’s Law of Physics states a force will create an equal and opposite force, so a foot landing out in front will create an impact force right back at the runner. If the goal is to keep moving forward, eliminating opposing backward forces would be good, right? If a runner can decrease their stride length so that the foot lands more under their body instead of outfront, it can significantly reduce the overall force absorbed, decrease contact time with the ground, and reduce/eliminate the backward impulse generated.

Source: https://groups.google.com/forum/#!topic/just-south/KdopHHtEU2o

Increasing stride cadence (step frequency) is another fairly easy modification a runner can make to reduce strain and improve running efficiency. Given a set overall speed/pace, the runner with a slower cadence must have a longer stride length than a runner with a quicker cadence. This longer stride increases ground contact time and forces the body has to absorb. Purposefully increasing stride frequency helps reduce stride length and improves foot landing placement, resulting in a more efficient motion (less braking forces) and decreased load. I recommend a cadence of 160-180 steps per minute. If your cadence is significantly lower than this, do not immediately increase your step frequency to match it. Start by increasing your current step frequency by 10% and gradually increase as you get more comfortable with a quicker yet shorter step. I heard from a buddy once that a runner should pretend to be a ninja trying to sneak up on someone (think quick and quiet feet!).

In summary, there are many variances to running form and technique with arguably the most disputed being foot strike pattern. To me, there are pros and cons of each. However, I feel adjusting foot landing placement and stride cadence are more beneficial (and easier) than adjusting foot strike. By focusing on landing more under the body and quickly transitioning into the next step, a runner will likely be more successful in reducing overload forces, improving efficiency, and reducing injury risk. If constantly dealing with overuse running injuries or feeling inefficient with running, try modify one or both of these instead of focusing on how your foot is landing!

Shameless Plug: Having pain with running and issues with modifying running mechanics, come see us at Vertex PT Specialists to have one of our trained therapists evaluate your running form, help address any physical impairments you may have, and get you back to running sooner!

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Trunk and Core Strengthening

It seemed like for a while the biggest fitness craze was core stability training with every fitness and rehab guru flooding the internet and social media with exercises using every combination of positions, movements, and equipment possible. I’m sure I saw someone doing quadruped bird dogs with ankle/wrist weights with a resistance band pulling them one way while maintaining balance on a BOSU ball that a buddy was unpredictably tapping to create perturbations on an unstable service. Yeah, exercises like that can be effective and meet the intent, but it doesn’t need to be that complicated. Additionally, oftentimes such exercises can be too challenging and complex for the “Average Joe”. In this article, we’ll dive into a simple way to progress trunk and core stability exercises. But first, let us quickly dive into a quick anatomy review and the why behind the importance of maintaining a strong trunk.

The trunk musculature can be divided into two categories based on their primary function: movers and stabilizers (note: each trunk muscle can have both a mover and stabilizer function but has a primary role of one over the other). The movers are the bigger muscles located more externally and primarily work to move the body in different directions. This includes the abdominals (flex the spine), paraspinals (extend the spine), and the obliques (side bend and rotate the spine). Stabilizers are deeper and function to maintain a spinal trunk position at rest and during movement. These include the transverse abdominis (TrA), quadratus lumborum (QL), and the lumbar multifidi (LM) muscles.

When looking at the trunk and reviewing its function, it helps to view the entire system as a three-dimensional cylinder around the spine and guts. The abs and anterior portion of the TrA comprise the front of the cylinder, the obliques with the lateral TrA fibers make up the outer walls, and the LM and paraspinals solidify the backside. Like a soda can, this cylinder also has a top (diaphragm) and a bottom (pelvic floor musculature). A healthy and properly functioning cylinder will be able to generate pressure against all walls within it, locking down and stabilizing the trunk during exertion (like the stiffness of a full unopened soda can). A poorly pressured cylinder will not be as strong and stiff (like the walls of an empty opened can). Now, the cylinder does not need to be fully pressurized all day, everyday but only when needed to complete the task. And the amount of pressure generated can and should be based on the demand. For example, generating 100% pressure and stiffness is needed for a max deadlift effort but not for picking up an empty laundry basket. Having an appropriately pressurized cylinder will reduce injury risk by maintaining proper mechanics and evenly distributing the force to the right load-bearing structures.

