STRENGTH TRAINING TIPS

School-age youth need to participate regularly in physical activities that enhance and maintain cardiovascular and musculoskeletal health. While children and adolescents have traditionally been encouraged to participate in aerobic activities such as swimming and bicycling, strength training can also be safe and effective for youth, provided that appropriate guidelines are followed. Despite the previously held belief that children would not benefit from strength training or that this type of exercise would harm the growing skeletons of young lifters, current public health objectives now aim to increase the number of children and adolescents who regularly participate in physical activities that strengthen muscles and bones. Strength training can be an important component of physical activities to achieve those objectives.
 

WHAT IS STRENGTH TRAINING?

Strength training refers to a specialized method of conditioning that involves a wide range of materials and activities, including dumbbells, weight machines, medicine balls, and body weight exercises that are specifically designed to enhance or maintain muscular fitness. Regular participation in a strength training program can reduce the risk of sports-related injuries in young athletes. This type of conditioning should start during childhood as a preventive measure to enhance physical fitness and prepare aspiring young athletes for the demands of sports practice and competition.
 

WHAT SHOULD I KNOW BEFORE STARTING MY CHILD IN A PROGRAM?

Although there is no minimum age for participating in a youth strength training program, children should have the emotional maturity to accept and follow directions and should appreciate the benefits and concerns associated with this type of training. In general, if a child is ready for participation in some type of sport activity (about age 7 or 8), then he or she may be ready to strength train. It is also important for a child to be physically fit enough to handle a program and not have any pre-existing conditions, which could increase the risk of injury.

Children and adolescents should not undertake strength training on their own. They need guidance from a qualified professional to match the strength training program to their needs, interests, and abilities. If qualified instruction and a safe training environment are not available, youth who train on their own are at an increased risk of injury. The key is to provide close supervision, age-related instruction, proper equipment, and a safe training environment.
 

WHAT SHOULD A STRENGTH TRAINING PROGRAM INCLUDE?

There is not one optimal combination of sets, repetitions, and exercises for all youth. Rather, the structure of the program, individual effort, and qualified instruction will determine results. General youth strength training guidelines include:

• Providing qualified instruction and supervision
• Making sure the exercise environment is safe and free of hazards such as loose weights to trip on
• Focusing on developing proper exercise technique
• Beginning each session with a 5- to 10-minute warm-up period
• Starting with one light set of 10 to 15 repetitions on a variety of exercises
• Performing 8 to 12 exercises for the upper body, lower body, and midsection
• Progressing to 2 or 3 sets of 6 to 15 repetitions, depending on needs and goals
• Increasing the resistance gradually as strength improves
• Strengthening train 2 to 3 times per week on nonconsecutive days
• Using individualized workout logs to monitor progress
• Keeping the program fresh and challenging by varying the training program within the given guidelines of an athletic trainer or coach
  
   

  SUMMARY

  
  Regular participation in strength training has the potential to offer observable health and fitness value to children and adolescents, provided that age-appropriate training guidelines are followed. Youth strength training programs must be appropriately designed, competently supervised, and properly taught. It is important that youth not train by themselves. They need a qualified instructor to provide close supervision, age-related instruction, proper equipment, and a safe training environment. 

  REFERENCES AND ADDITIONAL RESOURCES

  
  American Academy of Pediatrics (www.aap.org)
  
  National Strength and Conditioning Association
  (www.nsca.com)
  
  American Orthopaedic Society for Sports Medicine
  (www.sportsmed.org)
  
  LOOK FORWARD TO PART TWO OF DO'S AND DON'T'S AT THE GYM COMING THURSDAY OF THIS WEEK!

DON'T'S OF THE GYM

A TWO-PART BLOG POST

Coming from a person with a medically trained eye who has tried their fair share of workouts, ranging from kickboxing to rehabilitation-based resistance training to cross fit and everything in between, it can be very frustrating seeing people in all fitness settings doing the wrong things for their bodies.  It takes every ounce of my self control to walk away, because when you're at the gym, you're not a physical therapist anymore. 

From personal experience, work schedules in this area of the medical field can make it difficult to be able to attend scheduled fitness classes on a regular basis, so I use equipment at a fitness center to create my own workouts.  It's here that I've recognized with just a few simple facts, a lot of people could make their workout routines much safer and more effective for their bodies. Today we will focus on:

The "Don't's"

1. Weighted Machines

Let's first address the larger picture: many of the weighted machines are likely not going to be as good for your body as using free weights or body weight. These machines isolate singular muscles or muscle groups, and while that can be effective for muscle groups that are slightly weaker due to an injury, it is more likely that strengthening individual muscle groups at a time will  increase your chances of your musculature being off-balance. 

The musculature of the body, in peak form, has balanced counterparts; muscle length and tightness is similar, and both concentric and eccentric strength is similar. 

Concentric Strength: Force exerted by the muscle while the muscle length is shortening/decreasing
Example: Flexing your arms in a Hercules pose is concentric strength of the biceps. 

Eccentric Strength: Force exerted by the muscle while the muscle length is lengthening/increasing
Example: Slowly lowering yourself to sit in a chair is eccentric strength of the hamstrings and glutes. When eccentric strength is weak, a person may not be able to control the movement the entire way, and will end up just dropping to the seat of the chair. 

Counterparts of musculature include biceps and triceps, or quads to hamstrings. 

Certain isolating weight machines also put a very large force upon the muscle group, as the machine is designed to affect one muscle group only. Many daily activities will never require movements that isolate a single muscle group - so therefore, these machines are not only functionally less effective, but can even be harmful. 

