Wednesday, April 23, 2014
Inquirer Daily News

Desirea D. Caucci

POSTED: Thursday, February 13, 2014, 5:30 AM

Pain and dysfunction of any body part has many possible causes. I would venture to say that every single one of us can identify with nagging muscle pain or muscle “knots.” 

In medical terminology, this is a myofascial restriction of the actual muscle fibers and the connective tissue, fascia, that envelops them.  In my opinion, full healing is not possible without addressing this common soft tissue problem.  

There are several techniques available to address myofascial restrictions. I commonly utilize my hands for deep massage, myofascial release, acupressure and stretching. There also have been tools developed to accomplish muscle release when used by a skilled practitioner. 

In my office, we use HawkGrips tools for instrument-assisted soft tissue mobilization.  This allows the user to focus mechanical force along a small contact surface to treat the target tissue.  

HawkGrips are a surgical-grade stainless steel instrument designed to detect and treat soft tissue restrictions. We glide the tools over the skin and feel for any soft tissue adhesions. The tools actually transmit vibrations from the muscle and connective tissue to the instrument which can be felt and heard.  There are various different strokes applied for deep pressure to restricted tissue in order to break adhesions, soften tissue and promote oxygenation and circulation to the affected areas.

Performing tissue mobilization in this manner with my patients has resulted in reduced pain, improved range of motion, increased flexibility and overall enhanced performance. We have had great success in treating soft tissue restrictions of the neck, back, shoulders, knees and feet using HawkGrips in combination with therapeutic exercises, postural re-training and teaching optimal body mechanics.  

In general, soft tissue treatment, whether completed with hands or tools, is a highly effective hands-on approach in managing many acute and chronic pain syndromes, sports injuries, aging disorders, and traumatic and surgical scarring.  In my opinion, ignoring these soft tissue restrictions is the missing link in many people’s care.

POSTED: Monday, January 6, 2014, 10:33 AM

The topic of “no pain, no gain” is one that arises almost daily in my practice. Is pain during exercise appropriate? When is it too much, leading to muscle strain and injury?

We tend to follow a simple pain number scale (0-10) for determining the “allowable” amount of pain with exercise at my office. If you consider the exercise pain free, you score it a 0, moderate pain is a 5 and excruciating pain is a 10. For a healthy, pain-free population, exercise should not elicit pain other than the sensation of burning due to muscle fatigue. This is a normal sensation and indicates minor muscle “damage” that enables muscle growth, strengthening and repair with the appropriate rest between workouts. This type of pain goes away within seconds of stopping the exercise.

During rehabilitation of an injury where there is baseline pain present prior to initiating the workout, we allow up to moderate pain but no greater than a 7. For anyone, if the pain is described as sharp or shooting, it is suspect for impending injury. At that point, the exercise intensity (weight) should be reduced. If pain remains still, the exercise should either be modified to a smaller range of motion or stopped altogether. Similarly, if pain intensity increases more and more with each repetition, the exercise is not being done properly or the intensity is too high.

Another “normal” pain you may feel occurs 1-2 days after your workout. In the medical community this is termed DOMS, short for delayed onset muscle soreness. This muscle pain creeps up 12-48 hours after performing a strenuous activity and that lasts a few days. DOMS is a normal response to increased exertion to which the body is not accustomed. Once your muscles get familiar with the movement patterns, the same activity at the same intensity will no longer result in soreness. Although the soreness is, well, sore, it is not a cause for concern and it serves as a reminder of the great workout your body had!  It can also be perceived as the same type of “good hurt” you may have experienced after an intense deep tissue massage. Both allow you to feel muscles that you never knew you had!

Pain is the body's warning signal that injury is occurring or about to occur so it should never be ignored. It is important to become familiar with identifying the “good pain” associated with muscle growth and strengthening or healthy stretching and differentiating this sensation from a “bad pain.” Our bodies are pretty amazing and will tell us what we need to do; it's up to us to listen.

Read more Sports Doc for Sports Medicine and Fitness.

POSTED: Tuesday, December 10, 2013, 5:30 AM
Katrin Holtwick of Germany is taped during the London 2012 Olympic women's beach volleyball match between Germany and Czech Republic.