Now, how do we initiate a trunk strengthening program correctly with a good progression? There are certainly different strategies and approaches out there. For the most part, there isn’t a necessarily “right” or “wrong” way as long as the exercise and dosing is appropriate for the person. For example, it may not be a good idea to perform heavy deadlifts right away for a deconditioned individual with acute low back pain. I personally view trunk strengthening progression as a three phase process:

Phase 1: Isometric holds maintaining a static position for a designated period of time, starting with a shorter time then increasing duration to build endurance and confidence. Examples include front planks, side planks, and back bridges.

Phase 2: Build off the isometric holds from Phase 1 by incorporating an unweighted or minimally resisted dynamic limb movement. The purpose is to train the trunk to remain stable and strong while moving the arms and legs. Examples include bird dogs, dead bugs, and rolling planks.

Phase 3: This phase is where I introduce more dynamic movements and heavier loads to challenge the trunk strength and endurance. These are oftentimes referred to as more “functional” exercises as they replicate natural movements and carry over to tasks we commonly perform during the day. With these exercises, the trunk is usually not the primary focus or working muscle group but serves more of  a supporting role (but extremely important, nonetheless!). Examples include kettlebell swings, deadlifts, and weighted carries.

Check out the videos below for examples of this outlined progression for the lateral and posterior trunk musculature.

 

 

As you can see, phasing a trunk strengthening program like above helps progressively build up the trunk strength and endurance appropriately. It doesn’t seem smart to overload a patient or client with heavy deadlifts if they aren’t able to hold a basic unweighted back bridge for more than ten seconds, right? Overloading a patient or client too soon without the proper baseline strength and endurance will increase injury risk, aggravate an existing injury, create frustration, and/or compromise trust with the provider/trainer. Let’s train and rehab smarter!

This isn’t rocket science but hopefully seeing a phased trunk strengthening progression is beneficial for you. The goal is to start small and progressively build strength and confidence while keeping it simple!

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Squatting with Knee Pain

So, your knee is starting to give you a little trouble when you squat. Many times, people come to us having been told they need to stop squatting and rest it, or that “squatting is bad for your knees, you should never go that low.” And don’t get me started on the “knees shouldn’t go past your toes” myth… All of this couldn’t be further from the truth! If your healthcare provider is telling you otherwise, it’s time to find someone else. A big part of getting you back to 100% is volume management. This means your recent squat volume may have been a little too much for your tissues to handle and we need to take some time to calm them down and build them back up. But in the meantime, we can still find ways to get after it in the gym!

An experienced PT will not only assess your knee and design an appropriate loading program, but evaluate your squat mechanics, make future programming recommendations, and most importantly, find a way to keep you moving! Our goal with physical therapy is not about telling you what you CAN’T do, but helping you figure out what you CAN do. Rather than telling you to stop squatting, we work with each patient to figure out a squat variation that allows them to continue moving without increasing their symptoms. This could simply be moving them toward a more hip dominant squat to decrease the demand on the knees.

An easy rule of thumb is to move across the squat continuum to variations that utilize a more vertical shin. For example, if you’re having symptoms when you front squat, try a high bar back squat. When the load moves from the front rack to the upper back, the torso angle changes and the squat becomes more hip dominant vs ankle/knee dominant. Having an issue with high bar back squats? Try a low bar variation, or try box squats. This will let you really load the hips and keep your shins more vertical. From there we can keep adjusting by increasing the height of the box, decreasing range of motion to further remove the demand on the knees. There is a variation out there that will let you keep squatting, you just have to find it!

Over time, as the specific interventions for the knee continue to progress, we can gradually work back into the variation of the squat that was causing symptoms. Your rehab should be an active process, and there is no reason you can’t keep squatting!

Have questions? Send us a message at josh@vertexpt.com

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You Threw Your Back Out! Now What?

Most of us have experienced that sudden unexpected sharp low back pain and the inability to fully stand up erect afterward. If you haven’t yet, chances are you likely will at some point. Unfortunately, we oftentimes do not expect it to happen as it either occurs with the most obscure unthreatening activities (picking up a pencil, wresting with your kids, getting out of the car, etc.) or when we believe we are physically prepared to take on load (deadlifting, squatting, etc.) but the aftermath tells us otherwise. So, when it happens, what should you do?