EXAMPLES:

Knee Extension Machine (Quads)

This machine is particularly dangerous, as it is extremely easy to put so much strain on the muscle group that it causes damage. It has been proven that the increase of force and tension on the patellar tendon is so much so that if someone puts too much weight on for the tendonous insertions to handle, they are at an increased risk for quadriceps tendon tears, contusions, patellar mis-tracking, hip flexor tightness, and even ACL tears and tibial tuberosity fractures. 

Knee Flexion Machine (Hamstring Curl)

This machine is more ineffective than dangerous because it is truly not a movement we do in our daily lives, but there is a recorded increase risk in hamstring tightness, which can lead to pelvic rotation, hip pain, and back pain, and even a higher risk of PCL tears and hamstring tendon tears.

Adductor/Abductor Machine

I cannot express how many people I see doing these machines at the gym.  I'll start by saying that neither of these machines are particularly bad for your body. Hip abduction strength is crucial to a healthy hip and gait pattern, and even in a rehabilitation setting, we do seated hip abduction - but it is only helpful for so long. The body, in general, reacts quickly to strengthening in muscle groups that are not reached on a daily basis by someone who leads a more sedentary lifestyle, whether it be due to injury or just habit. This is the reason we start someone out with seated hip abduction - but after about a week, being seated is no longer beneficial since the muscles have adjusted.  Since everyone doing these machines at the gym are likely going to the gym too often to be considered sedentary individuals, and therefore seated hip abduction is not really beneficial or functional for their body.  

Now seated hip adduction is another story.  Like me before I started working in this field, I thought the seated hip adduction machine would make my inner thighs slimmer, and more toned. I, like so many others, was searching for a "thigh gap".  The truth is - it doesn't do any of that.  Like doing abs, this machine won't magically remove the stored fat from your inner thighs, just like doing abs won't give you a six-pack. 

2. MINIMAL OR EXCESSIVE MOMENTUM

This is most evident when watching someone do bicep curls. Someone who starts with their elbows in 90 degrees flexion and just pulls weight up to their shoulders is likely not going to get the results they're looking for unless they're maxing out on weight and doing minimal reps every time. This is minimal momentum.  Someone who is lifting using the full 180 degrees provided by the elbow joint, so the weight starts closer to the thighs, but who uses their entire body weight to  throw the weight up is using excessive momentum. This will also not likely lead to the results they're looking for, as they're recruiting so many other muscle groups that it no longer is primarily a biceps exercise. Not only is this ineffective, but can also put straight on the back if the core is not tight. The correct way to perform a bicep curl involves using almost the entirety of the elbow joint range of motion at a predetermined speed.  Faster contraction (pulling the weight up toward the shoulders and bending the elbow) is good for explosiveness, and increasing muscle mass, but it is equally as important that the bicep eccentric strength is improved by lowering the weight slowly to its return position. The arm should never be fully relaxed - therefore the weight should never return all the way to the thighs - just slightly above to keep some contraction in the arms. 

This is also very evident watching "Lat Pull-downs" as many people will use their entire body to pull the weight down, as opposed to just their arms and back. There shouldn't be any "rocking" as the weight lowers - the body should be almost entirely still.  This is true regardless of whether the lift is being performed standing or seated. 

3.  NOT STACKING YOUR JOINTS

More often than not, many individuals coming in for physical therapy who live active lifestyles are only injured because they need to make a few slight adjustments to their lifting and performing technique. Lifting doesn't necessarily mean lifting heavy weights, it can be as simple as picking a pencil up off of the floor, or putting a jug of milk in the refrigerator. 

SQUATS 

To activate as many muscle groups as possible while protecting the joints in the lower extremity, the joints need to be "stacked" so that a load is never more overbearing on one joint compared to another. The most common is probably the knees driving too far forward. When the knees drive further over the toes, the pressure on the anterior aspect of the knee joint is astronomical. Especially in this flexed and loaded position, the ACL (anterior cruciate ligament) is at it's longest and carrying the majority of the load. 

PUSH-UPS

More often than not, if you ask someone to do a push-up, it'll look like this: elbows out away from the body as if to be in a "T" position.  This position rotates the scapulae, or shoulder blades, out in a winging formation. While the body descends lower toward the ground, the shoulder joint is shifted forward and upward, into what is called external rotation. With the scapulae winging and the shoulders in external rotation, this is the position also known to cause impingement. Impingement syndrome is the result of slight damage to a rotator cuff tendon.  The damage causes swelling, which in turn, leads to blocked blood supply and pinched nerves because the tendons are so intricately weaved throughout bones in the shoulder joint. 

WHAT IS A Q ANGLE?

The Q angle of the knee is a measurement of the angle between the quadriceps muscles and the patella tendon and provides useful information about the alignment of the knee joint.

How To Measure the Q Angle

You will need a long-arm goniometer. The Q angle can be measured in laying or standing. Standing is usually more suitable, due to the normal weight-bearing forces being applied to the knee joint as occurs during daily activity.

Place the centre of the goniometer over the centre of the patella and position the bottom arm in line with the patella tendon and tibial tuberosity. Next position the upper arm so that it is pointed directly at the anterior inferior iliac spine (AIIS) of the ilium (point to which rectus Femoris attaches). The small angle of the goniometer is the Q angle.

