If you’ve ever had pain in your jaw (or currently have pain in your jaw) you’re not alone! According to the National Institute of Dental and Craniofacial Research, the prevalence of jaw pain is about 5-12% of the population. It is more common among individuals aged 20-40 years and is about twice as common in women as men. Jaw pain can range from a mild annoyance to something which is so severe that it limits an individual’s ability to talk, eat, and brush their teeth. Many providers - physicians and dentists alike - don’t quite know the best way to address their patients’ jaw pain, and many people have no idea that physical therapy can be so helpful in treating this condition. Before I tell you how physical therapy can help, let’s get a little better understanding of the anatomy of the jaw and the various things that can go wrong.
When we talk about jaw pain, we are usually referring to the temporomandibular joint, known as the TMJ for short. You can feel this joint just in front of your ears, try it! Place your fingers at the back part of your cheekbone just in front of your ear and open and close your jaw. That’s your TMJ! A fun fact is that you can also feel the TMJ move if you put your finger just inside the tragus of your ear, which is the little cartilage flap on the front of your ear. If you place your finger just on the inside of that and open and close your jaw, you can also feel your TMJ moving. The joint you’re feeling joins your mandible (jaw bone) to the temporal bone of your skull. There is an articular disk that separates the two joint surfaces.
When you come to physical therapy for jaw pain, you might be told that you have temporomandibular dysfunction (TMD for short.) This just means that something in that joint, or the structures surrounding that joint, isn’t functioning properly. Symptoms of this can be pain, clicking, popping, grinding, clenching, or tightness. It is important to note, though, that popping or clicking on their own don’t necessarily mean that something is wrong and that you need to seek treatment. In the absence of any other symptoms (such as pain or tightness,) clicking and popping can be just fine. Sometimes, you can also get symptoms which might not seem directly related to your jaw but can be associated with jaw dysfunction. These can include neck pain or stiffness, headaches, ringing in the ears, and even dizziness. These symptoms can be caused by dysfunction of the joint, the muscles around the joint, the articular disk, or any combination thereof. Your physical therapist will help narrow down which structures to focus on based on tests and measurements performed at your first visit, as well as from taking a thorough history to better understand how your symptoms began.
Treatment for TMJ pain often includes a combination of techniques including joint mobilizations, soft tissue techniques, home exercises, and even dry needling. Your therapist will tailor your exact treatment plan to you based on their findings at your initial evaluation. With this individualized treatment plan, physical therapy can be highly effective at treating any unpleasant jaw symptoms you might have!
Heather Shaughnessy, PT, DPT
Simply put, the deep neck flexors are the equivalent of the core for the neck. When we think about our core, we often are referring to our abdominal muscles in the trunk. These mostly support our low back or lumbar spine. The good news is that we have similar supportive musculature for our neck - the deep neck flexors!
There are two main muscles that make up the deep neck flexor group: the longus capitis and the longus colli. In as lay terminology as possible, the longus capitis muscle attaches from the base of the skull to the front side of vertebrae from C3-C6 and the longus colli muscle runs along the front of the spine from C3 down to T3. Any rehabilitation that is focused on improving a forward-head / rounded shoulders posture or any rehabilitation from a neck injury should include some form of exercise for these muscles. The typical exercise is something we call the “chin tuck.” I often refer to this as “the sit up for the neck.”
The challenging part of this deep neck flexor group is being able to isolate and access it without recruiting other neck musculature. When you truly look at the anatomy of the neck, you can see that this deep neck flexor group is named such because it lies “deep” to the esophagus and trachea. This is where the challenge of access comes into play because there are many muscles that work easily but are “superficial” to the esophagus and trachea. These muscles are used for swallowing, talking, chewing, etc. So, in physical therapy, we need to teach our patients how to turn those muscles off and turn the deeper ones on!
We learn in physical therapy school that strong deep neck flexor muscles are able to hold a chin tuck and lift position for 30 seconds. In my 8 years of working as a physical therapist, I can attest that upon initial evaluation of these muscles I have never had a patient be able to do that. With practice and guided exercise, my patients are able to strengthen this unique muscle group and this ultimately leads to improved stabilization of the neck. This equals significantly less neck pain and improved posture.
Most of our patients understand the importance of core strengthening to help maintain health and reduce injury in the low back. The same holds true for the “core of the neck.” If you have any questions or feel like this is an area of your routine that you are missing, any physical therapist at Altitude would be happy to help you properly learn how to strengthen this deep neck flexor group. It’s a small group of muscles but they sure are important!