I recently co-authored an article for a Physical Therapy magazine, Advance Magazine, regarding the use of elastic taping for the upper quarter. Much of the information is useful in helping to educate more people about its many positive effects. I have adapted it to read more informatively than scholarly and I have also included a list of references at the end to give credit to the appropriate sources.

Therapeutic taping techniques that employ elastic tape as an additional component of the management of patients with muscle, joint and nerve dysfunction, are becoming increasingly popular. My patients are increasingly requesting it after seeing these bright, spiderweb-like designs of tape on professional athletes and in colorful advertisements. More and more medical professionals are offering this service since more recent research has been emerging to support its use for several important functions.

Therapeutic taping is becoming an important and useful treatment option that serves as an aide for prevention and rehabilitation. Taping can be used to reduce strain on tissues that may be damaged, facilitate or inhibit muscle activity, facilitate body awareness, provide mechanical support to enable correct moving patterns, reduce swelling and alleviate pain.

POSTED: Thursday, November 7, 2013, 9:32 AM

A sports hernia is a tear to the oblique abdominal muscles in the pelvic region of the abdomen. Unlike other hernias, the sports hernia has no visible bulge under the skin. The pain associated with a sports hernia resembles a groin strain, but doesn’t respond as well to rest, ice and anti-inflammatory medications. The pain tends to return with a vengeance once the athlete returns to the sport.

A sports hernia occurs with the weakening of the muscles or tendons in a thin region of the lower abdominal wall. Once overexerted, a muscle tear occurs inside the groin. The oblique muscles attach at the top of the pubic bone while stronger hip muscles attach to the bottom of the pelvic bone. When both contract simultaneously and with a lot of force, a tug-of-war of the pelvis ensues.

Because the thigh muscles tend to be stronger than trunk, the weaker abdominal oblique muscles tear, resulting in a sports hernia. Sports hernias occur most commonly among football, hockey, soccer and tennis players. However, weekend warriors and athletes making extreme and repeated twisting-and-turning movements are also susceptible.

The initial treatment of a sports hernia is usually conservative in hopes that the symptoms will resolve. Resting from activity, anti-inflammatory medications, ice treatments, and physical therapy can all be utilized in an effort to alleviate the patient’s symptoms. If these measures do not relieve the symptoms, surgery may be needed to repair the weakened area of the abdominal wall. Most athletes are able to return to their activity after surgery and rehabilitation.

Other, more common, hernias occur when part of an organ (usually the intestines) bulges through a weak point or tear in the thin muscular wall of the abdomen. There are several types of hernias, based on where they occur:

  • Inguinal hernia appears as a bulge in the groin or scrotum. This type is more common in men than women.
  • Femoral hernia appears as a bulge in the upper thigh. This type is more common in women than in men.
  • Incisional hernia can occur through a scar if you had abdominal surgery.
  • Umbilical hernia appears as a bulge around the belly button. It occurs when the muscle around the navel doesn’t close completely.
  • Hiatal hernia occurs in the diaphragm and allows the upper part of the stomach to move up into the chest.
POSTED: Thursday, September 26, 2013, 5:30 AM

News flash: we are all aging! By the time we reach our thirties, we all begin to lose peak strength by approximately 10 percent per decade, increasing to 15-30 percent per decade by our sixties. Knowing that we are in a strength decline for roughly 75% of our lives, how is it that there are some 70, 80 and even 90-year olds running marathons, winning strength competitions and retaining the strength and power of their earlier years?  

We all have the ability to continually gain strength, power, and improve our cardiovascular performance. Just like younger adults, aging adults should pick up the weights and engage in strength training types of workouts on a regular basis—2-3 times per week. There is a common fear of injury or misconception that aging muscles will not respond, however, these are just that—unfounded misconceptions.

Using the appropriate weight training intensities at 8-15 repetitions, where the 8th to 15th repetition is completed pain-free, with proper form and is unable to be lifted again due to true muscle fatigue, will result in strength gains. Most importantly, choosing the appropriate type of exercise to improve/maintain functioning is best.

