“Two Conditions That Cause Similar Symptoms Are Hamstring Syndrome And Hamstring Tendonitis. Distinguishing Between The Two Is Important Because The Treatment Is Different." Anatomy The hamstring muscle group is made up of three different muscles, the biceps femoris, semitendinosus and semimembranosus. Two of these muscles (biceps femoris and semitendinosus) insert on the ischial tuberosities, the bottom part of the pelvic bones, commonly referred to as the sits bones. The hamstrings run all the way down the posterior thigh, crossing the knee joint and inserting onto the bones of the lower leg. They assist with bending the knee and extending the hip. Chronic microtears of the hamstring caused by inefficient running gait, muscular imbalances, or overuse can cause inflammation of the tendons where they attach leading to hamstring tendinitis. This injury is commonly seen in athletes and runners who have too long of a stride. Hamstring Tendonitis vs. Hamstring Syndrome Hamstring syndrome has more neural involvement and can be caused by chronic or acute hamstring injuries. While the pain is similar to Hamstring Tendonitis, the cause is MUCH different. In hamstring syndrome, the tendon that is attached to the sits bones become inflamed and form bands of tissue that can surround the sciatic nerve. This nerve begins at the spine and runs through the buttock and down the posterior thigh. It runs just outside of the sits bones and is very close to these hamstring attachments. Movements or activities that compress, stretch or irritate this nerve can cause severe pain. Most often, symptoms are felt when sitting because the sciatic nerve is being stretched (due to the flexed position of the hip), and compressed, (due to the close relationship to the sits bones). Pain when sitting is an important clinical symptom that helps to distinguish hamstring syndrome from hamstring tendonitis, but there are also some clinical tests that can help determine if the pain is caused by muscular or neural impairments. Physical Therapy Treatment Identification of the cause of hamstring pain is important because the treatment for these two injuries is different. Initially, both conditions will respond well to rest and decreased loads on the muscle. Hamstring tendonitis is treated by gentle stretching to relieve tension, cross friction massage to the tendons to stimulate healing, and strengthening of the lower extremities to address any weakness or muscular imbalances. Dry needling has also been shown to be effective to relieve any trigger points in the muscle bellies. Since tendonitis is a chronic issue, the patient’s mechanics when running, walking, or exercising also need to be addressed. Often, a shorter stride and increased cadence when walking and running can decrease the amount of tension and prevent further inflammation. With Hamstring syndrome, treatment initially focuses on reducing the tension and resting. Stretching of the muscles is not recommended because it will place increased tension on the sciatic nerve and will, often, cause increased pain and inflammation. Sitting on a wedge with the higher part positioned in the back, allows the hips to be flexed less and can provide some short term relief. Improving the mobility of the sciatic nerve can also be helpful. Since this nerve has such a close relationship to the gluteal and hamstring muscles, activities such as walking, squatting, and sitting require the nerve to move with the muscles. When it becomes stuck in one position, any movement that stretches or compresses the nerve can be very painful. Exercises can be given in an attempt to break up this tissue and gently glide the nerve up and down restoring mobility and relieving symptoms. Similarly to tendonitis, walking and running mechanics play an important role and both will be addressed in the later stages of treatment to prevent exacerbation and further injury to the tissues. Pain with sitting is the number one sign that can differentiate hamstring tendonitis from hamstring syndrome but there are several clinical tests that can also be performed. These tests place the muscles and nerve in different positions to determine the source of a patient’s pain. In severe cases, both may be present. It has been shown that chronic hamstring injuries can lead to tendinitis AND hamstring syndrome, making individual assessment and treatment very important for full relief of symptoms. Do I Need To Schedule An Appointment? Patients who are compliant with activity cessation and prescribed exercises but who do not experience resolution and healing may be candidates for surgical release to alleviate the pressure on the sciatic nerve. Hamstring injuries can be very confusing and frustrating because they can happen in many different ways and can be difficult to resolve if not treated correctly. If you want more information about hamstring syndrome specifically, think you have hamstring syndrome, or want information about other types of hamstring injuries please contact Zion Physical Therapy to set up an appointment. The therapists at Zion PT have extensive knowledge regarding hamstring issues and are able to tease out the important signs and symptoms to get you on the right rehab track.