Normal Q Angle

Normal for men is 14 degrees and for women is 17 degrees. Women usually have a higher Q angle due to their naturally wider pelvis. If measured laying down the angle will be 1-3 degrees lower.
A high Q angle often results in mal tracking of the patella, that is it does not travel over the front of the knee joint as it should. Overtime this can cause microtrauma to the cartilage on the rear of the patella which causes pain, often known as anterior knee pain, patellofemoral pain or chondromalacia patella. 
Having over-pronated feet also places additional strain on the Q angle due to excessive internal rotation of the tibia.

How To Decrease the Q Angle

A thorough biomechanical assessment is required in order to progress with a treatment plan. The first step is to correct any over-pronation at the feet using orthotics.
There is no manipulation or adjustment (such as you might receive at a chiropractor) to reduce Q angle. Correct biomechanics must be achieved through a rehabilitation program which focuses on restoring flexibility to tight muscles (commonly calves, hamstrings and quadriceps. 
Weaker muscles must also be strengthened. It is common that laterally positioned fibres of the Vastus medialis known as VMO (vastus medialis oblique) are weak. These fibres also play an important role in controlling the stability and positioning of the patella and so strength and timing of contractions should be restored. 
This can be achieved by placing a rolled up towel under the knee (whilst sitting) so that it is slightly flexed. Whilst palpating VMO push the knee down into the towel so that it straightens and the heel rises from the floor. You should feel the muscle fibres under your fingers contract. 
Once this is mastered half squats against a wall or fit-ball can be introduced, still maintaining contraction of the VMO.

LABRAL TEARS OF THE HIP

Introduction

Acetabular labrum tears (labral tears) are amongst some of the most difficult recoveries, and the most difficult to diagnose.  Generally, there are fewer orthopedic surgeons who perform minimally invasive hip labral repairs than any other surgical hip procedure involved with the hip. The reason is simply because these injuries can be worsened so quickly from small, seemingly-harmless movements - so a good reconstruction is vital. Labral tears can cause pain, stiffness, and other disabling symptoms of the hip joint. The pain can occur if the labrum is torn, frayed, or damaged. Active adults between the ages of 20 and 40 are affected most often, requiring some type of treatment in order to stay active and functional. New information from ongoing studies is changing the way this condition is treated from a surgical approach to a more conservative (nonoperative) path.

This guide will help you understand

• what parts of the hip are involved
• how the condition develops
• how doctors diagnose the condition
• what treatment options are available

Anatomy

What parts of the hip are involved?

The acetabular labrum is a fibrous rim of cartilage around the hip socket that is important in normal function of the hip. It helps keep the head of the femur (thigh bone) inside the acetabulum (hip socket). It provides stability to the joint.

Our understanding of the acetabular labrum has expanded just in the last 10 years. The availability of high-power photography and improved lab techniques have made it possible to take a closer look at the structure of this area of the hip.

The labrum is a piece of connective tissue around the rim of the hip socket (acetabulum). It has two sides: one side is in contact with the head of the femur, the other side touches and interconnects with the joint capsule. The capsule is made up of strong ligaments that surround the hip and help hold it in place while still allowing it to move in many directions,

Finding out that there are two separate zones of the labrum was an important discovery. The extra-articularside (next to the joint capsule) has a good blood supply but the intra-articular zone (next to the joint) is mostlyavascular (without blood). That means any damage to the extra-articular side is more likely to heal while the intra-articular side (with a very poor blood supply) does not heal well after injury or surgical repair.

The labrum helps seal the hip joint, thus maintaining fluid pressure inside the joint and providing the overall joint cartilage withnutrition. Without an intact seal, the risk of early Degenerative arthritis increases. A damaged labrum can also result in a shift of the hip center of rotation. A change of this type increases the impact and load on the joint. Without the protection of the seal or with a hip that’s off-center, repetitive motion can create multiple small injuries to the labrum and to the hip joint. Over time, these small injuries can add to wear and tear in the hip joint.

Causes

How does this condition develop?

It was once believed that a single injury was the main reason labral tears occurred (running, twisting, slipping). But with improved radiographic imaging and anatomy studies, it’s clear now that abnormal shape and structure of the acetabulum, labrum, and/or femoral head can also lead to the problem.

Injury is still a major cause for labral tears. Anatomical changes that contribute to labral tears combined with repetitive small injuries lead to a gradual onset of the problem. Athletic activities that require repetitive pivoting motions or repeated hip flexion cause these type of small injuries.

What are these “anatomical changes”? The most common one called femoral acetabular impingement (FAI) is a major cause of hip labral tears. With FAI, there is decreased joint clearance between the junction of the femoral head and neck with the acetabular rim.

Related Document: Femoroacetabular Impingement of the Hip

When the leg bends, internally rotates, and moves toward the body, the bone of the femoral neck butts up against the acetabular rim pinching the labrum between the femoral neck and the acetabular rim. Over time, this pinching, or impingement, of the labrum causes fraying and tearing of the edges. A complete rupture is referred to as an avulsion where the labrum is separated from the edge of the acetabulum where it normally attaches.

Changes in normal hip movement combined with muscle weakness around the hip can lead to acetabular labrum tears. Other causes include capsular laxity (loose ligaments), hip dysplasia (shallow hip socket), traction injuries, and degenerative (arthritic) changes associated with aging. Anyone who has had a childhood hip disease (such as Legg-Calvé-Perthes Disease, hip dysplasia, Slipped capital femoral epiphysis) is also at increased risk for labral tears.

Symptoms

What does this condition feel like?

