May
6
Physical Therapy Gone Wrong – A Case Study
When recovering from injury, physical therapy, if used, may be a significant investment of time and money for a runner. There are some definite signs that indicate the physical therapy may not be delivering what you need. Here is a case study of one such situation.
The runner (we’ll call him Sam) was trying to recover from Achilles tendinitis and a retrocalcaneal bursitis. He was prescribed a course of physical therapy by his sports medicine professional, and said prescription called for:
- Treatment of the bursitis
- Healing of the tendinitis
- Stretching and strengthening techniques for preventing recurrence
- Custom orthotics to deal with a long-term leg length discrepancy
The physical therapist was a runner himself (good), roughly the same age as Sam (good), and treated other runners (good). During most visits, 75% of the other patients in attendance were recuperating from surgery and trying to regain sufficient mobility to pursue their daily lives again, though they were not athletes (not so good).
The visit started with a very high level discussion of level what had happened since the last visit a year ago (won a marathon, etc., etc.), but no in-depth discussion of training approaches (bad). Observed which shoe Sam was wearing (good) but didn’t ask what other types of shoes Sam might run in (bad), which included a lower heel-to-toe drop model that could be a contributing factor to tendinitis (bad).
As a first step, Sam was fitted for orthotics, though there was no real discussion as to the purpose of the orthotics, and the primary goal was communicated to be to provide more arch support (bad). The therapist was unfamiliar with the recent trend towards more minimalist footwear, so it didn’t enter into the discussion, either positively or negatively (bad).
The next step in the first appointment was to evaluate Sam’s running form. The video below was taken during the evaluation.
Notice a couple of things about the approach. First, Sam typically trains and races in traditional running shoes, with anywhere from a 4mm to 10mm heel-to-toe drop, and incorporating some stability features. This doubtless impacts Sam’s form, so running in socks may not be representative of his typical mileage. Additionally, the space to run was only 15-20 yards – it’s hard to settle into a groove when running such a short distance. Finally, Sam knew he was being observed, which has to have impacted his form as well.
Now with all that, can you guess what the therapist observed? This question was posed to Sam’s friends previously, and the guesses ranged widely. When the actual conclusion was posted, there was broad disagreement, and it’s hard to see in looking at this video how the therapist reached his conclusion. It almost sounds like the answer was predetermined based on the nature of the injury. Sam can say that, after having run several times after the incident and closely observing his form, it is very unlikely that he suffers from the given diagnosis.
The rest of the visit focused on short-term fixes (good) including ultrasonic treatment (which has never seemed to provide much benefit to Sam) and ice/compression.
The next visit was a few days later (good) and Sam received his orthotics. The rest of the visit focused on balance drills to drive potential long-term form improvements (good), and short-term fixes like ultrasonic treatment, ice and compression, and Graston massage to work out tightness in the calves. Unfortunately, the Graston was done without much investigation as to wear the trigger points were located (bad) so it provided more psychological gains than physiological gains.
On trying out the orthotics over the weekend, he found they created a lot of soreness in his foot, Achilles, and iliotibial band (bad). Sam raised this at the next appointment, and the physical therapist said he wasn’t concerned that they caused Achilles pain (?), and cut them down a bit to try and reduce the soreness in the foot. This appointment consisted of more balance drills, and the remainder of the session was taken up by stretching, with exercises that Sam was already familiar with (bad). And he also learned that, for the second season in a row, the therapist himself was going to miss his A race due to injury (bad).
At this point, Sam stepped back and reassessed the situation. The PT appointments were scheduled at inopportune times, and Sam had no idea how much of the cost his insurance would cover. Sam felt that if he were going to continue to invest the time and money in the therapy, the sessions needed to be valuable, focusing on activities that he couldn’t do on his own. The stretching and balance drills clearly fit this bill, yet they were taking up more than half of the appointment time. The diagnosis on the form issues seemed questionable, and there was little really being done in the short term to get Sam back to running. And the orthotics created a lot of pain after just one hour of wearing them, so seemed a big waste of money.
On balance, Sam wasn’t getting his money out of the experience. While he could have explained his concerns to the therapist and sought some course correction, he felt a better investment would be in the same treatment regime that got him back to running from a hamstring injury last year – Active Release Techniques (ART) applied by a local chiropractor.
The moral of the story is, when investing your time and money in physical therapy, don’t be me Sam. Make sure you are getting what you need, or don’t hesitate to seek a different therapist.
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