The os trigonum and os peroneum are accessory ossicles (extra bones) in the ankle/foot that are present at birth (congenital) in some people.  Most of the time, these extra bones go unnoticed.  They may be identified on x-rays, but are often asymptomatic and do not need to be addressed.  However, as a result of overuse or an injury, these bones and the surrounding tissue and/or joints may become inflamed and painful.  The terms Os Trigonum Syndrome and Os Peroneum Syndrome are used to describe the painful symptoms.

The os trigonum can form behind the ankle bone (talus) during adolescence when it does not fuse with the rest of the ankle bone leaving a small extra bone.  This bone can get pinched between the talus and calcaneus (heel bone) with repeated downward pointing of the foot/toes during sports activity (eg – soccer).  Ballet dancers can develop a “nutcracker injury” due to spending frequent and prolonged time on their toes which can crunch the os trigonum causing inflammation in the area. 

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The os peroneum is an accessory bone that is located in the peroneus longus tendon which passes over the lateral aspect of the foot.  About 1 in 5 people have this extra bone.  This bone and the surrounding tendon can become inflamed with repetitive activity such as running and jumping or with an acute injury like an ankle sprain. 

Signs and symptoms of both these syndromes include:  swelling in the back of the ankle (os trigonum) or lateral foot (os peroneum), tenderness in the area, pain with pushing off the foot/toes when walking, and weakness.  X-rays or other imaging can confirm the presence of these accessory bones. 

Conservative treatment of these syndromes involve the following:

•             Rest – avoiding aggravating activities such as running, jumping, dancing, etc.

•             Immobilization – a walking boot may be prescribed to limited motion of the ankle/foot

•             NSAIDs and cold packs – to reduce pain and inflammation

•             Physical Therapy – to restore normal flexibility/mobility, increase strength/stability and assist with return to ADLs and recreation/sports

If symptoms persist, then steroid injections may be used.  Surgical intervention may be required to remove the os trigonum or os peroneum.  Following surgery, physical therapy can be prescribed to regain ROM, strength, balance/stability, endurance, and to facilitate return to prior level of function.

If you have questions or would like to learn more about this topic, contact the therapy professionals at ProActive Physical Therapy and Sports Medicine for help.

For Accessory Navicular Syndrome Exercises, Visit One of Our San Diego Area Clinics

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by Jayson Caalaman PT, DPT

Do you work from home and spend long hours at a desk? Sitting for extended periods can result in forward or slumped posture as you maintain a repetitive reach toward your keyboard. Try these simple exercises to open up your chest and spine! No equipment is needed.

Seated Chin Tucks

Sit with an upright posture and create a double chin with your neck – sinking your head in, rather than tilting your head backward. You should feel a slight pull in the back of your head.

What is the purpose of Seated Chin Tucks?

The purpose of this exercise is to strengthen your deep neck flexor muscles which often get weakened with prolonged forward head posture.

Scapular Retraction

Almost everyone suffers from low back pain at some point in their lives. Most recover in a few days, but for some the pain lingers and becomes chronic, making low back pain the world’s leading cause of disability. Most commonly, mechanical issues and soft-tissue injuries are the cause of low back pain. These injuries can include damage to the intervertebral discs, compressions of nerve roots, and improper movement of the spinal joints. The single most common cause of lower back pain is a torn or pulled muscle and/or ligament. A low back sprain or strain can happen suddenly or can develop slowly over time and repetitive movements. Strains occur when a muscle is stretched too far and tears, damaging the muscle itself. Sprains happen when over-stretching and tearing affect ligaments, which connect the bones together. Both Sprains and strains have similar symptoms and PT treatments are also similar.

What are the common causes of a low back sprain and low back strain?

• Lifting a heavy object, or twisting the spine while lifting
• Sudden movements that place too much stress on the low back, such as a fall
• Poor posture over time
• Sports injuries, especially in sports that involve twisting or large forces of impact

While sprains and strains do not sound serious and do not typically cause long-lasting pain, the pain can be quite severe.

Pain is considered chronic once it lasts for more than three months and exceeds the body’s natural healing process. Chronic pain in the low back often involves a disc problem, a joint problem, and/or an irritated nerve root.

Common causes include:

• Herniated Disc
• Degenerative Disc Disease
• Facet Joint Dysfunction
• Sacroiliac Joint Dysfunction
• Spinal Stenosis

Why are some people able to recover quickly from low back pain?