New to running? Or thinking of running your first marathon even though you haven’t run further than 5k before? You could possibly be at risk of developing Medial Tibial Stress Syndrome (MTSS), commonly known as shin splints. What is MTSS? Medial Tibial Stress Syndrome is a very common overuse injury where pain is felt along the inner part of your leg during and possibly after activity. I see a lot of patients with this pathology during the start of a new sport season and/or a drastic increase in their amount of running. Most commonly, people who are at risk for getting shin splints are young individuals with higher body mass index (BMI) and low bone density. Low bone density is most commonly found in women with a history of osteoporosis but can also be found in young women athletes. Activities that require a lot of running and activities on hard surfaces also increase the risk of developing MTSS. Anatomy and Physiology The lower leg is made up of 2 bones, the tibia and fibula. In MTSS, the periosteum of the inner part of the tibia is affected. The periosteum is the outer layer of the bone in which muscles attach. Inflammation and pain occurs due to repetitive pulling of the muscles on the periosteum. The most common muscles involved in MTSS are the posterior tibialis, flexor digitorum, and soleus muscles. These muscles primarily help stabilize the lower leg and foot and aid in pushing off while running. Another muscle commonly involved is the tibialis anterior muscle. This muscle primarily helps lift the foot off the ground. Diagnosis Medial Tibial Stress Syndrome is typically diagnosed by clinical symptoms. The primary symptoms include pain that is brought about with activity and tenderness to touch along the tibia. An MRI can be used to help rule out any more serious pathology such as a stress fracture or compartment syndrome. A stress fracture, although a separate injury, can develop if MTSS is left untreated. Your injury may have progressed to a stress fracture if you feel your pain even at rest and not just with activity. Compartment syndrome occurs when there is too much inflammation in the leg which then starts to compress the nerves and blood vessels that go to the foot. This is also accompanied by numbness in the foot and severe weakness in the leg. The severity of the injury depends on the amount of symptoms in correlation with the amount of activity that is performed. In the beginning stage, pain only occurs with activity and is resolved at rest. As the pathology worsens there is more intense pain with activity and discomfort lasts longer after exercise is stopped. In the final stage, pain occurs even at rest without activity and can indicate a more serious pathology. Medial Tibial Stress Syndrome Treatment Immediate rest is recommended right after the onset of pain. However, when returning back to activity it is beneficial to work with a physical therapist to gradually increase intensity. In the clinic, I like to use a set of guidelines depending on the pattern of pain and activity to successfully return my athletes back to their sport. Abdominal, low back, and hip strengthening can also help to alleviate the work of the lower leg muscles and in turn, decrease the stress on the tibia. Stretching and joint mobilization is also beneficial to decrease the forces on the tibia. Once my patients are feeling a low amount of discomfort, I do a gait/running analysis to see if there can be any changes made to the way they walk/run. This is crucial in preventing future injury. Shoe-wear while exercising is also important. If you are running in the same shoes as last season, you should consider getting a new pair. Sneakers that support your arch and have more shock absorption will help reduce the strain on the muscles of the leg. Also, I like to implement various taping techniques and modalities as necessary to facilitate healing. If you start having any shin pain with running, you should try and run on a softer surface (i.e. dirt versus concrete). If you are experiencing any discomfort during exercise or hit a plateau in your workout, contact us at Zion Physical Therapy at to help you reach your goals!