First, don’t panic. Take a moment to catch your breath and evaluate the situation. Yes, it can be extremely painful and alarming but 99.999% of the time it isn’t life threatening. To assist ruling out more severe pathology (cancer, spinal cord injury, etc.), think about the how the pain started and the resulting symptoms. Below are some criteria to help:

  • Is the pain associated with a low-traumatic specific cause or mechanism (picking something up, twisting, etc.)?
  • Does the pain change with movement and/or position (ex: worsens with bending, better with sitting, better with walking, worse in the morning, etc.)?
  • Are you experiencing any other concerning symptoms (ex: changes in bowel/bladder function, nausea/vomiting, numbness/tingling, unexplained weight fluctuations, paralysis or severe sudden weakness, dizziness, headaches, etc.)?

If you can answer “yes” to the first two questions and “no” to the third, then the pain is likely “mechanical”, meaning it is not life threatening and is associated with the movement-related parts of the body. More severe and worrisome causes of back pain typically present as a constant unrelenting pain without an identifiable cause, pain that does not change regardless of movement/position, and pain along with other worrisome symptoms like those in question three above. Additionally, high-velocity traumatic causes of back pain (high-speed car accident, fall from high surface, etc.) should also be medically evaluated to rule out fractures. If you deem your pain as life threatening or suspect a fracture, definitely get it medically evaluated as soon as possible. If not, then congrats! You are the proud owner of acute low back pain and should keep reading.

Next, keep moving. Old school medical advice directed back pain patients to stay off their feet and oftentimes prescribed “bed rest” for prolonged periods. Turns out this treatment strategy is more harmful than good. Current medical literature supports continued activity, starting with lower level activities and gradually increasing workload until back to prior level of function. Sitting and laying around avoiding aggravating movements may seem logical to allow the body to heal; however, it’s common for individuals to actually feel WORSE after prolonged periods of rest. The longer you stay away from being active, the higher the risk of becoming deconditioned, weaker, and stiffer while potentially developing fear avoidance behaviors and acute depression if avoiding activities typically enjoyed.

With that said, it is not wise to continuously push through painful movements with the “pain is weakness leaving the body” mentality. Doing so can aggravate healing tissues (similar to picking a healing scab) as well as increase your body’s sensitivity to movement, resulting in higher pain levels. (Note: Pain is a very complicated output of the brain after it receives/processes multiple stimuli, to include pain receptors. The complexity is a whole other article on its own, but you can trust me on this!). So, the goal is to avoid the far ends of the activity spectrum: not enough and too much. Like Goldilocks, you need to find the middle “just right” point that keeps you moving without overdoing it. Light range of motion exercises and stretching is typically recommended along with light cardiovascular exercise like walking or riding a stationary bike. Check out the video below for some good exercises commonly prescribed for acute low back pain.

While going through the recovery process, it’s crucial to maintain an overall healthy lifestyle to promote a good healing response. Because physical activity is usually restricted initially, maintaining a well-balanced diet is key to prevent unnecessary weight gain and provide the body the right nutrients to optimize healing. Binge watching Netflix and eating a tub of ice cream is not a good approach. Sleep, too, is very important. One of our biggest healing-promoting hormones is Growth Hormone which naturally spikes during our deep sleep cycles. Additionally, our biggest stress hormone Cortisol (which limits recovery) naturally lowers while asleep. Reducing and disrupting sleep patterns therefore decreases the body’s natural ability to heal by reducing the “good” hormone we need while maintaining elevated levels of the “bad” hormone. I also recommend avoiding tobacco use and heavy alcohol consumption as both can reduce blood flow and the oxygen/nutrients delivered by the cardiovascular system, resulting in delayed healing.

The last piece of advice I can offer is to stay positive, be patient, and embrace the roller coaster ride of recovery. You will get better, it may just take some time. Each injury and person are unique; therefore, timelines, progression, and symptoms will vary. And if you have a history of low back pain episodes, each recovery will be different. Mindset is HUGE when injured (go back to the previous comment about the complexity of pain output). Feeling down and out mentally can carry over to how you feel physically. Also, remember that recovery is not a smooth ride with predictable improvements each day but more like a bumpy roller coaster ride with ups, downs, and loopy-loops (see below image). It’s common to experience a “bad day” after a “good day”. This does not indicate further harm or reinjury but is a common response as the body progresses.

So, in summary, tweaking your back happens. And, unfortunately, it sucks. However, you will recover. The body is amazing and able to heal despite all the day-to-day abuse thrown its way. There are things you can do to promote the recovery progress as described above: stay moderately active, maintain a healthy lifestyle, and have a positive mindset. Typical acute pain episodes improve over one to three weeks. If your pain persists longer, intensifies, or progresses to include “red flag” symptoms (see question 3 above), you should consult a medical provider to further assist.

