Winter 2009

By Debbie Rockett, PT, Jared Ernest, PT Sarah Katsaras PT

Jacksonville Orthopaedic Institute

Stretch Winter 2009

JOI Stretch

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Low Back Pain and Sleeping Posture

Article By: Sarah Katsaras, MPT

Among the many patients with low back pain, one of the most common complaints is the inability to sleep well due to pain. This can be a significant problem for many reasons. The obvious problem is that lack of sleep greatly limits the ability to function during the day. The less obvious problem is that your spine does most of its healing from everyday stress at night when the discs and joints are unloaded. Without this healing time, symptoms may increase significantly. Therefore, without proper rest, low back pain can worsen and this may become a vicious cycle.

The Neutral Spine Position

The best solution to breaking this cycle of pain and loss of sleep is to try and maintain a neutral spine when you go to sleep. A neutral spine in the low back is when the back is close to straight with a slight backward curve. This position enables the discs and joints to be unloaded so they can heal and receive nutrition. Avoiding rotation in sleeping posture also takes unwanted stress off the discs and joints.

The best sleeping position is side lying with pillow support between the arms and legs. To keep your low back in neutral, you need to keep your hips and knees bent forward approximately 60-90 degrees. Lying on your back is also a good position if you use pillow support under your knees. Lying on your stomach is not usually the best position.  It puts your low back into increased extension (or arches your low back). If you can only sleep on your stomach, use several pillows under your hips and stomach to keep your low back as close to neutral as possible.

It may take time to get used to sleeping in neutral with pillow support.  You should see an improvement in low back pain and stiffness once you have done it consistently.


Deep Vein Thrombosis (DVT) In Therapy

Article By: Robby Hoenshel MPT, ATC, CSCTS

Blood clots or deep vein thrombosis (DVT) occur when a blood clot / thrombus blocks a deep vein from moving blood back to the heart. They are sometimes a consequence of limited mobility and are commonly seen in rehabilitation after surgery. A DVT is an emergent situation and not one to be taken lightly. The recommendation is to follow up with your physician or go to the emergency room if you are not able to reach your physician.

DVT Locations

They are commonly seen in the calf and lower extremities much more than in the upper extremities. Some signs of a DVT include but are not limited to swelling into one or both legs, tenderness to the calf, warmth of the affected leg, red or discolored skin of the affected leg, and/or leg fatigue. These signs and symptoms are important to recognize as early as possible, although some blood clots do not have any symptoms. If you are thought to have a DVT, you will be sent to the ER for a Doppler ultrasound or other diagnostic procedure that allows the physician to look at the blood flow through the veins.

DVT can become a major problem if the thrombus breaks free. A floating thrombus is called an embolus and from the leg it will travel to the heart and then the lungs where you can have a pulmonary embolus (PE), blockage of one of the pulmonary arteries. Signs and symptoms of a PE are as follows: sudden cough (may cough up blood), rapid breathing or shortness of breath, chest pain, and/or rapid heart rate.

Treatment of a DVT

Treatment of DVT commonly includes medication called anticoagulants or blood thinners. The goal of these medications is to prevent new clots from forming and keeping the current clot from breaking free or growing. Prevention of DVT is the most important thing that can be accomplished early after surgery. Some ways to prevent DVT are to perform calf pumps (activating the calf muscle causing the blood to continue to pump in the legs), putting weight on your leg when walking after surgery (as directed by your physician), wearing post operative stockings as prescribed by your physician (usually more invasive surgeries), and staying hydrated.

Deep vein thrombosis, though not common, is an emergent situation and needs immediate action taken to prevent further issues such as a pulmonary embolism. This problem can be averted in some instances just by being compliant with MD orders and performing some of the techniques listed above. DVT is diagnosed over 500,000 times each year in the US with death occurring in 1% of the cases. All of our therapists are trained to look for a DVT.  You should tell your therapist or call your doctor immediately if you have any of the signs and symptoms listed above.


Gluteus Medius Weakness

The gluteus medius is a very important muscle located on the outer side of the hip. It acts dynamically when the foot is fixed on the ground to stabilize the pelvis. Weakness in this muscle can contribute to several lower extremity injuries, so its strength and muscular endurance are critical to pain free activity.


The gluteus medius muscle originates on the iliac crest, or lateral hip bones and runs down to attach the greater trochanter, or outer part of the femur. Its action in non-weight bearing positions is to abduct, and to move the leg away from the midline of the body. It also assists in external rotation of the hip. During closed chain activity, where the foot is fixed on the ground, the muscle acts as a stabilizer of the trunk and pelvis. This occurs repeatedly with all daily activities including walking, running, and jumping. The gluteus medius contracts to prevent the downward movement of the pelvis on the opposite side. This contraction also prevents the knee from moving inwards toward the midline when squatting.