INJURY SPOTLIGHT: Obturator Internus Dysfunction Do you have hip pain? Do you also have hamstring pain? Have you been told that you have Hamstring Tendonitis or Hamstring Syndrome? When asked to describe where your pain is, do you feel like you need to point “up there” to really pinpoint the location of pain? If so, you may have obturator internus dysfunction. Anatomy The obturator internus (OI) is a hip muscle that originates deep within the pelvis, wraps out and inserts on the posterior aspect of the head of the femur (the thigh bone). The OI’s main function is to rotate the leg externally and has a major role in stabilizing the head of the femur into the hip socket. Muscle Dysfunction and Trigger Points Just like any other muscle in the body, the OI can become dysfunctional and trigger points (TrP) can arise for various reasons. In general, a trigger point is involuntarily contracted muscle fibers within a whole muscle. Because the TrP is involuntarily contracted and we cannot voluntarily relax the muscle fibers, blood flow is reduced to that area of the muscle as well as surrounding nerves and other tissues. This loss of blood flow can then result in hypersensitivity directly at the site of the TrP as well as aching pain in the surrounding area. TrPs can be latent or active. A latent TrP is one that does not cause pain unless provoked, like with direct pressure, but it possesses the ability to cause unprovoked pain. An active TrP is one that refers pain to other areas without being provoked. OI trigger points can refer throughout the hip and leg on the side that it is originating from. This is a main reason why many patients are treated unsuccessfully for possible hamstring syndrome and/or gluteus medius dysfunction when really the root of their problem is deeper and located at the OI muscle. IS IT OI? Having had personal experience with OI Dysfunction and treating patients with the issue, I have found that there are a few initial cues that help to tease out whether a patient is suffering from OI dysfunction versus hamstring, piriformis and/or gluteus medius syndromes. The first major sign is that the patient has difficulty pinpointing one location of pain. This is because the OI muscle has many different referral patterns. Patients might say one day that they have pain on the lateral side of their hip or the pain is in the buttock region. Then on another day they might describe a burning-type of pain at the insertion of the hamstring muscle at the “sit bone”; or maybe all three at once. Upon further investigation of these muscles with deep palpation, the patients might report that there is soreness in the area but that is not their “familiar pain.” The next appropriate question focuses on locating where the exact familiar pain is as best as possible. This can be achieved by ruling out other muscles first. When asking a patient to pinpoint the exact location of the majority of their pain I ask it three ways. First, I ask by pointing to a spot directly over the piriformis muscle. Second, I point to the origin of the hamstring muscle at the “sit bone” (red arrow). And thirdly, I ask is it “up there” (green arrow)? If with deep palpation just medially to the “sit bone” and above the bottom of the butt cheek, familiar pain is reproduced you could be suffering from OI Dysfunction. Common OI Dysfunction Symptoms The pudendal nerve runs in close proximity to the OI muscle which can become irritated with OI TrPs and can cause various other symptoms as well. Many patients come into Zion Physical Therapy for hip and leg pain with running and biking and the OI muscle is the culprit. However, the OI muscle is also highly involved with pelvic floor dysfunction due to the potential of the pudendal nerve involvement. The pudendal nerve branches into three smaller nerves which supply sensation and muscle control to the rectal, perineal and clitoral/penile areas. Because of these innervations, OI dysfunction and TrPs of the OI muscle can cause other symptoms such as urinary frequency, urinary burning, itching, tingling, shooting pains into the groin and abdomen and others. OI pain can manifest itself in many different ways. If you have hip, low back or groin pain or abnormal pelvic floor symptoms that have not resolved with medical attention of any kind, then call Zion Physical Therapy to schedule an appointment and determine if OI dysfunction might be the cause of your pain.

“For The Majority Of People With Hypermobile Ehlers-Danlos Syndrome (EDS), It Will Take An Average Of 10 Years To Be Diagnosed. We Can Do Something About It” Ehlers-Danlos Syndrome (EDS) is a group of hereditary connective tissue disorders that which causes a change in the protein, collagen. Collagen gives structure to our connective tissue and maintains the integrity of most organ systems in our body, from our heart to our skin, to our ligaments, tendons, and muscles. May is EDS awareness month, and awareness is essential to improve treatment for those with this condition. Low awareness and understanding of EDS means that many will be told that their pain is all in their head while others undergo unnecessary medical treatments and surgeries. Education will help, so I wanted to share some important information on this rare condition. The most prevalent type of EDS, of which there are 13, is hypermobile EDS (hEDS). In clients with abnormal collagen, the ligaments are weak and lack stiffness and tendons are subject to tearing, compromising the stability of the joints. Treatment should be provided and exercise prescribed with this in mind. The most commonly recognized symptom of hEDS is joint hypermobility with symptoms of musculoskeletal pain and complications of joint instability such as recurrent subluxations or dislocations. The disorder also comes with a host of associated co-morbidities, such as dysautonomia, gastrointestinal dysfunction, and mast cell activation disorder to name just a few. As physical therapists, we focus on the musculoskeletal dysfunction but need to make an effort to learn about each client’s medical history and how it plays a role in the overall care of the person. For instance, with postural orthostatic tachycardia syndrome, changes in body position may significantly impact the cardiovascular system, so the therapist may want to limit the positional changes within the session or reduce standing time. The other important thing to consider is that symptoms and associated conditions vary widely between patients, and the severity of symptoms might be vastly different from one person to the next. Also, note that the clinical presentation changes with age as the pain from hypermobility and instability is exchanged with stiffness and joint degeneration. Physical therapy plays an essential role in managing the chronic pain and musculoskeletal dysfunctions associated with Ehlers-Danlos Syndrome. A physical therapist can help you to strengthen weak muscles and stretch tight ones, as well as teach you how to modify your activities of daily living to reduce the impact of the condition. At Zion Physical Therapy, we specialize in the assessment and treatment of joint hypermobility, posture, and stability. We can help you manage fatigue, improve balance and coordination, and reduce the risk of injury. With the help of your physical therapist and other healthcare providers, you can learn to manage the physical challenges of EDS and live your life to its fullest. To find a specialist in your area, visit The Ehler-Danlos Society directory. Please see the below Beighton Score chart to help you assess the condition.