Pain in the front of the hip (most often in the groin area) accompanied by clicking, locking, or catching of the hip are the main symptoms reported with hip acetabular labral tears. Joint stiffness and a feeling of instability where the hip and leg seem to give away are also common. The pain may radiate (travel) to the buttocks, along the side of the hip, or even down to the knee.

Symptoms get worse with long periods of standing, sitting, or walking. Pivoting on the involved leg is avoided for the same reason (causes pain). Some patients walk with a limp or have a positive Trendelenburg sign (hip drops down on the right side when standing on the left leg and vice versa).

The pain can be constant and severe enough to limit all recreational activities and sports participation.

Diagnosis

How will my doctor diagnose this condition?

The history and physical examination are the first tools the physician uses to diagnose hip labral tears. There may or may not be a history of known trauma linked with the hip pain. When there are anatomic and structural causes or muscle imbalances contributing to the development of labral tears, symptoms may develop gradually over time.

Your doctor will perform several tests. One common test is the impingement sign. This test is done by bending the hip to 90 degrees (flexion), turning the hip inward internal rotation) and bringing the thigh towards the other hip (adduction).

Making the diagnosis isn’t always easy. In fact, this problem is frequently misdiagnosed at first. That’s because there are many possible causes of hip pain. The pain associated with labral tears can be hard to pinpoint. Your doctor must rely on additional tests to locate the exact cause of the pain. For example, injecting a local anesthetic agent (lidocaine) into the joint itself can help determine if the pain is coming from inside (versus outside) the joint.

X-rays provide a visual picture of any changes out of the ordinary of the entire structure and location of the hip position. Magnetic resonance imaging (MRI) gives a clearer picture of the soft tissues (e.g., labrum, cartilage, tendons, muscles).

One other test called a magnetic resonance arthrography (MRA) is now considered the gold standard for diagnosis. Studies show that MRA is highly sensitive and specific for labral tears. This test may replace arthroscopic examination as the main diagnostic tool. Arthroscopic examination is still 100% accurate but requires a surgical procedure.

With MRAs, contrast dye (gadolinium) is injected into the hip joint. Any irregularity in the joint surface will show up when the dye seeps into areas where damage has occurred. MRAs give the surgeon an excellent view of the location and extent of the tear as well as any bony abnormalities that will have to be addressed during surgery.

Treatment

What treatment options are available?

In the past, when arthroscopic surgery was the only way to confirm the presence of a labral tear, the surgeon would just go ahead and remove the torn edges or pieces during the arthroscopic examination procedure. However, studies over the years have called this approach into question. With removal of the labrum, changes in the way the hip functioned, increased friction of the joint, and increased load on the joint led to degenerative changes and Osteoarthritis.

Surgeons stopped cutting out the torn labrum and started repairing it instead. Physical therapists started doing studies that showed strengthening muscles and resolving issues of muscle imbalances could reduce the need for surgery with the traditional risks (e.g., bleeding, infection, poor wound healing, negative reactions to anesthesia).

More efforts are being made now to manage labral tears with conservative (nonoperative) care. This is a possibility most often when there are no symptoms of labral pathology. Patients with confirmed labral tears but who have normal Hip Anatomy or only mild changes in the shape and structure of the hip may also benefit from conservative care.

Nonsurgical Treatment

Physical therapy will probably be suggested. Your physical therapist will carry out an examination of joint motion; hip, trunk, and knee muscle strength; posture; alignment; and gait/movement analysis (looking at walking/movement patterns). A plan of care is designed for each patient based on his or her individual factors and characteristics.

Nonoperative care starts with activity modification. You should avoid pivoting on the involved leg and avoid prolonged periods of weight-bearing activities. You physical therapist will work with you to on strengthen your hip muscles, restore normal neuromuscular control, and improve your posture. All of these things can improve your hip function and reduce your pain.

Tight muscles around the hip can contribute to pinching between the femoral head and acetabulum in certain positions. A program of flexibility and stretching exercises won’t change the bony abnormalities present but can help lengthen the muscles and reduce contact and subsequent impingement.

A special strap called the SERF strap (SERF means Stability through External Rotation of the Femur) made of thin elastic may be applied around the thigh, knee, and lower leg to pull the hip into external rotation. The idea is to use the strap to improve hip control and leg movement during dynamic activities. It is important to strengthen the muscles at the same time to perform the same task and avoid depending on external support on a long-term basis.

Some patients may also benefit from intra-articular injection with cortisone. Cortisone is a very potent antiinflammatory medication. Injection into the hip joint may reduce the symptoms of pain for several weeks to months.

Surgery

Arthroscopy is commonly used to repair the torn labrum. The arthroscope is a small fiber-optic tube that is used to see and operate inside the joint. A TV camera is attached to the lens on the outer end of the arthroscope. The TV camera projects the image from inside the hip joint on a TV screen next to the surgeon. The surgeon actually watches the TV screen (not the hip) while moving the arthroscope to different places inside the hip joint and bursa.

During this procedure, your surgeon will trim the torn and frayed tissue around the acetabular rim and reattach the torn labrum to the bone of the acetabular rim. This procedure is called labral refixation. Each layer of tissue is sewn back together and reattached as closely as possible to its original position along the acetabular rim.

When repair is not possible, then debridement of the torn labral tissue may be necessary. Debridement simply means that the torn or weakened portions of the labrum are simply removed. This prevents the torn fragments from getting caught in the hip joint and causing pain and further damage to the hip joint.

