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Ask A Physical Therapist
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Need tips on recovery, icing or stretching?
Trying to trouble shoot those aches and
pains? Ask our featured Physical Therapist
about effective stretches, massage
techniques or just a question about an injury
you may have! Here you will find valuable
information on how to nourish your body after
a strenuous workout and help keep you
healthy.

Featured Physical Therapist: Proactive Solutions, Inc.
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My name is Rudy Haberzettl MSPT. I am the president and
owner of PROACTIVE SOLUTIONS, INC, a healthcare
consulting company specializing in injury prevention and
overall wellness. We currently have two physical therapy
clinics, Colorado Springs and Phoenix.

I am physical therapist specializing in orthopedics and injury
prevention for the past 9 years. I moved to Colorado Springs
in 2005 with my wife for the outdoor activities and beautiful
weather. I have worked with a variety of athletes of all ages
competing in various sports.

I believe the most important thing I can do for my patients is
empower them to effectively self manage their health through
education and effective treatment. I am happy to answer your
questions relating to injuries, custom foot orthotics, training
and prevention for overall health and exercise longevity.

My Motto: “Adapt and Overcome”, I learned it in the USMC and
it has served me well through life.

Ask Our Featured Physical Therapist a Question:
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Subject:

Question or Comment:

Proactive Solutions, Inc.
1855 Telstar Drive
Colorado Springs, CO 80922
T 719.310.1741

Gradual onset and worsens as the run progresses- This means it is mechanical in nature with the most common problems being a patella misalignment or an
over pronating foot; and once this is corrected the problem will resolve.

No history of trauma or surgeries- Surgery and trauma only complicate issues and leads to mechanical faults or compensations. You don't have this contributing
factor.

No orthotics- Foot alignment is huge for runners because the foot is the connection with the ground and starts the bio-mechanical chain. Some advice on
orthotics, be careful when you hear the term "Custom Orthotics". The ones you see on TV or at Good Feet are not custom orthotics. They all just ask for your show
size and take a pair off the shelf. Most of their tests are more gimmicky in nature then based in real science. These are made for the average person of that foot
size. They are also identical, right and left foot. I have never seen a pair of identical feet out there yet. Usually one side requires more support than the other. These
companies do not cast a mold specific to your foot, body weight, foot flexibility, activity level or perform a thorough evaluation of the entire lower extremity. As for
customs, evaluation and casting techniques vary and so does quality. The following health-care professionals fit custom orthotics and have received formal
education in bio-mechanics: Physical Therapist, Podiatrist, Orthotists and some Chiropractors. Most insurances do not cover orthotics fully unless you have a
diabetic foot problem. So it is an out of pocket expense. The price range is usually around $400-500 but should include the evaluation and follow-ups. I am
certified to fit custom orthotics and provide this service for my patients. I always perform an evaluation of the low-back and lower extremity to determine the root
cause of the problem. Then the patient is casted and follow-ups in 2 weeks for a fitting. The patient then goes through the break-in period and is given specific
exercises. Future follow-ups are set up determined by their response. If for any reason the orthotics need to be re-casted it is no charge during the first 6-months
from casting. Yes custom orthotics are more expensive but they should last for 7-10 years and save you from a host of problems, injuries and future medical
expenses. My success rate is 98% with my patients for full resolution of their condition if orthotics are indicated.

Symptoms only come on with running- This is a good sign because we have a specific related activity causing the problem. Running is a dynamic activity that
applies the full body force to one leg at a time. When you run at any point in the sequence of motion there are never two feet touching the ground at once or you
would be walking. So if you ask a runner to stand on one foot and perform a single leg squat you can look for bio-mechanical faults such as pronation of the foot,
knee and hip malalignment and muscular weakness. Also since you do not have symptoms with everyday activities (ie. walking, stairs, standing) you are in the
very early stages of the problem. This is the best time to address a problem.

Type of Running- You said you run on trails and when it becomes hilly it comes on within 30 minutes. Trails and hills challenge the body the most because of the
ever changing surface and angles the foot is placed in. You should stay with a flat consistent surface as you rehabilitate your injury. Once you are symptom free on
the flats then you add in one type of terrain change such as hills. Running small hills dispersed throughout your run till you are symptom free then progress to
light trails. Trails is the last type of environment to add because there are so many variables to account for. The whole time your distance and pace stay the same
to minimize the variables until you have returned to trail running symptom free.

Previous attempts at resolving the problem- Bracing and bands with no success. Advil and rest help. I can't comment on the bracing and bands because I don't
know which specific models you used and if they were fitted properly. If rest and Advil (anti-inflammatory medication) worked we have a mechanical irritant as
mentioned in the responses above.

So at this point we have a couple of things to consider:

Is this a foot problem requiring orthotics?
Is there a malalignment of the patella (knee cap) and what is causing it (muscle weakness, muscle tightness or a bio-mechanical fault at the foot or hip)?
Do you have proper foot wear for you activity?
What type of strengthening and stretching program do you need?
Is bracing still an option?