Shameless Physical Therapy Plug: Seeing a physical therapist early in the back pain episode can further assist in the recovery process. If your state and health insurance allow for direct access to physical therapy without a referral (like South Carolina), I encourage seeking a physical therapist first to avoid delayed care and possibly unnecessary imaging and medication prescriptions.

I hope this is helpful. Definitely reach out to us at Vertex PT Specialists if you have any questions or concerns. Or if you are in the Columbia, SC area, we would love to help you out if your back pain continues to nag you!


Dr. Pat Casey, PT, DPT, OCS, CSCS, SFMA, CF-L1
pat.casey@vertexpt.com
803.973.0100

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Not All ACL Injuries Require Surgery: Understanding Your OptionsPictured above is the iconic statue of Mickey Mantle outside of Oklahoma City’s Bricktown Ballpark. Mantle, the legendary New York Yankees outfielder, started his rookie year in 1951. In Game 2 of the World Series that same year, he sustained a right ACL injury that was never reconstructed or repaired. Despite this, Mantle went on to win 3 MVP awards and a Triple Crown in 1956—all without a functional ACL. What does this tell us? Mantle was what we call a “Coper”—someone who can function at a high level despite having a torn ACL. The ACL: Why It Matters The anterior cruciate ligament (ACL) is one of the main stabilizers of the knee joint. Its role is to: Prevent the shin bone (tibia) from sliding forward on the thigh bone (femur) Provide stability for cutting, pivoting, and side-to-side movements ACL tears are common, especially in athletes. One study cites an incidence of 68.6 per 100,000 people. Contact injuries: when another player collides with your knee in a way that ruptures the ligament Non-contact injuries: more common, often from planting and turning, or a hyperextension moment Research suggests up to 75% of ACL ruptures are non-contact. Female athletes are at higher risk due to anatomical, hormonal, and neuromuscular differences. The “Rule of Thirds” After an ACL Tear Recovery after an ACL tear doesn’t look the same for everyone. Experts often use the rule of thirds: One-third can resume normal activities without limitations (copers) One-third require modifications to improve stability One-third need an ACL reconstruction to return to their desired activities Do You Really Need ACL Surgery? The answer depends on your activity goals: Weekend warrior runners: Surgery may or may not be needed, depending on knee stability after rehab. Active parents: If your goal is walking, light exercise, or playing with your kids, you may not need surgery. Competitive athletes: For those who cut, pivot, and jump in high-demand sports, surgery is often required. Why Pre-Hab Matters Pre-habilitation (pre-hab) before surgery—or instead of surgery—is key for better outcomes. Pre-hab focuses on: Reducing swelling Restoring muscle activation and firing Improving movement patterns Setting realistic expectations Many patients find that after pre-hab, they can do everything they want without surgery—meaning they may be a coper. Why See a Physical Therapist First? When an ACL injury happens, your first step should be a consult with a physical therapist. Here’s why: PTs can assess whether you may function without surgery PTs see many post-surgical patients and can recommend trusted orthopedic surgeons if needed PTs can start your recovery immediately, restoring range of motion and function faster PT gives you the best chance at returning to activity—with or without surgery The Bottom Line Not every ACL tear needs surgery. Some people thrive with rehab alone, while others require reconstruction to achieve their goals. Your activity demands, goals, and response to pre-hab should guide the decision. Start with a physical therapist—you’ll get clear guidance, an individualized plan, and a faster path to recovery. References Plutnicki, K. (2014, May 4). Mantle’s Knee Injury Was Just the Start. NY Times Kaplan, Y. Identifying Individuals With an Anterior Cruciate Ligament-Deficient Knee as Copers and Noncopers: A Narrative Literature Review. Journal of Orthopedic and Sports Physical Therapy, 2011; 41(10), 758–766. Boden, B., Sheehan, F., Torg, J., Hewett, T. Non-contact ACL Injuries: Mechanisms and Risk Factors. J Am Acad Orthop Surg, 2010; 18(9): 520–527.

Pictured above is the iconic statue of Mickey Mantle outside of Oklahoma City’s Bricktown Ballpark. Mantle, the legendary New York Yankees outfielder, started his rookie year in 1951. In Game 2 of the World Series that same year, he sustained a right ACL injury that was never reconstructed or repaired.