In some cases, open treatment of Femoroacetabular Impingement and/or correction of bone abnormalities are required. These procedures are much more involved and usually will require a stay of several days in the hospital.

Related Document: A Patient's Guide to Femoroacetabular Impingement

Rehabilitation

What should I expect after treatment?

Nonsurgical Rehabilitation

The goal of conservative management is to relieve pain and improve function by correcting muscle strength imbalances. When both legs have nearly equal strength, it is possible to resume a full and normal level of all activities as long as there is no pain during any of those movements or activities.

For the young or active adult, this includes activities of daily living as well as recreational and sports participation. Older adults experiencing labral tears from degenerative Arthritis may expect to be able to resume normal daily functions, but may still find it necessary to limit prolonged sitting or standing positions.

After Surgery

Correction of the problem causing labral tears can result in improved function and pain relief. The hope is that early treatment can prevent arthritic changes but long-term studies have not been done to proven this idea.

Recovery after surgery needed to address hip labral tears usually takes four to six months. In other words, patients can expect to resume normal activities six months after surgery. Many athletes or highly active adults find this time frame much too long for their goals and preferences.

Patients who follow the recommended rehab plan of care respond well to progression of the exercises and seem to recover faster. Discharge from rehab takes place when the patient can perform all exercises with good form and without pain or other symptoms. Any repeat episodes of groin and/or hip pain must be reported to the orthopedic surgeon for evaluation right away.

CERVICAL RADICULOPATHY

Introduction

Neck Pain has many causes. Mechanical neck pain comes from injury or inflammation in the soft tissues of the neck. This is much different and less concerning than symptoms that come from pressure on the nerve roots as they exit the spinal column. People sometimes refer to this problem as a pinched nerve. Health care providers call it cervical radiculopathy.

This guide will help you understand:

• how the problem develops
• how doctors diagnose the condition
• what treatment options are available

Anatomy

What part of the neck is involved?

The spine is made of a column of bones. Each bone, or vertebra, is formed by a round block of bone, called a vertebral body. A bony ring attaches to the back of the vertebral body. When the vertebra bones are stacked on top of each other, the bony rings forms a long bony tube that surrounds and protects the spinal cord as it passes through the spine.

Traveling from the brain down through the spinal column, the spinal cord sends out nerve branches through openings on both sides of each vertebra. These openings are called the neural foramina. (The term used to describe a single opening is foramen.)

The intervertebral disc sits directly in front of the opening. A bulged or herniated disc can narrow the opening and put pressure on the nerve. A facet joint sits in back of the foramen. Bone spurs that form on the facet joint can project into the tunnel, narrowing the hole and pinching the nerve.

An intervertebral disc fits between the vertebral bodies and provides a space between the spine bones. The disc normally works like a shock absorber. An intervertebral disc is made of two parts. The center, called the nucleus, is spongy. It provides most of the shock absorption. The nucleus is held in place by the annulus, a series of strong ligament rings surrounding it. Ligaments are strong connective tissues that attach bones to other bones.  Cervical Radiculopathy usually affects nerve roots C6 and C7, and can vary from slight pain to severe pain that will likely continue to increase if left untreated. 

Related Document: A Patient's Guide to Cervical Spine Anatomy

Causes

Why do I have this problem?

Cervical radiculopathy is caused by any condition that puts pressure on the nerves where they leave the spinal column. This is much different than mechanical neck pain. Mechanical neck pain is caused by injury or inflammation in the soft tissues of the neck, such as the discs, facet joints, ligaments, or muscles.

The main causes of cervical radiculopathy include degeneration, disc herniation, and spinal instability.

Degeneration

View animation of degenerative changes

As the spine ages, several changes occur in the bones and soft tissues. The disc loses its water content and begins to collapse, causing the space between the vertebrae to narrow. The added pressure may irritate and inflame the facet joints, causing them to become enlarged. When this happens, the enlarged joints can press against the nerves going to the arm as they try to squeeze through the neural foramina. Degeneration can also cause bone spurs to develop. Bone spurs may put pressure on nerves and produce symptoms of cervical radiculopathy.

Herniated Disc

Heavy, repetitive bending, twisting, and lifting can place extra pressure on the shock-absorbing nucleus of the disc. A blow to the head and neck can also cause extra pressure on the nucleus. If great enough, this increased pressure can injure the annulus (the tough, outer ring of the disc). If the annulus ruptures, or tears, the material in the nucleus can squeeze out of the disc. This is called aherniation.

Although daily activities may cause the nucleus to press against the annulus, the body is normally able to withstand these pressures. However, as the annulus ages, it tends to crack and tear. It is repaired with scar tissue. Over time, the annulus becomes weakened, and the disc can more easily herniate through the damaged annulus. If the herniated disc material presses against a nerve root it can cause pain, numbness, and weakness in the area the nerve supplies.

Spinal Instability

Spinal instability means there is extra movement among the bones of the spine. Instability in the Cervical Spine (the neck) can develop if the supporting ligaments have been stretched or torn from a severe injury to the head or neck. People with diseases that loosen their connective tissue may also have spinal instability. Spinal instability also includes conditions in which a vertebral body slips over the one just below it. When the vertebral body slips too far forward, the condition is called Spondylolisthesis. Whatever the cause, extra movement in the bones of the spine can irritate or put pressure on the nerves of the neck, causing symptoms of cervical radiculopathy.

Symptoms

What does the condition feel like?