1. You feel like you are peeing....A LOT 2. You feel like you’re sitting on a golf ball 3. You feel burning and/or numbness in your Perineum (aka the Taint, Grundle, Gooch, it’s that area between the shaft of your penis and your rectum) 4. Your libido is decreased 5. Your erections aren’t as strong as they used to be...or not happening at all 6. Your genitals look like one side or both are retracted or “just look different” 7. Pain in your glutes and/or inner thighs 8. Burning or hot/cold sensation in your penis or testicles 9. When you have to pee, you can barely hold it in 10. You are constipated but haven’t changed your diet, meds, or lifestyle What the heck is a pelvic floor and how do you rehab it? Your pelvic floor is a sling of muscles in your pelvis responsible for healthy bladder, bowel, and sexual function. If these muscles are too tight, too weak, or have experienced trauma, you can experience bladder, bowel, and/or sexual dysfunction. The good news is that they can be rehabilitated like any other muscle. It is no different from the diagnosis of other common cycling injuries, such as Achilles Tendonitis or knee pain. What is the connection between your pelvic floor and cycling? When you are cycling, you are literally sitting on your pelvic floor. The way in which you engage your hip/ab/back extensor/leg/ glute muscles and your posture may actually be causing muscle pain and tightness. This can impact the internal muscles just as much as the external ones, which can lead to potential decreased blood flow and nerve compression. You may also be compensating with those internal muscles due to a weak core which can also cause these symptoms. What to expect: Your PT will walk you through a thorough evaluation to determine range of motion, muscle strength or weakness, quality of movement, and pain. You will receive comprehensive patient education which may include exercises to do and exercises to avoid, lifestyle modifications, and optimal posture and positioning during sitting, walking, cycling and everything in between. Soft tissue mobilization in the office and at home can release muscle tension and guided exercise can stretch the muscles that need lengthening or can strengthen the muscles that are weak. Pelvic floor physical therapists are specially trained to assess both internal and external muscles. They’ll guide you in internal and external workouts targeted for your pelvic floor muscles and other muscles which support your pelvic floor so you feel better and can keep on going! Next Steps: Consult a pelvic floor PT who can help resolve your symptoms, discuss proper cycling posture, and perhaps a specialized seat so you don’t have to give up the sport you LOVE! I f you’d like to make an appointment with a Pelvic Health Physical Therapist, please call Zion Physical Therapy at (212) 353-8693 or email schedule@zionpt.com.