Here are some simple self-tests to attempt with the possible solutions. If this only confuses you or your are not feeling confident self-resolving this I would be happy to
meet and evaluate you.

Foot problem- You may need a helper. Stand on one foot and see if your arch drops down. Yes everyone will drop a little but if you are getting close to flattening out
this could be a sign of a problem. Usually on the side of the problem. Now stand on one foot in front of a mirror and squat about half way down, does your foot
really flatten out now and does your knee move inward and hip move outward. Sometimes if you repeat this 10x the symptoms may present. This is a positive sign
for poor foot alignment. If you purchase an inexpensive pair of Dr. Scholls arch supports, athletic type and you receive some improvement in your symptoms
custom orthotics will give you a great response.
Patella (knee cap) Malaligment- This is harder to self test. You sit on the floor with your legs straight out in front of you. You place your hand on the inside border of
your patella and tighten your quadricep (thigh muscle) hard. You may have to tighten it slowly to feel the subtle change. Does your knee cap pull up and inwards or
up and out? If it is up and out this is a sign of VMO (vastus-medialis-oblique) weakness and/or tight ITB (illio-tibial-band). This is resolved with VMO strengthening,
ITB stretching and sometimes the use of taping and bracing initially. This can be difficult to diagnose and a physical therapist is needed to evaluate correctly.

Try these two self-tests and then we can decide what to do next: self treatment or a physical therapy evaluation.

Thanks for your question, stay healthy;
Rudy Haberzettl MSPT
PROACTIVE SOLUTIONS, INC.

Waiter's Bow Stretch - the runner bows forward keeping the back straight and only pivoting from the hips till a stretch is felt in the hamstrings, hold for 10-20
seconds and repeat for 3-5 reps. You should not feel it in your lowback, just your hamstrings.

Calf Stretch - assuming a lunge position keeping the knee straight on the rear foot leg that you are stretching, keep your weight on the outside portion of the rear
foot, hold for 10-20 seconds and repeat for 3-5 reps. Avoid allowing the stretching foot to drop inwards flattening your arch.

Gastroc Stretch - same position as the Calf stretch except the knee is flexed slightly. The stretch will be felt closer to the achilles tendon. Keep your weight on
the outside portion of the rear foot, hold for 10-20 seconds and repeat for 3-5 reps. Avoid allowing the stretching foot to drop inwards flattening your arch.

Standing Quad Stretch - standing straight bring the heel of the leg you are stretching to your butt, grasp the leg by the ankle not the foot, tighten your lower abs
and keep your back straight, hold for 10-20 seconds and repeat for 3-5 reps.

Hip Flexor Stretch - assume a lunge position, keep your back straight, keep the leg straight on the side you are stretching with heel slightly off the ground,
gently arch your back till you feel a stretch in the front of the hip, raise your chest up to the sky while slightly arching the back.

When you are done running repeat the stretches again to help prevent injury. Stretching before and after exercise is most effective.

Thanks for your question, stay healthy;
Rudy Haberzettl MSPT
PROACTIVE SOLUTIONS, INC.

Question for Rudy Haberzettl MSPT:
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Q: When should I apply Ice or Heat? I have heard some people say for hamstrings apply heat because applying Ice shortens the muscle but when I have applied
heat it aches even after applying ice for the 1st 72 hours. Also for lower back stiffness is it ok to apply heat in the morning before getting up and starting the day?
Alan H.

A: The standard practice with heat and ice is as follows:

ICE: The physiological response is decreased blood flow to the area and decreased sensation by slowing the transmission of nerve signals.

If you have an acute injury (just happened, swollen and inflamed) you should ice for 20-30 minutes or till the area goes numb whichever comes first every 3-4 hours for
the first 48-72 hours. The area should be elevated above the heart and compression should also be applied.

HEAT: The physiological response is increased blood flow through vasodilation and inhibiting the sympathetic nervous system causing muscle relaxation. Heat also
increases the extensibility of collagenous soft tissue (ligaments and tendons). Moist and dry heat only have a average penetration of less than an inch of soft tissue,
closer to half and inch. Anything deeper requires exercise or a therapeutic modality (ultrasound).

If you have a tight muscle or stiffness relating to an older injury or prior to activity heat is applied to the area for 10-30 minutes or hydrotherapy (whirlpool or hot-tub). The
area should become slightly red and should be checked frequently to avoid burns. I use the rule that the heat applied to the area should feel warm like towels out of the
dryer. Gentle exercise works the best such as a slow walk before a run for deep muscles.

That being said there are variations to the rule. Arthritis is inflammation of the joint but responds better to heat than ice. Contrast baths, this can be used for semi-acute
injuries, alternate cooling and heating the area.

Caution: The following items should be considered prior to icing or heating. If you have the following you should consult a physical therapist prior.

Loss or decreased sensation of the area to be treated
Previous or current malignancies (cancer) in the area
Diabetes
Pregnancy
Cardiac Related Issues
Bruising (heat should be avoided)
Raynard's Disease (avoid cold)

Thanks for your question, stay healthy;
Rudy Haberzettl MSPT
PROACTIVE SOLUTIONS, INC.