The symptoms from cervical radiculopathy are from pressure on an irritated nerve. These symptoms are not the same as those that come from mechanical neck pain. Mechanical neck pain usually starts in the neck and is likely to spread far enough to cause upper back or shoulder pain. Less frequently, radiculopathy extends below the shoulder, and can sometimes radiate through to the elbow or hand. Headaches are also a common complaint of both radiculopathy and mechanical neck pain.

The pain from cervical radiculopathy usually spreads further down the arm than mechanical neck pain. And unlike mechanical pain, radiculopathy also usually involves other changes in how the nerves work such as numbness, tingling, and weakness in the muscles of the shoulder, arm, or hand. With cervical radiculopathy, the reflexes in the muscles of the upper arm are usually affected. This is why doctors check reflexes when people have symptoms of cervical radiculopathy.

Diagnosis

How do doctors diagnose the problem?

Doctors gather the information about your symptoms as a way to determine which nerve is having problems. Diagnosis begins with a complete history of the problem. Your doctor will ask questions about your symptoms and how your problem is affecting your daily activities. Your answers can help your doctor determine which nerve is causing problems.

Next, the doctor examines you to see which neck movements cause pain or other symptoms. Your skin sensation, muscle strength, and reflexes are tested in order to tell where the nerve problem is coming from.

X-rays of the cervical spine can show the cause of pressure on the nerve. The images show whether degeneration has caused the space between the vertebrae to collapse. They may also show if a bone spur is pressing against a nerve.

If more information is needed, your doctor may order magnetic resonance imaging (MRI). The MRI machine uses magnetic waves rather than X-rays to show the soft tissues of the body. This test gives a clear picture of the discs, nerves, and other soft tissues in the neck. The machine creates pictures that look like slices of the area your doctor is interested in. The test does not require any special dye or needles and is painless.

Sometimes it isn't clear where the nerve pressure is coming from. Symptoms of numbness or weakness can also happen when the nerve is being pinched or injured at other points along its path. (An example of this is pressure on the median nerve in the wrist, known as Carpal Tunnel Syndrome.) Electrical studies of the nerves going from the neck to the arm may be requested by your doctor to see whether the nerve problem is in the neck or further down the arm. However, most doctors take X-rays and try other forms of treatment before ordering electrical tests. These tests are usually only needed when the diagnosis is not clear.

If your doctor orders electrical studies, several tests are available to see how well the nerves are functioning, including theelectromyography (EMG) test. This test measures how long it takes a muscle to work once a nerve signals it to move. The time it takes will be slower if nerve pressure from radiculopathy has affected the strength of the muscle.

Another electrical test that may be used instead of EMG is cervical root stimulation (CRS). This test involves putting a small needle through the back of the neck into the nerve where it leaves the spinal column. Readings of muscle action are then taken of the muscles on the front and back of the upper arm and along the inside of the lower arm. Doctors use the readings to determine which nerve is having problems.

What Next?

Patients have many options regarding treatment, that vary widely between physical therapy all the way to slightly more invasive surgical procedures.  Kansas City is lucky to have wonderful, top-notch orthopedic and neurological surgeons all throughout the metro.  Talk to your doctor about what options would be best for you, and should physical therapy not help as much as you'd hope, surgery can be an option. 

WHY AQUATIC REHABILITATION?

WHY AQUATIC REHABILITATION?

Performing exercise in the water is beneficial for several reasons:

• The thermal properties of water are therapeutic because it helps increase circulation.
• The hydrostatic pressure of the water compresses the tissues causing decreased swelling, and improved lymphatic return.
• The buoyancy of the water helps to “un weight” the body and facilitate movement, with less stress on musculoskeletal system.
• Drag is a property of water that creates resistance to movement, facilitating strengthening of the musculoskeletal system.

WHO CAN BENEFIT FROM AQUATIC REHABILITATION?

A variety of patients with musculoskeletal conditions benefit from aquatic rehabilitation:

• Patients with arthritis benefit from the being able to exercise in an environment where there is minimal stress on the joints, improved circulation, and facilitation of movement.
• Patients with joint replacement surgery benefit from the decreased stress on their joints, reduced swelling and facilitation of movement.
• Patients with low back pain benefit from the decreased stress on the back and relaxation of the water temperature.
• Patients with sports injuries benefit from performing exercises at a faster pace due to the reduced stress on the joints.
• Patients who are unable to perform dry-land exercises due to pain or swelling

CAN I GET THE SAME BENEFITS FROM LAND THERAPY AS AQUATIC?

Yes, most of the time, you can.  Aquatic therapy is best for some cases with severe pain, or to gain range of motion.  The kicker is: it'll only get you so far.  Manual therapy is going to be the best solution to improve your range of motion, and aquatic therapy does not permit the proper positioning to perform manual therapy, so even if your therapist is in the water with you or you're using buoys or body weight to increase your range of motion, land therapy will still be more beneficial.  Aquatic therapy provides a natural resistance to perform activities, but the water also provides a natural stabilizer which doesn't allow your muscles to contract as well as they need to to help maintain your balance - it will only allow you to practice the movements you need to work on, but patients usually still struggle when the time comes to perform those activities on land. For example: a meniscus repair requires that patients be non weight bearing or partial weight bearing for several weeks after surgery. Aquatic therapy is going to allow them to practice walking in the resistance of the water before they can do so on land.  And while by the end of 6 weeks after surgery they may be walking flawlessly in the water, they will still struggle to walk on land because aquatic therapy does not provide the circumstances under which patients complete their daily activities. By no means is this to say aquatic therapy is not beneficial - because it definitely is - land therapy will just help a wider range of patients get back to their end goal at a more efficient rate. 