For example, completing squats while holding free weights, a barbell with weights, a medicine ball, etc., is a better exercise for maintaining sit-to-stand strength than a seated knee extension machine. Functional strengthening is more effective in improving daily tasks than traditional strength training; this is also easier and more convenient to complete since it requires body weight resistance without a lot of fancy gym equipment. Other examples of functional strengthening exercises include repeated trunk curl ups (holding weights as needed), lunges, single leg squats or single leg lunges in different movement planes, push-ups, and step-ups/step downs forward/laterally. All of these can be progressed with adding more weight, depth of movement, ankle weights, holding weights, adding step height, etc. 

Focus on controlling all exercises with smooth, slowed movements is also key. Often times, when the focus is on completing a certain number of repetitions, people rush to get to the last rep. Momentum generated from rushing reps will make the exercises ineffective, sloppy and risk injury. Keep all reps to at least 2-4 seconds through the entire range of motion available. Further, there is evidence that just one set of 8-15 is just as effective as multiple sets. You will get more out of your strengthening routine if you do multiple types of different exercises to target a specific muscle group than many sets of the same exercise.

An ideal workout routine is to walk briskly for 5-10 minutes before strength training, then complete 30-45 minutes of varied functional strength training exercises, followed by 10 minutes of stretching. Warm-ups are important to stimulate adequate blood flow through the body and to allow the heart to respond to the higher physical demands. Stretching of various muscle groups is important to keep adequate range of motion and tissue length; stretches should be held one minute in each position to allow the elastic properties of the muscle to take effect.

POSTED: Wednesday, September 4, 2013, 6:00 AM

In 1st grade, my gym teacher made us all memorize the definition of “physical fitness.” Decades later, I still recall it as: “Physical Fitness–learning to use your body in many different ways.”

While this serves as a fine elementary definition, I now realize the actual definition is much more involved. So, what defines true physical fitness? Considering the total body, there are six elements of fitness: aerobic capacity, body structure, body composition, balance, muscular flexibility and strength. Let’s consider each one of these.

Aerobic capacity is your cardiovascular system’s ability to transport oxygen to working muscles to serve as fuel for energy. Aerobic capacity improves with cardiovascular exercises, like walking, running, bicycling, jumping rope, swimming, hiking, and dancing. Performing any of these types of activities at an intensity of approximately 60-80% of your total maximum heart rate (220 minus your age) for 30-60 minutes daily will provide you with the first element of fitness.

The second element of fitness is body structure. This is your overall posture, looking for any misalignments of the arms, legs and trunk. Even a small imbalance in the way you regularly stand or sit may lead to pain or injury. Ideal posture aligns your ears over your shoulders, shoulders over your hips, equal leg lengths, pelvic symmetry and neutral joints throughout the body, creating equal pressure on both feet. Any deviations from good posture need to be corrected with the proper stretching, strengthening and muscle releasing exercises.

Body composition is the third element of fitness. This is the ratio of body fat to lean body mass (bones and muscles). Weight alone does not tell us about body composition. Body composition measurements are taken with calipers at specific parts of the body to determine the percent of total body fat. There are also scales and devices that measure body fat. In general, the ideal range of body fat is 10-15 percent of total body mass for males and 15-22 percent for females. Your body functions most efficiently at the ideal fat-to-lean ratio.

Balance makes up the fourth element of total body fitness. There are simple balance tests that can be administered to determine your balance level. For example, standing on one leg with eyes open versus eyes closed. Depending on your age, there are set values of time for this test to determine if your balance is good. 30 seconds is the goal for younger, healthy individuals. Even minor balance problems place you at risk for injuries like ankle sprains, muscle strains, falls and fractures.

The fifth element of fitness is muscular flexibility. Your muscles should be flexible enough to allow for the full range of motion required by life’s many activities. Muscles can become shortened if not purposefully stretched and by completing the same sport or lifting routine without enough variation. Inactivity also causes muscles to shorten, become inflexible and more susceptible to stress and injury. Muscle imbalances lead to many of the most common injuries in people who have strong, but tight muscles in some areas and weaker, unstable muscles/joints in others.