Lisa Corken, PT, DPT
We get this question a LOT in our profession. Much like every other question in our industry, the answer is not so straightforward. I’ve been working as a physical therapist for 25 years and have been casting orthotics for 20 years and I still don’t have the exact answer to this question! However, I have learned a great deal regarding this topic over time, and I’m here to share it with all of you.
First let me start out by saying that I truly don’t believe everyone needs orthotics. Sometimes it is a matter of wearing the correct shoe or supplementing with the correct exercise. That being said, by the time someone comes to see a physical therapist with a significant gait abnormality, it can be very challenging to fix it through manual therapy and exercise. We start walking around age 1, the arches in our feet finish developing around age 10, and it usually isn’t until age 30, 40, or 50 that we start thinking we are walking funny. That’s potentially 20, 30, 40 YEARS of an established motor program that needs to be reset. Now, I said “challenging” to fix it…. not impossible.
The way we decide if someone truly needs orthotics is if all our other avenues fail. As movement experts, we use external support as a last resort. We first assess your posture from head to toe. We look for things like scoliosis, leg length discrepancies, hip dysfunction, ankle restrictions, big toe mobility, balance issues and strength. We use manual therapy techniques like joint mobilizations, dry needling, taping, and myofascial release to improve quality of gait movement. We emphasize strength throughout core, hips, knees, ankles and feet to ensure proper motor control.
Depending on what the issue is, we typically can identify if someone is a good candidate for orthotics after 8-10 sessions of physical therapy. That usually equates to around 6-8 weeks of care. If we don’t see a significant change in gait AND you, as the patient, don’t report an improvement with our strategies, we dive into the orthotic discussion.
From my personal experience, casting orthotics is the best way to go for the most custom design. There should be a non-weight-bearing foot assessment, a weight-bearing static assessment and a barefoot gait assessment. We know that not everyone should walk exactly the same way, but there are certain aspects of gait that should be apparent in every gait cycle. For example, the ability of the rearfoot (heel) to move through neutral should be present, but some patients will move through 10 degrees of motion whereas others may move through 3. That may sound like gibberish to you, but I share it with you so you can understand that not all gaits are created equal, but they serve their purpose to allow us to walk! Ultimately, I believe the orthotic should support the way your body wants to walk and not necessarily CHANGE it - an assessment we would make in our physical therapy visits. Custom orthotics can be quite the investment and there are semi-custom options that are available and help determine if a full custom option is worth it. These are typically heat-moldable but less durable. The BEST news: Altitude can help you with any of your orthotic needs!
So, to answer the question of “how do I know if I need orthotics?”.... the answer is to come see us! We can ensure a thorough evaluation and attempt all other options of exercise and manual therapy prior to making the orthotic decision. Like I said in the beginning of this post: not everyone needs orthotics. Let us help you figure it out!
Bob Cranny, PT, Owner
There has to be something like over 1 million different types of shoes out there, right? How do you know which shoe is best for you? The answer to that question is one that we hear in physical therapy school a lot….. IT DEPENDS!!! **also note that these are my professional opinions and I have no affiliations or relationships with any particular shoe brands**
There are always going to be fads and trends when it comes to footwear. For example, the finger toes, the barefoot running shoe, the Skecher ShapeUPs, the HOKAS, the skater shoe, Converse, AirJordans, Asics, Nikes, and the list goes on and on. This blog is meant to cover shoe selection generically and finish with the burning question I get from aging runners - Should I switch to HOKAS (or cushioned shoes)??
When it comes to shoewear, there are a lot of things to consider. Are you running? What type of surface are you running on? How often do you run? How far do you run? Are you walking? Where do you walk mostly? Are you in any foot pain? Do you have any pain with walking? Do you wear gym shoes all day? Do you wear high heels for work? Do you wear sandals in the summertime? It’s quite the specialty to pick the perfect shoe for someone and we almost never get it right the first time…
When you come to physical therapy and ask the question, “but which shoes are best for me?” your physical therapist will start asking the above questions. They’ll also follow it with a gait or running analysis in addition to a movement screen. They’ll check the range of motion of your low back, hips, knees, ankles, and the tiny joints in your feet. The most important thing about selecting a shoe is finding one that will SUPPORT your current and preferred movement pattern versus attempting to CORRECT it. In my 7 years of working with runners and hikers in Colorado, I have only once ever recommended a MOTION CONTROL shoe for a patient. More frequently, we are able to address motor control deficiencies before relying on an external source, like a shoe, to correct any gait or running deviations.