For many, the answer may be early treatment with physical therapy, according to a new study by researchers at John Hopkins Medicine. The goal of the study was to determine if early PT for patients with lower back pain had an impact on their overall heath care resource utilization. They analyzed healthcare data from 2010 to 2014 for nearly a million U.S. adults with acute low back pain, excluding those suffering from serious disorders such as arthritis or spinal cord injuries. About 10% of the patients received early treatment with physical therapy. The study showed patients getting early PT were significantly less likely to see a chiropractor, orthopedic surgeon, or pain specialist after 30 days than those who did not get physical therapy. They were also less likely to get advanced imaging, epidural steroid injections, or visit an emergency room. The researchers also estimate healthcare costs for a typical patient getting early PT was about $500 less over those 30 days than those not receiving physical therapy.

As the U.S. population ages, the prevalence of lower back pain is expected to increase, along with the associated costs of treating it. With advances in imaging and treatments, the cost of managing lower back pain today has also increased substantially. Additionally, previous studies have found that physical therapy and regular exercise significantly reduce low back pain.

Other studies also found little evidence to support the use of opioids, spinal injections, and acetaminophen for low back pain. The findings of this John Hopkins study may have important implications that could guide health care policy when examining downstream health care costs and resource utilization.

For Help With Neck Pain or a Consultaion, Visit One of Our Clinics

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Does Aquatic or Water Based Physical Therapy Help With Fibromyalgia & Easing Pain?

It is well documented how aquatic therapy benefits many orthopaedic diagnosis, but not many know of the benefits it has for Fibromyalgia and Chronic Regional Pain Disorder (CRPS).  The Mayo Clinic states that Fibromyalgia is a disorder characterized by widespread musculoskeletal pain accompanied by fatigue, sleep, memory and mood issues.  Researchers believe that fibromyalgia amplifies painful sensations by affecting the way your brain processes pain signals. The Mayo Clinic describes Complex Regional Pain Syndrome (CRPS) as a form of chronic pain that usually affects an arm or a leg and the cause isn’t clearly understood.  The pain is out of proportion to the severity of the initial injury. CRPS occurs in two types, with similar signs and symptoms, but different causes:

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What is Chemotherapy-Induced Peripheral Neuropathy?

Chemotherapy-induced peripheral neuropathy (CIPN) is a problem that can develop during chemotherapy treatment for cancer. It occurs due to the toxicity of certain chemotherapy drugs which may damage the peripheral nervous system. Symptoms may include pain, numbness, or tingling of the hands or feet, and there may be balance problems as well. As many as 68% of cancer patients may experience CIPN, depending on their medications and other factors. The symptoms associated with CIPN are usually temporary but may last longer. People with prior nerve problems of the upper extremities or lower extremities are more vulnerable to developing CIPN (1). 

If you’ve ever walked into a Physical Therapy clinic, you’ve probably seen the ubiquitous hamstring stretch. Whether it’s done on one’s back while pulling the leg skyward or bending over trying to touch your toes, it’s one of the most common muscle stretches. So why is this? The reasons are a little more complicated than simply “having short hamstrings.”

The Muscle

A tight muscle is an overactive muscle; meaning it is unable to relax enough to move through its full range of motion. This may occur due to poor biomechanics or lack of movement. The hamstrings, composed of four different muscles, have a primary function to bend the knees and extend the leg backward. One factor in the prevalence of hamstring tightness is sitting. The modern world often demands long hours working at a desk, which has a few biomechanical consequences. One of them is keeping the hamstrings partially contracted for hours on end (specifically: bent at the knees). This means the hamstrings don’t move through their full normal range often enough. Another effect of sitting is that it encourages anterior pelvic tilt, meaning our pelvises tilt forward and our low backs arch. This pelvic tilt pulls on the hamstrings, preventing them from relaxing, even while standing and walking. This over-reliance on hamstrings causes people to engage their gluteals less, cyclically weakening them and leading to further dependence on the hamstrings for movement that is inefficient.

Tight Hamstrings

Tight hamstrings are often implicated in low back pain, one of the most common musculoskeletal complaint- 80% of the population will experience it at some point in their lives. It can be difficult to discern whether tight hamstrings lead to low back pain or vice versa but a good rehabilitation program will focus on both. Tight hamstrings are prone to muscle strain; they account for 29% of sports injuries involving running, jumping, and kicking, not to mention a re-injury rate of 12-31%. Hamstring flexibility has also been implicated in patellar tendinopathy, patellofemoral pain, and sacroiliac pain. Aging further exacerbates the problem as flexibility decreases due to changes such as fascial thickness and stiffness. Incorporating hamstring stretching into an everyday routine is a simple way to reduce the likelihood of injury and improve overall mobility.