The sixth element of fitness is muscular strength. In addition to being flexible, your muscles should be able to exert force and control movement. Strength is improved with weight- resistance exercises. Strengthening programs can be designed using body weight, machines, free weights, kettle bells, TRX, etc. based on individual preferences and goals. In general, strengthening muscles appropriately uses resistance heavy enough to allow 8-15 slow and controlled repetitions with good form completed in 1-3 sets.

A person who is physically fit has a properly aligned and balanced body, flexible yet strong muscles, an efficient heart and healthy lungs, and a good ratio of body fat to lean mass. Being physically fit, according to the true definition, does not come easy. It is something we all should continually work towards in our daily routines.

Read more Sports Doc for Sports Medicine and Fitness.

POSTED: Tuesday, August 27, 2013, 6:00 AM

Shoulders take a lot of abuse in our daily lives. We lift and carry heavy objects, reach in awkward ways, hang bags from them, throw things and undoubtedly stress them with the repetitive tasks demanded by our professions. Additionally, the misguided workout positions, routine recreational pursuits and participation in sports unintentionally lead to the most common shoulder injuries.  

I usually see people in my office by the time things have gotten so bad that they can no longer participate in their sports, workouts, and many of their regular daily activities.

One injury that involves the shoulder is rotator cuff dysfunction. Whether in the form of tendonitis, weakness, or tears, the muscles that make up the rotator cuff are usually part of the problem.
Four shoulder blade muscles work together to make up the rotator cuff. These muscles are responsible for all of the motions involved with throwing (lifting the elbow out to side, rotating the forearm backward, forward and extending the arm behind back). When these muscles are working properly they do more than just allow us to throw. They help keep the shoulder in the correct position to allow for pain-free reaching in all different directions. When rotator cuff weakness or dysfunction develops, an imbalance of the forces at the shoulder occurs with reaching and the shoulder joint position is altered. Over time, this causes friction on the tendons when we reach in different ways and “tendonitis” or "bursitis" is a common result.

Similarly, since the shoulder is not being held in proper alignment, the tendons may also become ‘pinched’ between the shoulder bones, resulting in impingement syndrome.  I see this develop commonly in people who lift weights to strengthen the larger muscles of the front of the body (chest, biceps, deltoids), but neglect the smaller mid-back and shoulder blade muscles.  This muscle imbalance at the shoulder is similar to many of the dysfunctions I have written about previously that also develop at other joints (low back, knees/hips/ankles) due to an imbalance of forces where the larger muscles dominate without the control of the smaller stabilizing muscles.

Other common shoulder injuries involve separations, dislocations and generalized laxity of ligaments. In all cases, the ligaments, which are responsible for joint stability, have been injured and are less effective at holding the bones in place. The surrounding shoulder muscles need to compensate for the ligament damage with proper strength and stabilization training to control large shoulder movements in addition to quick, smaller arm motions.

Another common problem involving the shoulder is ‘frozen shoulder’ or adhesive capsulitis. This may occur secondarily to painful dysfunctions like the ones described above, after periods of immobilization (i.e. with fracture healing) or due to an unknown cause. In any case, significant loss of shoulder range of motion develops as the capsule of the shoulder tightens due to disuse over time. A cycle of pain and dysfunction develops, consciously or not, in which pain with shoulder movements causes one to stop performing the painful movements. This lack of movement and disuse allows the capsule to tighten and the surrounding muscles to weaken. Further attempts at use of the shoulder cause more pain so, over time, lack of movement takes over and people end up with a shoulder that is “frozen.”

With traumatic injuries or slowly progressing shoulder pain, it is always beneficial to seek treatment sooner than later. I have seen some people fully recover within days after initiating a rotator cuff strengthening program. This quick recovery will not happen, though, if months or years worth of damage is already done. Symptoms can still be alleviated and even fully abolished, but the rehab will be much longer.

Be kind to those hard working shoulders, be aware of pain with any shoulder movements and be sure to seek treatment should the need arise.