Despite this, Mantle went on to win 3 MVP awards and a Triple Crown in 1956—all without a functional ACL. What does this tell us? Mantle was what we call a “Coper”—someone who can function at a high level despite having a torn ACL.

The ACL: Why It Matters

The anterior cruciate ligament (ACL) is one of the main stabilizers of the knee joint. Its role is to:

  • Prevent the shin bone (tibia) from sliding forward on the thigh bone (femur)
  • Provide stability for cutting, pivoting, and side-to-side movements

ACL tears are common, especially in athletes. One study cites an incidence of 68.6 per 100,000 people.

  • Contact injuries: when another player collides with your knee in a way that ruptures the ligament
  • Non-contact injuries: more common, often from planting and turning, or a hyperextension moment

Research suggests up to 75% of ACL ruptures are non-contact. Female athletes are at higher risk due to anatomical, hormonal, and neuromuscular differences.

The “Rule of Thirds” After an ACL Tear

Recovery after an ACL tear doesn’t look the same for everyone. Experts often use the rule of thirds:

  • One-third can resume normal activities without limitations (copers)
  • One-third require modifications to improve stability
  • One-third need an ACL reconstruction to return to their desired activities

Do You Really Need ACL Surgery?

The answer depends on your activity goals:

  • Weekend warrior runners: Surgery may or may not be needed, depending on knee stability after rehab.
  • Active parents: If your goal is walking, light exercise, or playing with your kids, you may not need surgery.
  • Competitive athletes: For those who cut, pivot, and jump in high-demand sports, surgery is often required.

Why Pre-Hab Matters

Pre-habilitation (pre-hab) before surgery—or instead of surgery—is key for better outcomes. Pre-hab focuses on:

  • Reducing swelling
  • Restoring muscle activation and firing
  • Improving movement patterns
  • Setting realistic expectations

Many patients find that after pre-hab, they can do everything they want without surgery—meaning they may be a coper.

Why See a Physical Therapist First?

When an ACL injury happens, your first step should be a consult with a physical therapist. Here’s why:

  • PTs can assess whether you may function without surgery
  • PTs see many post-surgical patients and can recommend trusted orthopedic surgeons if needed
  • PTs can start your recovery immediately, restoring range of motion and function faster
  • PT gives you the best chance at returning to activity—with or without surgery

The Bottom Line

Not every ACL tear needs surgery. Some people thrive with rehab alone, while others require reconstruction to achieve their goals. Your activity demands, goals, and response to pre-hab should guide the decision.

Start with a physical therapist—you’ll get clear guidance, an individualized plan, and a faster path to recovery.

References

  • Plutnicki, K. (2014, May 4). Mantle’s Knee Injury Was Just the Start. NY Times

  • Kaplan, Y. Identifying Individuals With an Anterior Cruciate Ligament-Deficient Knee as Copers and Noncopers: A Narrative Literature Review. Journal of Orthopedic and Sports Physical Therapy, 2011; 41(10), 758–766.

  • Boden, B., Sheehan, F., Torg, J., Hewett, T. Non-contact ACL Injuries: Mechanisms and Risk Factors. J Am Acad Orthop Surg, 2010; 18(9): 520–527.

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Five Most Common Bladder Irritants In My Personal Diet

So, what are bladder irritants anyways? Bladder irritants are anything that causes the inner liner of the bladder and the muscles of the bladder (mainly the detrusor muscle) to contract, causing a feeling of urgency to empty. In most instances, this isn’t any problem at all. You feel you need to urinate, possibly with some urgency, and you find your way to the restroom. However, in individuals with increased sensitivity to the bladder or urinary tract this can become a symptom that controls their life. Diagnoses such as “Overactive Bladder” (OAB) or Interstitial Cystitis can become extremely frustrating, however these diagnoses aren’t the end-all-be-all. These diagnoses can be controlled with food restrictions/choices, pelvic floor physical therapy, exercise, and cognitive-behavioral changes.

Now, back to the main title – what do I eat/drink the most often that are bladder irritants?

  1. Coffee: I LIVE off coffee. However, the acidity in this drink causes an irritation of the bladder, which leads to a sense of urgency for urination.

 

  1. Carbonated Beverages: Sodas and carbonated water are bladder irritants, however the reason behind their irritation to the bladder is not well known. In my case, this is carbonated water – I just can’t get enough of the bubbles!

