Summer 2009

By Johnny Barthel, OTR, CHT Ashley Martin, PTA Robert D. Lim, PTA Chad Evans, PT


Summer 2009

The Felon

Article: Johnny Barthel, OTR, CHT

There are a variety of conditions that can affect the hand as well as the fingers. Infections to the finger may seem to be a small concern, however, it may often lead to something more severe. One type of infection is a felon. This condition is defined as a deep infection of the pulp of the finger tip. This is usually caused by someone having a puncture wound (maybe by a wooden splinter) or an opened injury to the tip of the finger.

The fingertip pulp is divided into numerous small compartments called vertical septae. These vertical septae divide the pulp and stabilize the skin. The infection gets between the septae where it stays and has the ability to get progressively worse.

Clinically, the patient has throbbing pain at the tip of the finger. The pulp is usually swollen, warm, and tender to the touch. A collection of exudate, commonly known as pus, may be visible under the skin as well. This injury can be very serious and lead to complications, if not treated properly. An untreated felon can lead to more serious conditions such as, osteomyelitis of the distal phalanx, pyogenic arthritis of the distal
interphalangeal joint, flexor tenosynovitis, or skin necrosis. Xrays of the finger should be taken to rule out the presence of a foreign body or distal phalangeal osteomyelitis.

Nonoperative treatment includes the use of warm water soaks, intensive local wound care, oral antibiotics, and careful follow-up. Surgery may be indicated in cases with moderate to severe symptoms, such as the presence of osteomyelitis, septic arthritis, or flexor tenosynovitis to treat the symptoms. This will help to preserve the tissues, decrease pain, or improve function. In some cases, an incision is made to drain the felon. The incision should be made near the nail skin margin and may extend to the tip of the digit. Overall, these procedures or modes of treatment should help with assisting an individual to improving his or her function or activities of daily living.

Driving Can Be a Real Pain

By Ashley Martin, PTA

Have you ever felt tired, achy, and sore after driving in your car all day? Chances are that your seat is not in the proper position. Most people are aware that excessive driving is detrimental to the general health of the spine. When driving for prolonged periods of time, the lumbar curve in the spine is lessened, and extra stress and strain is put on the vertebrae. If you add in the constant subtle bouncing and jolting from a moving car, you end up with increased soreness from your neck to your lower back.

Modern day vehicles claim to be equipped to make your driving experience more comfortable. In reality they are only promoting the problem! Modern cars have a lowered roofline reducing the internal space. This forces the driver to lower and recline the seat, and put extra strain on the cervical and lumbar spine. Not only is it uncomfortable, it can make you tired. Many accidents and near misses are caused from the driver being fatigued, drowsy, or sometimes dozing off while driving. Good seat posture might seem minute, but it takes only seconds to make you more comfortable and alert.

First, make sure the backrest is adjusted so that your shoulder blades are resting against the back of the seat, your lower back fits the seat, and your bottom is all the way back against the seat so your thighs are completely supported. The cushion should hit near the back of your knees. The seat should only be reclined slightly. If it is too low, you will have to flex your neck forward as a compensation to be able to see. Forward neck flexion over 15 degrees over a prolonged period of time can increase neck pain. Make sure that the seat is adjusted so your knees are slightly bent when you press the pedals to the floor. If you have a manual transmission, this is very important. Many people complain of increased lower back pain when pushing in the clutch. If your car has a lumbar support feature, use it. If not, consider purchasing a lumbar support pillow that can be attached to the seat.

Second, if your steering wheel is able to be adjusted up and down, make sure it is at a level where the wrists of both arms (when stretched out completely) are directly over the top of the steering wheel. Your arms should be bent when holding the steering wheel at the 10 o’clock and 2 o’clock positions. If you have ever experienced neck or shoulder pain while driving, it is most likely due to increasing tension from gripping the wheel too tightly. Try to relax while driving.

A simple test to check to see if your seat and steering wheel are in the correct position is to place your hands on the steering wheel and look down at your legs. You should be able to see the same amount of your leg on both sides. If your right leg is slightly obscured by your arm, your shoulder girdle is slightly rotated to the left and your steering wheel is offset.

Keep in mind that your back is weaker and more susceptible to injury after long periods of driving. On long trips make frequent stops to get out and move around. These simple adjustments can make a world of difference to someone who suffers from chronic neck and back pain.

Patello-Femoral Syndrome: “Knee-Cap” Pain

By Robert D. Lim, PTA

Chondromalacia, technically termed chondromalacia patellae, is the most common cause of chronic knee pain. The condition develops due to softening of the cartilage beneath the knee cap (the patella), resulting in small areas of breakdown and pain around the knee. Instead of gliding smoothly over the knee, the knee cap rubs against the thigh bone (the femur) when the knee moves. The changes can range from mild to complete erosion of the cartilage. This process is sometimes referred to as the patello-femoral syndrome. Chondromalacia commonly occurs in females. Girls in their teens are at elevated risk because the cartilage of the knee is subjected to excessive and uneven pressure due to the structural changes that accompany rapid growth.