Now, to address the most recent fad or trend in shoewear, I’m going to talk a little bit about HOKAS or shoes that have a lot of cushion. I took two intensive running courses over the past 7 years and they presented similar information regarding the theory behind HOKAS. The idea is that the significant cushion will reduce shock absorption through the rest of the body. The reason I write THEORY is that this is almost impossible to prove with the current technology (at least at the time I’m writing this blog). There are studies that show ground reaction forces when wearing HOKAS and when BAREFOOT. Ground reaction forces are a measurement of how hard you stomp on the ground. This measure has an equal and opposite force through your body. Ultimately, the study found that there was no change in the magnitude of your ground reaction force. Where the study is limited is showing WHERE the ground reaction force is being absorbed. Hence, THEORY. With that great of a cushion, the assumption is a large amount of that force is being absorbed by the shoe and not your joints.
So, I always get the question from the aging runner - should I switch to HOKAS? And just as I started this blog, the answer is - IT DEPENDS! If I watch you run, jump, hop and I can see you have a difficult time with absorption through musculature and joints, I may recommend the HOKA-type shoe. But if I think it’s something that you can train and work up to, I would go down that path first. In my opinion, the downside of HOKAS is that the cushion significantly increases the distance between the sensors in your feet and the ground. Basically, your entire lower kinetic chain takes longer to process any feedback from the ground and this can often lead to ankle sprains, falls, and other injuries.
I also mentioned in the beginning of the blog that selecting the perfect shoe is incredibly challenging and that we almost never get it right the first time. There are so many factors in addition to what I’ve already discussed from a physical therapy standpoint. We need to take into consideration cost, cosmetics, comfort, durability, fit, and ease of getting them on and off. I may very well pick a shoe that I think is perfect for you, you’ll test it out and absolutely hate it! This is where your shoe history is incredibly helpful. I often find that whatever shoe you used to wear all the time is likely the correct shoe for you - we just may need to adjust your motor control for efficient muscle firing during walking or running.
And if we simply cannot find the right shoe for you, that’s when we start considering orthotics. The question of “how do I know if I need orthotics?”.... Well, that’ll be for another blog post :)
Lisa Corken, PT, DPT
Why do people get Achilles tendonitis and plantar fasciitis???
There are many factors that can contribute to Achilles tendonitis and plantar fasciitis. The number one factor is usually an overuse of the gastroc-soleus complex. The two muscles in your calf join together at the Achilles tendon in the back of the heel. When this structure gets overused, it can pull the heel bone (calcaneus) in a way that irritates the plantar fasciitis in addition to it just getting irritated right at the Achilles tendon.
The real question we ask as physical therapists is “Why Are You Using Your Calf So Much!?” Ironically, your calf being tight may be the immediate source of your pain but more often than not your pain is probably coming from a lack of strength or range of motion somewhere else entirely. I have found throughout my experience in physical therapy and taking two intensive courses on running injuries that there are two main places that can cause an overuse of your calf muscle: 1. Hip Extension Range Of Motion and 2. Great Toe Extension Range Of Motion
In the gait and running cycle, we have phases called “terminal stance” and “pre-swing,” which is when our toe just barely comes off the ground to take that next step forward. This particular position requires a certain range of motion at the hip and big toe. The hip should be able to achieve at least 10 degrees of extension and the big toe should be able to achieve at least 60 degrees (if walking) and up to 90 degrees (if running) of great toe extension.
If you take a look at this picture, you can see that the femur (thigh bone) is angled slightly behind a totally vertical line (imagine a straight line from the pelvis down to the ground) and that the big toe is starting to extend or bend as the foot/ankle rolls through. This position allows optimal contraction of our gluteus maximus muscle - the huge power generating muscle of the entire lower kinetic chain. When the range of motion is limited in the big toe, we cut the terminal stance and pre-swing phase of gait short. This means we get off of the foot more quickly and we don’t access the range of motion that allows the glute to work. Thus, we use something else - the CALF. The same principle applies with limited hip range of motion. If we can’t get our femurs to extend beyond neutral and into that 10 degrees of extension, the glute cannot properly fire so we again ask the calf to help with power more than we normally would. As luck would have it, when I have a patient come in with plantar fasciitis or Achilles tendonitis, they are usually lacking BOTH hip range of motion and toe range of motion - double whammy.
Can it be fixed?! YES! My approach to treating plantar fasciitis and Achilles tendonitis is to treat locally first. This means treating calf tightness to help with symptom management right away - massage, dry needling, stretching, etc. As the calf responds to treatment, we are able to shift gears to the actual origin of the injury. This usually includes manual therapy to the big toe or the hip to improve any limitations noted. Whilst improving the range of motion is a big component to improving the motor efficiency in your gait cycle, there needs to be accompanying functional exercises to promote muscle activation in the appropriate positions. This is where physical therapy can get really fun and creative using balance equipment, speed adjustments, plyometrics, and sport-specific exercises.