 

  1. Chili and Spicy Food: The reason behind this irritation is the acidity, which irritates the bladder causing a need to empty (and rid the bladder of this irritation). I love the challenge of not sweating through my clothes when eating spicy foods! Or acting like my mouth is not in complete agony.

 

  1. Alcohol: This irritant can be caused by the diuretic properties of the solute, which causes more urine to end up in the bladder. Also, the sweeteners and fruit juices that can be combined with alcohol are also bladder irritants. My alcohol of choice? IPAs – hipster or not, the bitterness of the beer and the sweetness of the fruit of choice is delicious.

 

  1. Acidic Fruits: Tomatoes, oranges, strawberries – all of these fruits have some degree of acidity associated with them. As such, they cause irritation to the bladder liner and urinary tract, which leads to more frequent urination. I eat strawberries/blueberries everyday in my oatmeal and yogurt!

Overall, consuming these foods/drinks won’t cause you to have to run to the restroom. What’s the explanation for that? Solvent! Water! The more water you drink, the more dilute the solution and the less likely your bladder is to become irritated by the acids, sweeteners, and carbonation. The more you understand about your pelvic floor and your digestive system, the better able you are to spot a problem and the better you understand yourself!

If you’re noticing a urinary frequency that is higher than 5-7 times per day, or an inability to control voiding (leakages)– this may be a sign of bladder irritation or pelvic floor dysfunction. At no point is leakage “normal” – regardless of the number of children you’ve carried. If you’re concerned about anything you’ve read or noticed, contact your primary care physician or contact Dr Tristan Faile, PT, DPT at Tristan@vertexpt.com for more information. 

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Exercise: Add Life to Your Years

As we age, it can be tough to maintain a regular exercise routine. We have other things going on in life, and not to mention any aches and pains that may have developed along the way! The truth is that exercise can improve the quality of life for anyone at any age, but may in fact be even more important as we get older.

In physical therapy, we have a common saying that we often find ourselves telling our patients: Exercise is Medicine. It sounds cliché, but it could not be more true. While you cannot prevent every injury, and can’t predict when a body part will start to hurt, there are many health factors you can control. And exercise is one of the most efficient and effective ways to do that. Here are a few of the many benefits that you can expect to gain from regular physical activity:

  • Heart Disease

Exercise improves blood circulation, which is very important for preventing heart disease. Even moderate intensity physical activity has been shown to decrease the risk of heart disease and premature death. It is also highly effective for improving cholesterol and blood pressure! The American Heart Association1 reports that those who are physically active and at a healthy weight live about 7 years longer than those who are sedentary and obese.

  • Weight Control

It’s true, you can’t out-exercise a bad diet, but you can certainly make your diet work better in your favor. Both aerobic and resistance exercise increase your overall caloric expenditure, which means what you eat will be less likely to be stored as fat. It’s not just the calories you burn while exercising, either: your body will be burning more calories throughout the day even while resting! Think of your body as a furnace, and calories will just be fuel for the fire, rather than sitting around and piling up waiting to get used.

  • Diabetes Prevention and Management

General exercise is one of the first things we recommend for people with diabetes or pre-diabetes. To move, your muscles utilize sugar that is either stored in the body or free in the bloodstream. This means that not only does exercise has a direct positive impact on blood sugar immediately, but it can also improve insulin sensitivity, making it easier for your body to utilize sugar when it is already available. Of course, this does not replace any other medical management you may require for diabetes: always talk to your doctor about any lifestyle changes that can affect long term health conditions.

  • Improved Mental Health and Function

Several studies show that exercise has a positive impact on mental function and acuity, regardless of your age. In one systematic review of the literature, researchers concluded that exercise even helps improve brain function and depression in individuals with Alzheimer’s disease.2 When you exercise, your brain produces a protein called brain derived neurotrophic factor, or BDNF.3 This protein enhances mental function, and improves anxiety and depression in mice, and is thought to do the same in humans. Along with the production of endorphans, this can leave you feeling much better when you have a regular exercise routine!

  • Longevity

As we age, losing independence can be one of the most difficult things for a person and their family to go through. In clinical practice, this is one of the top priorities (if not THE top) for many patients in their older years. The number one thing I tell people to do to if this is something they’re worried about? You guessed it: Exercise.