Chondromalacia may also occur in adults over the age of 40 as part of the wear-and-tear process that eventually leads to osteoarthritis of the knee joint. Other factors that may precipitate chondromalacia include trauma, overuse, or abnormal forces on the knee joint. It can develop in skiers, runners, cyclists, and soccer players, especially if someone is knock-kneed or flat-footed. The pain of chondromalacia occurs in the front or inside of the knee. It is generally worse with activities such as running, jumping, climbing stairs, or kneeling. Pain is also typically worse after prolonged sitting with the knees bent. This pain is called the “theater sign” of chondromalacia.

There may be tenderness of the knee along with a grating or grinding sensation when the knee is extended. X-rays of the knee are generally normal, but may show a slight displacement of the knee cap. (Even if you have symptoms consistent with chondromalacia, your doctor may still order an X-ray to rule out other reasons for your knee pain.)

Nonsteroidal anti-inflammatory drugs medications, such as ibuprofen (Advil/Motrin) or naproxen (Aleve), are often prescribed both to alleviate pain and reduce the chronic inflammatory processes that increase the structural damage. Icing the knee can also help.

Chondromalacia is usually treated conservatively with exercises designed to strengthen the muscles around the knee and restore normal alignment of the knee cap. These exercises should be carefully designed to selectively strengthen the thigh muscles (the quads) and realign the patella.

About 85% of patients with chondromalacia improve with conservative treatment alone and require no further therapy. In about 15% of cases, the pain persists or worsens to the extent that surgical correction of the knee joint may be needed. While it is not always possible to prevent chondromalacia, avoiding trauma and abnormal stresses on the knee and keeping the leg muscles strong and flexible may be able to help to prevent its development in many cases.

Dynamic Stretching

By Chad Evans, PT

If you are like most people, you probably have not heard of dynamic stretching. When one thinks of stretching it usually means bending or straightening a body part until a stretch is felt in the muscle, and then holding the position for a prolonged period of time, or maybe even bouncing a little at the end range of the stretch position. This is how most of us learned to stretch back in our early school days. It has worked for all of these years, so why change now? Well, science is now supporting a more beneficial way to stretch known as dynamic stretching. This is not to say that we need to stop stretching the way we have been, but to ask ourselves why we are stretching. How you answer this question will decide which method is best for you.

If you are stretching simply to improve flexibility or range of motion, then the traditional method of static stretching is fine. With this method, a stretch is held for 20-30 seconds. When performed routinely (daily), it can help increase the length of your muscles, or soft tissue and decrease stiffness. Traditionally, this same method has been used to warm- up or loosen up muscles before an athletic performance. Research is now showing that this may not be the best way. A neuromuscular inhibitory response to static stretching causes the straining muscles to become less responsive and stay weakened for up to 30 minutes following static stretching. This does not mean that static stretching is bad, it is just not the best choice if you are trying to warm up to play sports.

Dynamic stretching seems to be more beneficial for preparing the body to perform athletic activities. Dynamic stretching is simply stretching muscles while moving. It is a method of stretching that incorporates speed of movement, momentum, and muscular effort to bring about a stretch. It is the stretch of choice when trying to warm-up the muscles before playing a sport. It allows increased blood flow to your muscles, lubricates joints, and decreases muscle tightness. Opposite to static stretching, dynamic stretching provokes an excitatory response. So, not only do you increase flexibility and range of motion, you also help wake-up the neuromuscular system. To be most effective, you will want to incorporate movements that are sportspecific. Keep in mind that you warm-up to stretch and not stretch to warm-up. So before trying to stretch, you will want to perform at least 3-5 minutes of a full body warm-up prior to stretching.( i.e. jogging, jumping rope, jumping jacks, etc.) The following examples of dynamic stretching are performed 2-3 times each for about 10-20 seconds.

Walking Knees


  • Glutes
  • Lower Back
  • Quads


  • While walking, take an exaggerated high step, driving, the knee as high as possible, while pushing up onto toes of the opposite foot
  • Alternate swinging arms up and down with the elbows bent

Walking Straight Leg Kicks


  • Hamstrings
  • Calves
  • Lower Back


  • While walking, kick one leg out keeping the knee straight with your toes flexed towards the sky, and reaching with opposite hand to touch the toes with the fingers. Repeat for each side 6-7 times.

Running Butt Kicks


  • Quads
  • Hip Flexors


  • While jogging, with a slight forward lean, flex the knees enough to allow heals to touch your glutes with each step. Stay on the balls of your feet. Repeat for about  reputations.



  • Lower Back
  • Hip Flexors
  • Glutes


  • Laying face down, legs together, arms perpendicular to body and feet flexed so that you are only touching the ground with your toes. Kick you left leg towards your right arm , then perform the same with right leg towards left arm. Repeat 8-10 times. Begin slowly and use caution as to avoid irritating your lower back.

Where is Telemedicine frequently used?

All JOI Physicians, Physical Therapists and Occupational Therapists now offer Telemedicine services for virtual visits from the convenience of your home. If you feel that it is best to stay in your own home during this time, we can still provide orthopaedic Telehealth services for you. Through the download of the free Zoom app on the your phone, tablet or laptop. Our physicians and Telehealth for Physical Therapy can evaluate you and provide the care you need.

JOI Fracture and Injury Care

JOI Physicians are currently offering ASAP Fracture care. Make an appointment by calling (904)JOI-2000. This is a new option for patients who would like to avoid the emergency room if they have suffered a fracture or soft tissue injury. To learn more about this service, read this article about fracture and injury care.


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