How did it start and how long has it been going on?
What location on the foot did it start and has it spread or changed location?
Is it constant or intermittent and what activities make it worse or better?

When patients report similar symptoms as you have and just started running one thinks of "plantar fascitis". This condition mainly starts in the arch or heel region. It is
worse with prolonged weight bearing activities; ie. running, walking, hiking and better with rest. Also individuals report the first couple of steps in the morning or after
being off their feet are very painful. If you press your thumb along your arch it is tender. Sometimes there will be swelling but this can be difficult to notice.

The most common cause is poor arch or biomechanical support. Support can come from proper foot wear and/or orthotics. The majority of the time once this is corrected
and the individual slowly returns to activity the problem resolves and rarely returns. In addition to proper footwear and orthotics the following are beneficial:

Massage using a rolling pin and gently rolling the foot over massaging the arch daily for 5-10 minutes
Ice 10-20 minutes ( if the area goes numb remove the ice) then a warm soak for 20 minutes performed daily (massage afterwards)
Calf and gastroc stretch but only with the arch correctly supported otherwise you will only progress your problem in the long run.
Anti-inflammatory medication (Alleve, ibuprofen, etc.), 600mg every 6 hrs. or 800 mg. every 8 hrs. for 5-7 days. Consult with your physician if you are on medication,
have stomach or intestinal issues along with other concerns.

If performing the above recommendations along with a gradual progression back to desired mileage does not resolve your problem in 3-4 weeks consult a physical
therapist. Remember gradual progression back to mileage would be: (below is an example)

If you are a 3 mile runner then rest one week no running, week 2 walk one mile if no pain increase your walking distance by half a mile a week if symptoms do not
return. Once you have returned to 3 miles walking pain free start walking half a mile to warm up then run half a mile. Each week after increase your distance by a
quarter mile as long as you are symptom free. Once you have returned to running 3 miles symptom free you can increase your speed. You should perform all this
on a flat surface, no hills till you have returned to 3 miles running symptom free. If your cardio is suffering you can supplement with biking, rowing or swimming.

If all this sounds too confusing or this does not describe your current condition consult a physical therapist for a more exact diagnosis after a formal evaluation.

Stay Healthy,
Rudy Haberzettl MSPT, CEES

NEW! Question for Rudy Haberzettl MSPT:
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Q: I am a 62 year old female, very good health, good condition, active, work out 3 times a week. Last August (2008) I noticed sore knees while on a long walk.
Now, it's March 2009, and I am still trying to resolve sore knees. I'm seeing an ortho doc who diagnosed mal-alignment of both knees. I've been doing the
prescribed stretching and strengthening exercises for the past six months (part of that time under the care of physical therapist). In November of last year, I
received cortisone shots to calm down knee soreness, tingling (in lower legs and feet), pain, and sore shins, which helped my symptoms. I also take Aleve. The
ortho doc wants to give me another round of shots at the end of March. My only other choice, he said, is partial knee replacement. How long can it take to
strengthen quads and areas around both knees? When is surgery the only option left? - Sandra R.

A: Sandra there are several causes and treatments to the diagnosis of malalignment of the knees. This term usually refers to your patella (knee cap) tracking
improperly.

The underside of your patella has a rounded V shape, like an upside down triangle. The rounded V shape rides in a groove on your femur. Just like a car that the steering
is out of alignment and the tires wear uneven this also happens to the cartilage that covers the underside of your patella. The cartilage gets worn and irritated; this
causes pain and inflammation at the knee. You may also feel a grinding sensation and sometimes a audible grinding sound. The pain gets worse with prolonged
walking, going up and down stairs along with squatting activities. You may notice the knee swells slightly around the patella after activities.

The following are the most common causes:

Poor foot alignment such as over pronation during weight bearing activities.
Weakness of the VMO (vastus-medialis-oblique), a small muscle that is part of your quadriceps that helps with proper tracking.
Weakness of your gluteus medius and hip stabilizers.
Tightness of your ITB (illio-tibial-band), this pulls the patella laterally out of alignment.
There may be other knee alignment problems and underlying health conditions that can cause the problem. These can be evaluated through X-rays, MRI's and
lab testing from your orthopedic surgeon.

Your physical therapist can evaluate the causes mentioned above easily in the clinic and prescribe appropriate stretches, strengthening, knee braces (patella
stabilization) and orthotics to address your problem.

Depending on the cause(s) and the duration of your condition prior to seeking medical care the course of recovery can be 2-3 weeks up to 6 months. You stated you have
seen a physical therapist, performed your exercises and received a cortisone with no success over the past 6-months.

A couple of things to think about:

I mentioned causes above, did you have each of these areas of concerns evaluated and addressed?
Is the original diagnosis of mal-alignment correct?
Have you been consistent with your exercises as prescribed and is your technique correct?
Is it time for a second opinion?

Hopefully this information has provided some insight for you and may have stirred up other questions. Please feel free to email me if you have additional questions.

Stay Healthy,
Rudy Haberzettl MSPT,CEES