There is this concept we discuss in physical therapy where we describe being strong throughout the available range of motion. What this means is that even if we improve your flexibility and range of motion, you’re still at risk for injury if you don’t know how to CONTROL that new range of motion. But once you learn to do this, your risk of re-injury is significantly less - assuming you keep up with your homework!
This blog was meant to discuss the most common reasons plantar fasciitis and Achilles tendonitis may occur, but is certainly not all-inclusive. Overall, I want to remind all patients that the longer plantar fasciitis or Achilles tendonitis are bothering you, the longer it takes to heal. Don’t wait too long to get it checked out! Key identifying factors are sharp pain felt in the center of the heel, pain felt along the inside of the heel, pain in the arch of the foot, pain in your Achilles tendon, and pain with your first steps out of bed in the morning. If you feel like you have any of these nagging pains, let us know and we can get you started on your road to recovery!
Lisa Corken, PT, DPT
The importance of unilateral training for overall body strength
A question we often get as physical therapists is: “What’s the best way to protect my body when lifting weights?” Of course, there are several different ways to answer this question. This blog is going to emphasize my professional and personal approach on how to reduce risk of injury when you are lifting weights.
There are so many amazing different lifting techniques that are great for strength building. A few of the popular ones are deadlifts, snatch and cleans, front squats, back squats, pull-ups and bench press. These are more of your power moves that are great for strengthening, but often are performed incorrectly. Now, you may have every intention of performing the exercise perfectly, but your body just won’t cooperate. This is where I incorporate my approach to protecting your body.
We commonly see patients in the clinic who have a dominant side. This is totally normal! However, this can also lead to imbalances in your squat, deadlift, pull-up, etc. I use slow motion video technology to see if you are using one side more than the other and then address it with a more appropriate warm-up for these power moves. This usually involves a more unilateral approach to strengthening. Thus, I prescribe SINGLE LEG squats, SINGLE LEG deadlifts, and other challenges that will engage each side of your body prior to bigger lifts.
The reason that this ends up protecting the entire body is that it increases overall core activation. The big squat and deadlift are very bilateral motions where the majority of the force is going through the center of our body - the spine. While the spine is a very strong structure with complex ligamentous support, muscular stability, and discs - it still has its limits. Now, if we take your standard front squat with dumbbells as shown in the picture on the left you can see that the force is through the midline of your body. Most of my patients believe this to be ideal as they feel centered, but in fact it places more strain through the spine if not performed perfectly. If we compare it to the picture on the right where you are holding a dumbbell on just one side, this will create a sidebending force thus increasing more oblique and core activation to stop you from leaning or falling that way. This more rotational torque helps move the force from straight down your spine to now requiring that core control.
The same principle can be applied to upper body lifting as well. See below the difference between bilateral overhead military press compared to unilateral military press. If the man on the right didn’t engage his RIGHT obliques, that weight in his left hand would cause him to tip over!
Overall, these are just a few tips I like to educate my patients about when returning to bigger powerlifting or weight lifting. They are great ways to continue strengthening while promoting a healthier and stronger core. The purpose of this blog was meant to shed light on how unilateral vs bilateral forces on the spine can be manipulated to improve muscle activation in addition to adding a balance component for full body involvement. Ultimately, the best approach to a routine like this is to schedule an appointment with your physical therapist to have them evaluate your squat, bench press, deadlift, etc after which they can create an individualized program for your specific workout needs!
Lisa Corken, PT, DPT
Acromioclavicular Joint Separation
If you live on the Front Range of Colorado you probably know at least a few mountain bikers, if you are not one yourself. And if you talk to mountain bikers about their injuries you will start to see a trend: lots of collarbone injuries. Falling over the handlebars -- a right of passage among mountain bikers -- is a common culprit for collarbone injuries. The most common collarbone injury amongst mountain bikers is an AC joint separation.
AC joint separation occurs most commonly when a downward force is placed on the shoulder or upper arm, tractioning the arm from the body (including the clavicle). This occurs in biking with a crash onto the shoulder, or in football when a player takes a strong hit to the top of the shoulder. The joint at the end of the clavicle -- the acromioclavicular joint -- takes the most stress in this injury and the ligaments that hold the joint in place can tear.