Weakness in this muscle will contribute so several deviations when walking, running or squatting. First, this weakness allows the hip to adduct or move too far to the midline and the knee to move into a valgus or bent-inward position. Secondly, weakness can contribute to internal rotation of the tibia on the foot causing an increased weight transfer to the inside of the foot known as pronation.

Common Causes of Weakness

First, the inward movement of the hip into adduction can contribute to lateral hip pain or bursitis as the muscles compress the trocanteric bursa. This is more common in older patients. Second, and most common in running athletes, is lateral knee pain. This occurs because of the bent-inward position of the knee. This allows the illiotibial band to shorten and rub across the lateral femur. It also contributes to lateral tracking of the patella through an improper line of pull of the quadriceps muscle.

Finally, weakness of the gluteus medius can contribute to excessive pronation of the foot. It can aggravate foot conditions such as plantar fasciitis. The gluteus medius muscle is critical to mechanically efficient lower extremity movement. Weakness in this muscle can contribute to several mechanical deviations with every day activity and eventually cause injury. There are several ways to strengthen this muscle and prevent injury. Ask your therapist to show you the best ways for your particular case

Anterior Knee Pain

Article By: Jared Ernest, MPT

JOI Rehab

Anterior Knee Pain

Knee Pain

Do you have pain in the front of your knee(s) with running, going up/down stairs, sitting for a prolonged time? Have you ever been diagnosed with Runner’s Knee, Chondromalacia, Patellofemoral Pain Syndrome or IT Band Syndrome? All of these diagnoses are synonymous with anterior (front of the knee) knee pain. Often times the pain associated with all of these diagnoses is a result of poor tracking of the patella (knee cap). The mal-tracking of the patella in the femoral groove is usually related to a few problems:

Tight muscles and lateral knee structures

Weak muscles


Continue reading to find ways to address these issues and hopefully put an end to that knee pain.


Tight lower extremity musculature can cause compression of the patella into the femoral groove by creating direct pressure (quads) or excessive flexion of the knee (hamstrings & calves). In addition, other tight muscles can cause the patella to pull out of the femoral groove. Both of these scenarios can cause significant pain, inflammation and possibly arthritis if left untreated resulting in a very painful and debilitating condition.

Stretches: Hold for 30 seconds.

Hamstrings: lay on your back with uninvolved leg out straight. Keep involved leg straight and pull it up and over your head until you feel a stretch in the back of your leg.

Iliotibial Bands: lay on your back with uninvolved leg out straight. Place a rope or golf putter around the outside of foot of involved leg. Keep leg straight and pull it across body and up towards opposite shoulder until you feel a stretch along the outside of leg/buttocks area.

Quadriceps: Lay on stomach with. Place a rope around foot of involved leg. Bend knee and pull foot to buttocks until feel stretch in front of thigh. Calves: Stand with toes and balls of feet on a step and let your heels hang off and down toward floor.


Tight lateral structures of the knee cause the patella to track improperly in the femoral groove. An improperly tracking patella can result in several problems including, but not limited to, baker’s cysts, fat pad inflammation and early arthritis due to wearing down of the articular cartilage of the patella and/or femur. Patella mobilizations can assist to keep these lateral structures loose and the patella tracking normally.

Patella Mobilizations: Medial Glide and Medial Tilt


It’s good to keep all the muscles in the lower extremity strong, but the two most important to focus on are listed below:

Quads VMO-Vastus Medialis Obliques: keeps the patella tracking properly by pulling it medially into the femoral groove.

Quad sets With both legs straight contract thigh muscles. Hold for 5 seconds and repeat 20x.

Mini Squats With feet shoulder width apart and toes straight forward bend hips and knees as if sitting in chair. Make sure knees align with middle of foot and stay behind toes. Perform 30-50 reps.

Buttocks PGM-Posterior Gluteus Medius: maintains proper hip/knee mechanics when climbing/descending stairs, bending, and standing.

Gluteus sets While standing and feet straight forward and planted, rotate knees out and squeeze buttocks together. Hold for 30 seconds and repeat 6x.

Gluteus sets Side lying straight leg raises- lay on uninvolved leg with leg slightly bent. With involved leg straight and thigh muscles contracted, extend leg behind body, rotate hips so toes point to the ceiling and lift leg up toward the ceiling. Don’t allow your body to roll backwards as you lift your leg. Perform 30-50 reps.


Mechanics play an important role in avoiding and eliminating anterior knee pain. Many times people don’t realize how poor their mechanics are when they stand, bend, climb stairs, etc.. Improper mechanics can cause compression of the patella in the femur and/or medial and lateral knee structures. Improper mechanics can cause compression of the patella in the femur and/or

Alignment of hip knee-ankle: Keep knees aligned with middle of foot when standing, bending and climbing or descending stairs.

Keep knees behind toes when bending: Foot Hyperpronation (flat feet) can lead to a valgus knee causing mal-tracking of patella and/or compressive forces on medial/lateral knee structures. An evaluation may be needed to assess this condition. Correction can be attained with foot orthotics.

Call 904-JOI-2000 today to book an appointment

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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