 

MEDICAL INNOVATION - WHATS NEW ON THE HORIZON

Champion Performance and Physical Therapy sits right on the edge between Prairie Village and the Ward Parkway/Mission Hills neighborhood.  We are fortunate to receive patients from both the northern and southern halves of the metro area - and through our extensive network, we've seen some incredible successful surgical feats occur here in the heart of America. 

With so many nationally-ranked medical centers and surgeons who practice in the greater Kansas City area, it is no surprise to those of us in the medical field that there are doctors near our own homes who are at the forefront of medical innovation. These physicians and surgeons travel throughout the nation, and throughout the world, learning and teaching techniques and surgical improvements that decrease risk factor possibilities by the exponent, and improve overall patient recovery and quality of life.

Mayo Clinic in Rochester, Minnesota publishes the best and most recent discoveries in orthopedic surgery on a monthly basis, and while your physical therapy staff keeps up on their annual clinical education courses, a little extra knowledge helps us inform our patients and start them a step ahead in the rehab process.  

Attached below is a link to the 2016 publications from that same publication. 

INJECTIONS TO MANAGE PAIN

Introduction

Injections are commonly used by pain specialists, both to help diagnose the painful condition and to help treat the painful condition. 

This guide will help you understand

• the difference between diagnostic and therapeutic injections
• what the common medications injected are intended to do
• the risks and benefits of injections for pain

Rationale

What is the difference between diagnostic and therapeutic injections?

Injections used for pain management can be divided into two categories: diagnostic injections and therapeutic injections.

Diagnostic injections are intended to help your doctor determine what part of the body is causing the pain you are experiencing. The part that is causing the pain is sometimes referred to as the pain generator. Diagnostic injections are used by your doctor to determine the pain generator by a process of elimination. You should also understand that there may be more than one part that is painful. There may be several pain generators.

The process of finding the pain generator begins with a careful history and physical examination. This may lead to a differential diagnosis. The differential diagnosis is a list of all the possibilities that the physician can think of that best fit with the findings from the initial history and physical examination. Once the differential diagnosis list has been determined, the goal is to figure out which item on the list is actually causing your symptoms.

The next step may be to obtain x-rays, MRI scan, or CT scans. Each of these radiological tests gives your doctor information about the structure of your spine, bones and joints. These images may show abnormalities that may account for your pain. For example, a spine x-ray may show Arthritis of the joints of the spine that could be causing the pain that you are experiencing. But, simply because the structural abnormality could be causing your pain does not mean that it is. Structural abnormalities are commonly seen on radiological tests. Many of these abnormalities are not necessarily causing pain.

The rationale behind diagnostic injections is simple: If a structural abnormality identified on the radiological tests is causing your pain, and if your doctor can inject that structure to temporarily numb that and only that specific structure and the pain stops temporarily, then it makes sense that this is what is actually causing your pain.

It is also likely that you may have several abnormalities visible on the radiological tests. It may be unclear which abnormality is the cause of your symptoms. For example, you may have several intervertebral discs that appear worn out on the MRI scan of your lumbar spine. It could be that all of the discs are causing your pain - or it could be that there is only one disc causing your pain. If you are considering surgery, you would want to be sure which disc is causing the pain so that you did not undergo any additional, unnecessary surgery.

Finally, your pain may actually be coming from somewhere else in your body altogether. For example, it is not uncommon for a patient to have a worn out hip joint and a worn out lower back. When a patient with this combination of problems has hip and thigh pain, it is not always obvious whether the pain is coming from the hip joint or being referred from the lower spine - or both. 

By injecting the hip joint with medication to temporarily numb the hip joint and eliminate the pain that is coming only from the hip, the physician can determine what portion of the pain is coming from the hip joint - if any - and what pain is originating from the spine. This helps diagnose the problem accurately and prevent any unnecessary procedures.

Almost all diagnostic injections follow a similar strategy. First, determine what could be causing the pain. Next, inject the structure that is most likely the cause of the pain with a medication that should reduce or eliminate the pain temporarily. If the pain is eliminated, then the structure injected is almost surely the cause of the pain. It is the pain generator.

Unlike diagnostic injections, therapeutic injections are intended to treat your problem. Therapeutic injections are used when your doctor already has a very good idea what structure is the pain generator. This means that therapeutic injections should be expected to reduce, or eliminate, your symptoms for some period of time. Injections rarely eliminate pain permanently. But, some injections may last weeks to months.

Preparations

How do I prepare for this procedure?

To prepare for the procedure your doctor may tell you to remain "NPO" for a certain amount of time before the procedure. This means that you should not eat or drink anything for the specified amount of time before your procedure. This means no water, no coffee, no tea - not anything. You may receive special instructions to take your usual medications with a small amount of water. Check with your doctor if you are unsure what to do. 

You may be instructed to discontinue certain medications that affect the clotting of your blood several days before the injection. This reduces the risk of excessive bleeding during and after the injection. These medications may include the common Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) such as aspirin, ibuprofen, naproxen and many other medications that are commonly used to treat arthritis. If you are taking any type of blood thinning medication you should let your doctor know. You will most likely need to have this medication regulated or temporarily discontinued prior to the injection. Your doctor will need to determine if it is safe to discontinue these medications in order to have the injection. 

You may need to arrange to have transportation both to and from the location where you will undergo the injection. Wear loose fitting clothing that is easy to take off and put on. You may wish to take a shower the morning of the procedure, using a bactericidal soap to reduce chances of infection. Do not wear jewelry or any type of scented oils or lotions. 