Do you ever feel like you never know where your body is in space? Or you end up sitting like a noodle on the couch and you didn’t even realize you got into that position? Or that your joints are always subluxing or dislocating? These are some of the common symptoms along with pain and chronic tightness that people with hypermobility syndromes combat daily. What is hypermobility and the syndromes that go with it? Hypermobility syndromes such as Ehlers-Danlos Syndrome, Marfan’s Syndrome, Hypermobility Spectrum Disorder or Joint Hypermobility Syndrome can cause instability and weakness in the joints leading to pain and other symptoms listed above. Both stability and strength training can be very beneficial for these individuals in order to increase joint stability, strength as well as reduce pain, fatigue, lack of endurance and improve overall function. Here are some tips for incorporating stability and strength training into your exercise routine! 1. When thinking about exercise you want to work on exercises that will help you improve the foundation of your body- your core, as well as the stability in your joints. The first thing that is important to work on is joint and body proprioception (proprioception is when you know where your body is in space). A good rule of thumb is that anything with a closed kinetic chain (CKC) is safe. A closed kinetic chain exercise is an exercise where you are in contact with a surface such as a wall, table or the floor. Exercises like this would include wall sits or table planks. 2. Next, think about stability. So now we’re thinking about core stability exercises and making sure to engage the deepest parts of your core! You can also use balancing on one leg or unstable surfaces to start to challenge your stability and help to improve your functional stability! 3. Once you have set the foundation with your CKC and core exercises you can begin to strengthen the muscles surrounding the joints in order to create more awareness (proprioception), stability, and strength as well as control! You can do this with body weight exercises which you will progress to weighted exercises such as squats or deadlifts as well as resistance band exercises. 4. Proper form is important within exercises but it is important to note our bodies need to be strong enough to manage many postures throughout the day so we are training our bodies to do that pain free! So while remembering proper form with exercise is important, know there is no perfect posture to maintain after exercise is done. 5. Next work on compound exercises in order to improve overall functionality and strength as well as endurance. Compound exercises can be squats and deadlifts or combining upper and lower body exercises such as a squat to overhead press or a deadlift to a row! 6. The last step is working on power, power is essential to maintaining good bone health and help us absorb and transfer strength and force well throughout our bodies. This can be done by starting with agility ladders and progressing to different jumping activities like forward hops, single leg hops, skater jumps, and finally box jumps or single leg box jumps. 7. Gradual increase in resistance and weights are important! Make sure to pace yourself, hydrate often and take breaks as needed. Building up into exercise is important in how often you exercise as well! Start with exercise once every 3 days and progress to every other or even every day with one or two rest days a week! 8. Consider calling Zion Physical Therapy at (212) 353-8693 to work with one of our very qualified physical therapists who can help you feel safe in your progressions and exercise as well as develop an individualized home exercise program for you! In conclusion, stability and strength training can be very beneficial for individuals with hypermobility syndromes to improve joint stability, reduce pain, improve strength and improve overall function. By incorporating stability exercises, resistance training, proper form, compound exercises, balance and coordination exercises, and progressing gradually, you can create a safe and effective exercise program that meets your individual needs.

A great running friend has struggled with plantar fasciitis for years on and off. She eloquently refers to exacerbation of pain as “the Planted Fascists” drilling into her foot. This always makes me laugh thinking of angry politicians banging sharp tools into her foot- clearly not what is happening, but certainly an apt description of this pathology’s pain! If you struggle with this very frustrating, often chronic, foot ailment - here are 5 tips to calm down the ‘Foot Fascists’: Stretch your calf muscles -- All 3 (2 leafs of the gastrocnemius and the soleus) calf muscles contribute to tightness in the posterior lower leg, which then pull on the Achilles tendon which then yanks on the plantar fascia; loose calf = happy foot! Roll your foot on a ball -- the most effective tends to be a frozen golf ball, but anything small and hard to get into the firmest parts of the plantar and relieve knots; if it hurts you’re probably in the right spots! Think about how you sleep: is your foot pointed? If so, try to avoid this! It leads back to tip #1. There are socks that help you avoid doing so, some that provide compression to the medial foot/assist in correct ankle position and others that actually hook/strap so your foot remains more neutral as you sleep. Burn all your thong sandals… kidding, sort of...make sure your footwear has a good supportive arch and that your foot is secure in the shoe. Sandals that only go around your toes and slap when you walk are the worst for plantar problems, followed by very flat shoes, and of course/sadly -- high heels. Seek physical therapy! From soft tissue massage to the plantar surface, to ankle stretching, to hip mobility - PT can assist in changes throughout the kinetic chain to make foot strike and functional mechanics more agreeable for all parts of your body, including the bottom of your feet.