According to the CDC4 show that even moderate intensity exercise at 150 minutes per week (that’s only 30 minutes a day, 5 days a week!) leads to significantly less chance of disease and early death. The healthier you are, the more you can do on your own. But not only that! Exercise is the only way to maintain your muscle mass and bone mineral density, which naturally decline as we age. If muscles get too weak, or bones too brittle, we are at significant risk of falls, injury, or hospitalization. Performing some regular aerobic and resistance training can keep you stronger, longer!

 

So: If you have a regular routine, keep it up! If not, the thought of starting one can be a daunting task. Talk to your physical therapist or physician about different options and they can help work with you to develop a plan. It doesn’t have to be much – 20-30 minutes of walking on most days of the week is enough to see significant benefits. Not only will it help you add years to your life, it will also help you add life to your years!

-Sean Jacobs, DPT, PT, CSCS

 

 

References:

  1. American Heart Association: Physical Activity Improves Quality of Life (2015). http://www.heart.org/HEARTORG/HealthyLiving/PhysicalActivity/FitnessBasics/Physical-activity-improves-quality-of-life_UCM_307977_Article.jsp#.W28yuuhKg2w
  2. Gremeaux, V., Gayda, M., Lepers, R., Sosner, P., Juneau, M., & Nigam, A. (2012). Exercise and longevity. Maturitas, 73(4), 312-317.
  3. Sleiman, S. F., Henry, J., Al-Haddad, R., El Hayek, L., Haidar, E. A., Stringer, T., … & Ninan, I. (2016). Exercise promotes the expression of brain derived neurotrophic factor (BDNF) through the action of the ketone body β-hydroxybutyrate. Elife, 5, e15092.
  4. Center for Disease Control and Prevention: Physical Activity and Health (2018). https://www.cdc.gov/physicalactivity/basics/pa-health/index.htm
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What Joining CrossFit Taught Me as a PT and an Athlete

My first introduction to CrossFit was by Olivia Ferguson – my best friend on my softball team at Francis Marion. She started the fall of our senior year, and I would tag along to not be alone in the apartment. But I wasn’t really interested in it. As I went to PT school the following year, the consensus was that CrossFit kept us in business. Those crazy athletes just moved around erratically and injured themselves, which led them to physical therapy. My first knowledge of Brandon Vaughn (part-owner of Vertex) was that he had a private practice within a CrossFit box – and that was a lucrative business model because they were always injured! Never did I think I would actually join a box myself or ever do CrossFit.

What I realized once I was out of PT school and began practicing was that all of my pre-conceived notions were totally false. CrossFit wasn’t a place where people did exercise with reckless abandonment.

I wanted to do Olympic Lifting because of Summer Strong. I knew without any introduction to Oly Lifts that I would end up injuring myself…and I knew I didn’t have friends. So, I finally decided to drink the Kool-Aid.  I joined CrossFit Soda City in June of 2017. What I realized the more that I went was that I found my new “thing.” I’d played softball in college for the physicality and for my Patriot-family.  I’d competed in Obstacle Course Races for the community and the challenge. And now I’d joined and began to love CrossFit for the community and the challenge.

So, what I learned joining a Crossfit Box is this:

  1. These people are way nicer than any other people you’ll ever meet in any gym environment. They genuinely care how you’re doing and what’s going on in your life.
  2. CF is not dangerous, if you’re being smart about it. You’ll always have people who take it too far – every box has “that guy.” But on average, people want to do it right and don’t want to get injured.
  3. CF gives you that competitive environment if that’s what you’re looking for. You push yourself hard because you have something to prove to yourself or you have a love of competition. If you don’t want to go hard, you don’t.
  4. CF helps you become a better mover. If you practice those motions, you build a better motor program for the motion. You get cleaner in your bar movements. You get better and faster.
  5. CF changes people’s lives. People become motivated to become healthier. It’s not JUST about losing weight. It’s about getting strong: mentally, physically, and emotionally. It helps you see who you are and how strong you are. Can you get through “Fran,” can you get through the MetCon when you’re dog tired and worked 10 hours that day? Yes. You can. You’re a beast.

I love my gym-Fam. Is CrossFit for everyone? Absolutely not. That’s why we have so many options – Pilates, Barre, Yoga. It doesn’t matter what you do, as long as you move. Once we STOP moving, we’re much more likely to sustain injuries. Find your thing, Jelly Bean!

-Tristan Faile, PT, DPT, OCS, CF-L1

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