There have been many studies on the best way to improve hamstring flexibility. The shortest answer is regular (i.e., daily) static stretching, wherein a muscle stretch is held to a comfortable level of tension for 30 seconds. To increase this benefit, myofascial release, such as foam rolling or soft tissue mobilization by a physical therapist, have been demonstrated to increase stretch tolerance when performed beforehand. Physical therapists also employ neuromuscular techniques, such as Contract-Relax, where a muscle can be induced to relax via neural feedback. Improvements in range of motion can be seen in as little as one week with regular stretching. It’s easy to see why this is such a PT favorite: it’s effective, it helps with a number of related conditions, and above all, it’s easy to do just about anywhere.

References

Bandy, W. D., & Irion, J. M. (1994). The Effect of Time on Static Stretch on the Flexibility of the Hamstring Muscles. Physical Therapy,74(9), 845-850. 

Freburger, J. K., Holmes, G. M., Agans, R. P., Jackman, A. M., Darter, J. D., Wallace, A. S., . . . Carey, T. S. (2009). The Rising Prevalence of Chronic Low Back Pain. Archives of Internal Medicine,169(3), 251. doi:10.1001/archinternmed.2008.543

Junker, D. H., & Stöggl, T. L. (2015). The Foam Roll as a Tool to Improve Hamstring Flexibility. Journal of Strength and Conditioning Research,29(12), 3480-3485. 

Medeiros, D. M., Cini, A., Sbruzzi, G., & Lima, C. S. (2016). Influence of static stretching on hamstring flexibility in healthy young adults: Systematic review and meta-analysis. Physiotherapy Theory and Practice,32(6), 438-445.

Mohr, A. R., Long, B. C., & Goad, C. L. (2014). Effect of Foam Rolling and Static Stretching on Passive Hip-Flexion Range of Motion. Journal of Sport Rehabilitation,23(4), 296-299. 

Wan, X., Qu, F., Garrett, W. E., Liu, H., & Yu, B. (2017). Relationships among hamstring muscle optimal length and hamstring flexibility and strength. Journal of Sport and Health Science,6(3), 275-282. 

Blood Flow Restriction (BFR) training uses a pressurized cuff to apply external pressure on an extremity, which maintains arterial inflow but occluded venous outflow. Doing this produces a systemic response comparative to heavy weight training. In short, the goal is to enable users to make greater strength gains while lifting lighter loads, thereby reducing the overall stress placed on the limb. Users usually work at 20-30% 1RM or 15-20 min at 40% VO2max.

Sinding Larsen-Johansson Syndrome (SLJS) is classified as a repetitive overuse injury leading to juvenile osteochondrosis and traction apophysitis.^1,2 SLJS typically occurs in the adolescent population between the ages of 10-14 and may occur during a growth spurt.^1,2 This syndrome can be diagnosed with radiographic imaging showing fragmentation of the patellar pole (distal/bottom of the patella).¹ One may also experience swelling, pain and tenderness, at the distal pole of the patella leading to functional limitations.¹ If gone untreated, this acute injury can become chronic which causes calcification at the distal pole of the patella and possible life-time impairments. It is important to make an appointment with your Physician to rule out other possible diagnosis such as Osgood-Schlatters Disease (OSD), Jumpers knee syndrome, Bursitis, Iliotibial Band syndrome, and patellofemoral pain syndrome to name a few.¹

Low back pain is an extremely common condition that affects individuals worldwide.  It is estimated that 80% of the population will experience a significant bout of low back pain at some time during the life span, and approximately 25% of adults in the United States will likely have had one entire day of low back pain in the last three months.  Low back pain is the most common disorder managed in outpatient physical therapy, accounting for 50% of all referrals. A common question asked by patients with low back pain is, “do I need an X-ray or MRI of my low back?”

A common concern of patients coming to outpatient physical therapy is whether the condition they are receiving treatment for will require surgery.  Patients presenting with lateral hip pain, or pain located at the outer portion of the hip, are often concerned whether arthritis is causing their pain, and worry that they may require a total hip replacement.  The good news is that lateral hip pain is usually not a result of arthritis, but more likely a condition involving the soft tissues of the lateral hip.