“As I Tell All My Clients, It’s Important To Trust Your Instincts. No One Can Feel Or Understand Your Body The Way That You Do” Rib dislocation is a matter of debate. Most doctors will tell you that it is nearly impossible. For the population of patients who have Ehlers-Danlos Syndrome (EDS), I find the idea to be extremely likely. Anatomy: There are 12 ribs with varying amounts of stability. The “true ribs” include ribs 1-7, as they are connected to the sternum, or breastbone. Ribs 8-10 are considered “false ribs”, in that they are connected only to the cartilage in the front. Ribs 11 and 12 are also called “floating ribs”, since they are only connected to the thoracic spine and then float in space. Most documented cases of “slipping rib syndrome” involve ribs 8-12. Since collagen makes up two-thirds of cartilage, it makes sense that the connection of the ribs in clients with EDS might be even more unstable than in the general population. Another reason that the ribs can be a source of pain is due to the nature of their attachments to the spine. The head of the rib, attaches to two vertebral bodies, one above and one below. This is called the costovertebral joint and is reinforced by ligaments. It is a planar joint which means that it allows for sliding motion. There is a second attachment which is the tubercle of the rib attaching to the transverse process of the adjacent thoracic vertebra and this is called the costotransverse joint. People with EDS are more likely to have rib subluxations because: They might have spinal instability and have significantly more joint play at these attachment sites They have decreased proprioception throughout the thoracic cage which results in uncoordinated movement of the ribcage and less effective breathing patterns They have a higher prevalence of scoliosis and may be at a structural disadvantage Rib subluxations mean that the rib slips out of place but does not fully dislocate; it maintains some contact with the joint. Rib dislocation would mean that the rib completely separates from the joint. They can both be very painful. The pain associated with subluxations and dislocations usually comes in the form of muscle spasm. True, because it is difficult to “diagnose” these rib injuries, most doctors will conclude that it is only a muscle spasm. The image below is one a patient of mine brought in. There was no evidence of a rib dislocation on the radiology report and the doctor had never mentioned it. She, however, noticed it on first glance and recognized it as a long-standing source of her pain. Rib Subluxation Physical Therapy Treatment: If you’re suffering from what you believe to be rib subluxation or dislocation, there are a few things you can do to minimize your pain. These include slow, controlled breathing for pain management and relaxation, using heat to relax the muscle spasm, and/or gently massaging the area to try to relax the tissues and reduce the tone surrounding the joint (you may need to employ a friend or family member in this area). Often times, hypermobile joints will slide in as easily as they slide out. If not, your physical therapist may be able to assist with muscle energy techniques, gentle joint mobilization, or taping techniques. Physical Therapy would then follow with stabilization exercises aimed at preventing recurrence, as well as some training of the diaphragm for better, more effective breathing. As I tell all my clients, it’s important to trust your instincts. No one can feel or understand your body the way that you do, even if your proprioception is impaired. If you want more information about Ehler-Danlos Syndrome specifically, please check out our EDS resource page and contact Zion Physical Therapy to set up an appointment. The therapists at Zion PT have extensive knowledge treating EDS and hypermobility syndromes and can help get you the treatment you deserve.

The  pelvic  floor  consists  of several layers of muscles that cover the bottom of the pelvic cavity. These muscles have several distinct roles: To support the pelvic organs, the bladder and colon within the pelvis. To assist in stopping and starting the flow of urine or the passage of gas or stool To aid in sexual appreciation. How to Locate the Pelvic Floor Muscles The Urine Stop Test At the midstream of your urine flow, squeeze the pelvic floor muscles. You should feel the sensation of the openings close and the muscles pulling up and in to the pelvic cavity. If you have strong muscles you will slow or stop the stream of urine. Try to stop or slow the flow of urine without tensing the muscles of your legs, buttocks. Do this only to locate the muscles, NOT AS A DAILY EXERCISE!!! Feeling the Muscle Place a fingertip on or into the rectal opening. Contract and lift the muscles as though you were holding back gas or a bowel movement. You will feel your anal opening tighten and your penis move slightly. Watching the Muscles Contract Begin by lying on a flat surface. Position yourself with your knees apart and bent with your head elevated and supported on several pillows. Use a mirror to look at the anal opening and penis. Contract or tighten the muscles around the anal opening and watch for a puckering and lifting of the anus and slight movement of the penis. If you see a bulge of your anus this is an incorrect contraction and you should notify your health care provider for more instructions. Contact Zion Physical Therapy for an appointment today! Phone: 212-353-8693 • Fax: 347-507-5510 • Office Email: frontdesk@zionpt.com