Degree of Injury
AC joint separations are graded from I to VI depending on the type and severity of separation. In a Grade I sprain, the ligaments are minimally torn and normal activity can usually resume painfree within a few weeks. Grade II includes more ligament tearing and can result in a small bump deformity on the top of the shoulder, but usually heals within two months without functional deficit. Grade III sprains involve a complete tear of the ligaments and visible “step deformity” over the top of the shoulder. The “piano key sign” occurs with this grade of separation where you can push down on the raised collarbone and it will pop back up like a piano key. Grade III injuries can be treated surgically, especially if someone is concerned with their physical appearance, however, functional outcomes are roughly equal between those who undergo surgery or not. Grade IV-VI AC joint separations are rare, but more serious, and require surgery.
So what can you do if you separate your AC joint? In the short term you want to let it heal without injuring it again. Icing it is likely beneficial for at least the first week and taping over the joint with kinesiotape or a more rigid tape can help give a feeling of stability for a few months. Avoiding high contact sports until it’s completely healed will help prevent a worsening of the joint separation. As it starts to feel pain free, the strengthening phase begins. Because of the separation of the joint and tearing or stretching of ligaments, the shoulder joint will be inherently less stable; using muscular strength to support the AC joint becomes more important. Strengthening exercises include rotator cuff, shoulder blade, upper trap (top of shoulder), and chest strengthening to provide support all around the joint. A physical therapist can guide this strengthening phase over the course of a few weeks to a few months, depending on the severity of injury
As a rule of thumb, if there is a visible bump on the shoulder more than a quarter inch and/or pain lasting more than 2 weeks it is advised to get the injury evaluated by a physician or physical therapist to help grade the injury and guide recovery. If pain is severe or the separation is more than a half an inch then immediate medical attention is advised as surgical treatment for this injury, if needed, can be time sensitive.
What is a tendon
A tendon is a strong rope like structure that attaches a muscle to a bone. A common example of a tendon is the Achilles, which attaches your gastrocnemius and soleus muscles to your calcaneus or heel bone. Tendons are an essential part in allowing our bodies to move. They help transfer forces from our muscles (when contracted/tighten) to the bones they attach to, which leads to movement of that bone/body part. Often, they will attach from a large muscle such as your bicep to a small single point on a bone. Therefore, they must be made of strong material as they often undergo strong force transfers
(tendons are known to have one of the highest tensile strengths of any soft tissue in the body).
Anatomy of a Tendon
Tendons are made of dense fibrous connective tissue that is made up of mostly collagen fibers (structural proteins). These fibers are found in very tightly wound bundles throughout the tendon. This collagen and bundling make them very strong and resistant to tears. Another important aspect of tendon anatomy is that they do not receive as much blood as the muscles and bones that they attach to. This is because they have a lower density of blood vessels (reason for their white color). This is an important factor when it comes to tendon injuries. While tendons are strong and resistant to injury they do occur and can be classified into 4 categories: tendinitis, tendinosis, tendon tear and tendon rupture.
The medical definition of the suffix “itis” is inflammation, so the term tendinitis translates to
“inflammation of a tendon.” This is often more of an acute injury (short-term) and is associated with
swelling around the tendon and pain when that tendon is used (contracted by muscle). This
inflammation and pain is caused by micro-tears in the tendon that occur when there is a force applied
that is too heavy and or to sudden applied on that tendon. The treatment goal for tendinitis is to reduce
inflammation. This can be done in a number of ways, starting with RICE (rest, ice, compression, and
elevation), anti-inflammatory medications, and physical therapy techniques including soft tissue
mobilization. Recovery time varies between days-6 weeks.
This term refers to degeneration of a tendons collagen fibers often caused by chronic overuse (longer
periods of time). This degeneration of collagen fibers can lead to loss of fiber continuity, causing
decreased overall tendon strength. These are often seen when a tendon is injured and not given the
appropriate time to rest and recover. Because tendinosis is a chronic issue, there is no tendon
inflammation/swelling present, so the treatment goals are different. Primary treatment goals are to
inhibit the cycle of injury (or tendon overuse) and to optimize normal collagen production and
maturation so that the tendon regains normal tensile strength. To do this we must determine what is
causing the repetitive injury by looking at ergonomics, biomechanics, etc. Once this is determined we
can use support (braces, tape, etc.) to help reduce forces on the tendon and allow for appropriate
healing. Light stretching while minimizing pain is crucial to limit shortening of muscles and maintain
flexibility. Eccentric strengthening and loading the tissue without pain is essential to help with collagen
production and improve collagen alignment. Treatment time can vary from 6-10 weeks (if caught early)
all the way up to 3-6 months.
If you are having any tendon pain (most commonly in heel, elbow, shoulder, knee) please give us a call.
We can help evaluate this pain and determine the underlying cause then come up with a plan to get you
back on track!