Below are links to a few basic videos of shoulder strengthening exercises that target the posterior muscle groups, rotator cuff and postural muscles:

POSTED: Tuesday, July 30, 2013, 5:00 AM

A strong and well-aligned spine is key to improving performance with sports, recreation, work and home activities. A repeating theme that keeps arising in discussing injury prevention is the need to balance muscle strength and flexibility in all planes (anterior, posterior and sides).

Most athletes are quite strong with trunk flexing muscles, like the rectus abdominus (‘6-pack’ ab muscles) but lack trunk extensor strength. The trunk extensors keep the spine erect when upright and lift the trunk upwards when positioned face down. Similarly, there are a many common exercises focusing on the big, powerful trunk muscles, but there is a lack of knowledge about how to effectively strengthen the smaller stabilizing muscles of the trunk.

Our bodies are equipped with a group of muscles that surround our trunk and work perfectly together to create a stable bracing effect for the spine. This is what prevents discs from bulging out of place and painful spinal conditions. One of the most important stabilizing muscles, the transversus abdominus (TA), is engaged when you activate the lower abdomen wall by "drawing-in." 

Not to be confused with the diaphragm, which controls breathing or the rectus abdominus, which flexes the trunk forward, the TA serves to act like a girdle for the abdomen. In standing, it contracts along with the main posterior spine stabilizer, the multifidis for a bracing action all the way around. This co-contraction is the basis for a stabilization program that can be made more challenging by adding numerous arm, leg, and trunk positions either statically or dynamically and with the use of equipment including physioballs, medicine balls, body blade, Bosu, Pilates, TRX, etc.

It is equally important to strengthen these muscles while maintaining correct spinal posturing. Whether seated or standing, a neutral spine is key. The natural curve of the low back, the lordosis, needs to be maintained by tilting the pelvis slightly forward. In sitting, you will know it is in the correct position when you feel weight through the "sitz" bones, the ischial tuberosities and all of the spinal segments stack naturally from bottom, up.

About this blog

Whether you are a weekend warrior, an aging baby boomer, a student athlete or just someone who wants to stay active, this blog is for you. Read about our growing list of expert contributors here.

Robert Senior Sports Doc blog Editor
Alfred Atanda, Jr., M.D. Nemours/Alfred I. duPont Hospital for Children.
Robert Cabry, M.D. Drexel Sports Medicine, Team physician - U.S. Figure Skating, Assoc. Team Physician - Drexel
Brian Cammarota, MEd, ATC, CSCS, CES Symetrix Sports Performance, athletic trainer at OAA Orthopaedics
Desirea D. Caucci, PT, DPT, OCS Co-owner of Conshohocken Physical Therapy, Board Certified Orthopedic Clinical Specialist
Michael G. Ciccotti, M.D. Rothman Institute, Head Team Physician for the Phillies & St. Joe's
Julie Coté, PT, MPT, OCS, COMT Magee Rehabilitation Hospital
Peter F. DeLuca, M.D. Rothman Institute, Head Team Physician - Eagles, Head Orthopedic Surgeon - Flyers
Joel H. Fish, Ph.D. Director - The Center For Sport Psychology, Sports Psychology Consultant - 76ers & Flyers
R. Robert Franks, D.O. Rothman Institute, Team Physician - USA Wrestling, Consultant - Philadelphia Phillies
Ashley B. Greenblatt, ACE-CPT Certified Personal Trainer at The Sporting Club at The Bellevue
Cassie Haynes, JD, MPH Co-Founder, Trap Door Athletics, CrossFit LI Certified
Eugene Hong, MD, CAQSM, FAAFP Team Physician - Drexel, Philadelphia University, Saint Joe’s, & U.S. National Women’s Lacrosse
Jim McCrossin, ATC Flyers and Phantoms
Kevin Miller Fitness Coach, Philadelphia Union
Heather Moore, PT, DPT, CKTP Owner of Total Performance Physical Therapy, North Wales, Pa.
David Rubenstein, M.D. Main Line Health Lankenau Medical Center, Team Orthopedist - Philadelphia 76ers
Justin Shaginaw, MPT, ATC Aria 3B Orthopaedic Institute, Athletic Trainer - US Soccer Federation
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