Did You Know Symphysis Pubis Dysfunction Has Been Reported In Over 30% Of Pregnant Women?! Some Studies Even Suggest Up To 60%! Symphysis Pubis Dysfunction, aka SPD, is a condition typically associated with pregnancy or diagnosed postpartum, in which the patient may experience a cluster of the following symptoms: Pain in the groin area Pain at the pubic bones Low back pain Lower abdomen pain Pain in the inner thighs, buttocks, or hips Pain going up and down stairs Pain while walking Pain sitting or standing for a while Pain when moving her legs apart (or widening her stance) Pain can vary in intensity but it is often described as “shooting, radiating, stabbing, or aching” (ouch!). What is the Pubic Symphysis? The pubic symphysis is a cartilaginous joint between your right and left pubic bones. The joint can become less stable and can even separate resulting in SPD. Why might cause SPD? Hormones such as Relaxin increase during pregnancy which may lead to laxity of the ligaments around the symphysis pubis joint and in the pelvis Muscle weakness in pelvic floor muscles Biomechanical straining of the ligaments in region Fetal and pregnancy associated weight gain Tearing of the fibrocartilagenous disc during delivery Data even suggests that stress, cortisol, and lack of sleep may act as culprits! Good News! Pelvic floor PT can help! Pelvic Floor Physical Therapy can help with SPD in the following ways: Strengthen and Stabilize! Your physical therapist will guide you through exercises to help your muscles function optimally and gain stability. This may include strengthening exercises for those weak muscles in hips, glutes, pelvic floor, and core and lengthening exercises for muscles that may be too tight as they compensate for weak muscles elsewhere Safety First! Your PT can *safely* guide you into a fitness routine, tweak your old one, and enable you to walk down the street pain free What to EMBRACE or AVOID! The PT will direct you to avoid certain exercises, postures, and movements which may worsen pain or even the separation such as high impact exercise, twisting, wide stance, heavy lifting, and especially moving your legs apart Tools and Tips! Pelvic Floor Physical Therapists have loads of suggestions to get you more comfortable! Such as: sleeping with a pillow between your legs, proper body mechanics (how to safely pick up your baby and how to get out of bed), or a pelvic support belt and how to wear it! Breathe! Your PT will teach you proper breathing habits and Meditation tips to calm your whole system to release overall muscle tension Hands On! Your PT will perform Manual Soft Tissue work to release tight muscles and teach you and even a friend to perform it on you Remember: It is not normal to be in intense pain during or post pregnancy! I treat a lot of postpartum women who say “I was in excruciating pain when I left the hospital and they told me it was normal”. Trust your body. Repeat after me: Trust MY body, and speak to a pelvic floor PT if you are experiencing these symptoms. Call 212-353-8693 or email schedule@zionpt.com to make an appointment with one of our skilled Pelvic Health Physical Therapists today! 1. Depledge J, McNair PJ, Keal-Smith C, Williams M. Management of symphysis pubis dysfunction during pregnancy using exercise and pelvic support belts. Physical Therapy. 2005;85(12):1290–1300 2. Borg-Stein J, Dugan SA. Musculoskeletal disorders of pregnancy, delivery and postpartum. Phys Med Rehabil Clin N Am. 2007;18(3):459–476. [PubMed] [Google Scholar] 3. Leadbetter RE, Mawer D, Lindow SW. The development of a scoring system for symphysis pubis dysfunction. J Obstetrics Gynecology. 2006;26(1):20–23. [PubMed] [Google Scholar] 4. Nilsson-Wikmar L, Holm K, Oijerstedt R, Harms-Ringdahl K. Effect of three different physical therapy treatments on pain and activity in pregnant women with pelvic girdle pain: a randomized clinical trial with 3, 6, and 12 months follow-up postpartum. Spine. 2005;30(8):850–856. [PubMed] [Google Scholar]

“If You’re Struggling From Hypermobility, Don’t Wait For The Pain To Be Too Much That You Can No Longer Ignore It." Hypermobility Spectrum Disorder (HSD) is a group of conditions characterized by joint hypermobility. It can affect a few joints (localized) or many (generalized). Symptoms can span a full spectrum from asymptomatic (no pain or dysfunction) to very symptomatic. Many of my clients fall into this category, and while it seems it should be a blessing to find out you don’t fit the criteria for hypermobile EDS (hEDS), sometimes it’s just the opposite. There is an additional challenge of feeling like the disorder is not clearly defined or recognized by others, whether it be a doctor, insurance provider, spouse, or parent. The musculoskeletal symptoms from HSD can be equally severe and the challenges one faces are equally legitimate and can be just as difficult to cope with. Hypermobility means that the joint moves beyond a range that is normal, and is a primary feature in both hEDS and HSD. Joint hypermobility is often a primary cause of pain, physical trauma, and the potential decrease in the ability to function. Most often, this excessive movement causes: ● Poor coordination or difficulty balancing because the joint receptors do a bad job telling the brain what the body is doing- referred to as proprioception ● Instability, because the ligaments that provide stability to the joint are too loose; this often causes the sensation of joints “popping” but can also partially or even fully dislocate. ● Microtrauma, which is small tearing or bony degeneration that can happen over time as a result of excessive movement ● Macrotrauma, which are more recognizable injuries like when your kneecap moves out of place or the ankle sprains when you trip ● Acute Pain- after injury or dislocation ● Generalized, chronic pain that comes with time, as the body lowers its threshold to recognizing threat and increases the overall pain response Some or all of these concerns can be reported by clients with either HSD or hEDS. In the musculoskeletal system, the severity of symptoms is independent of the diagnosis. And for people who don’t look “sick,” clients often deal with anxiety from people not believing them and doctors dismissing their concerns. Something that we can do is listen and acknowledge that these complaints are valid and the pain is real. If you’re struggling from hypermobility, don’t wait for the pain to be too much that you can no longer ignore it. Go see someone who understands or is willing to learn and get the help you deserve. Seek help from your primary care physician, a physical therapist, rheumatologist, geneticist or physiatrist. A directory of physicians can be found on The EDS Society website. Physical therapists are in a unique position to help clients with joint hypermobility with techniques including: bracing recommendations, taping, neuromuscular re-education, posture retraining, gait training, strengthening, and pain management techniques. Rest assured that all of our therapists at Zion PT have a thorough understanding of connective tissue disorders. Here, you can count on having the time and attention you deserve to address your concerns with expert care and advice. Phone: 212-353-8693 • Fax: 347-507-5510 • Office Email: frontdesk@zionpt.com

You just started working out more and now the front of your knee hurts. Most likely scenario? It’s patellofemoral dysfunction. Let’s break this down: The patella is the kneecap. It’s a floating bone that lives in the tendon of your quadriceps. The femur is your thigh bone. The patellofemoral (PF) joint is where the two come together. Your kneecap slides up and down your femur as your knee bends. In a perfect world, this is a pain-free motion, but for many people, it’s not. The first question to answer- is it structure or function? A thorough examination will reveal if there is an alignment issue in the leg or if there is a muscular dysfunction (or both). Determining the cause is always the most important to ensure effective treatment. In most cases, quadriceps weakness and/or tightness is the main culprit. However, a thorough exam also requires looking at the joint above and below the knee. Both hip weakness and ankle/foot weakness have been shown to add stress to the knee and aggravate PF symptoms. One of my favorite functional tests to evaluate all three of these options is the step down test. When the hip abductors are weak, the pelvis won't stay level and the opposite side drops. This collapse creates increased stress to the inside of the knee. Similarly, a weak foot or ankle may cause excessive pronation which encourages the tibia to roll in, also stressing the inner knee. As the knee crosses toward the middle, the patella is no longer able to track in a straight line in the groove and starts to create friction in the joint. With repetitive loading, as in running, this can quickly become painful. So what to do? Perform your own step down test and see if you can uncover where your form might be failing. If you notice a hip drop, aim for gluteus medius exercises like band walks. If it seems to be your ankle wants to roll in, try these easy theraband exercises. And if your form is great, but your quad feels shaky, practice these heel taps to improve your eccentric strength. At Zion PT, we are experts at honing in on the cause of your pain instead of using a band-aid approach to temporarily cover up symptoms. If you’re having trouble getting to the bottom of your PFPS, let us help. With additional mobility and strength testing, we can define what muscles are weak and throwing off your form. We can then create a home exercise program individualized to your needs that will prevent injury down the line. Don’t wait - races aren’t going to run themselves. Phone: 212-353-8693 • Fax: 347-507-5510 • Office Email: frontdesk@zionpt.com