Procedure

What happens during the procedure?

Injections are commonly performed in several different settings. Some simple injections may be done in the office. Other injections that require special equipment may be done in the operating room, the radiology department or a surgery center. 

Many injections are done with the help of fluoroscopic guidance. The fluoroscope is an x-ray machine that allows the doctor to actually see an x-ray image while doing the procedure. This allows the doctor to watch where the needle goes as it is inserted. This makes the injection much safer and much more accurate. Once the needle is in the right location, a small amount of radiographic dye is injected. This liquid dye shows up on the x-ray image, and the doctor can watch where it goes. The medication used for the injection will go in the same place. The doctor wants to make sure the injection will put the medication where it can do the most good. Once the correct position is confirmed, the medication is injected, and the needle is removed. 

The medications that are normally injected during a therapeutic pain injection include a local anesthetic and some type of cortisone, or steroid, medication. A local anesthetic medication, such as lidocaine or bupivicaine, is the same medication that is used numb the area when you are having dental work or having minor surgery, such as a laceration sutured. The medication causes temporary numbness lasting one hour to six hours, depending on which type of anesthetic is used. 

Cortisone is an extremely powerful anti-inflammatory medication. When this medication is injected around inflamed, swollen nerves and connective tissues, it can reduce the inflammation and swelling. Decreasing inflammation reduces pain in joints. Reduced swelling can allow the nerves to function better, reducing numbness and weakness. 

After Care

What happens after the procedure?

If everything goes as planned, you will be able to go home soon after the injection, probably within one hour. After most types of pain injections, you will probably not have any restrictions on activity or diet following the procedure.

When the pain injection is a diagnostic injection, your doctor will be interested in how much the pain is reduced while the anesthetic, or the numbing medication, is working. You may be given a pain diary to record what you feel for the next several hours. This is important for making decisions, so keep track of your pain.

You will be expected to cease all physical activity for 48 hours following your injection, so if you are participating in physical therapy or other therapeutic activity, be sure to let your therapist know you'll have to reschedule any appointments. 

Most doctors will arrange a follow-up appointment, or phone consult, within one or two weeks after the procedure to see how you are doing and what effect the procedure had on your symptoms. 

And remember, injections are not usually a cure for your pain; they are only a part of your overall pain management plan. You will still need to continue working with the other recommendations from your pain management team.

CONCUSSIONS AND LONGTERM EFFECTS

Multiple untreated concussions and their longterm effects have been painted in red across the media more and more frequently within the past 5 years as knowledge slowly seeps out to the general public. While concussions are likely to occur as a result of a motor vehicle accident, the most prevalent cause is from athletics, and although new rules and regulations are introduced almost every year to increase prevention in contact sports across the globe, no amount of padding in a helmet can prevent a concussion.  Therefore, as spring sports start up again within the next couple of weeks and tournament season starts for winter sports, athletes and their loved ones alike being informed on what to look for and what to expect is the best way to prevent further injury, and longterm effects. 

According to the U.S. Centers for Disease Control and Prevention, about 200,000 people in the United States suffer concussions while playing sports every year. Concussions occur most commonly in a wide range of sports and affect all athletes, from professional players to little leaguers.  However, they are also prevalent in motor vehicle accidents, as well, as a result of whiplash. Car accidents can lead to many injuries that seem "bigger" than a concussion, so it is vital that loved ones close to the victim keep a close eye on their neurological responses as they recover from an accident.

Concussions are mild traumatic brain injuries, and sports concussion has become a significant problem.  Recognizing concussion and providing proper treatment is especially important for younger athletes because it typically takes them longer than adults to fully recover.

In addition, coaches, parents, and school administrators must be aware that concussion causes a wide range of symptoms and can interfere not only with sports participation, but with school and social relationships. Most athletes will fully recover from concussion, and understanding the varied symptoms can help with the healing process.

Description

Despite many attempts by experts, there is no clear definition of concussion. It is uncertain whether any damage to the brain occurs from a concussion. Imaging tests, such as computed tomography (CT) scans and magnetic resonance imaging (MRI) scans, typically do not detect any brain damage — such as bruising or bleeding — in concussion patients.

A concussion does, however, temporarily impair how the brain functions and processes information. For example, after a concussion, a patient may have difficulty with balance and coordination, memory, and speech.

A concussion is typically short-lived. Most people recover within 7 to 10 days. Unfortunately, once an athlete has sustained a concussion, he or she is at greater risk for additional concussions. Repeat concussions can have long-term consequences, so prevention is essential.  Most professional teams now have a 2-4 week timeframe before a player can even be considered to be pulled off the injured list, and many high schools in the Kansas City area have at least a 2 week benched timeframe. This may vary based on the severity of the concussion received, and the duration of symptoms following.  

Cause

Derived from the Latin word concusses, concussion means to shake violently. A concussion happens when a force causes the brain to rapidly move back and forth inside the skull. This may be caused by either a direct blow or by a blow to the body that forces the head to quickly rotate.

Although some sports have higher instances of concussion — such as football, ice hockey, and soccer — concussions can happen in any sport or recreational activity.

Symptoms

Because of the potential long-term consequences of sports concussion, it is important that athletes, coaches, and parents know as much as possible about how to recognize them.

Symptoms are not always obvious. Although it is commonly assumed that concussions cause loss of consciousness, many people with concussions have not been "knocked out."

Concussion causes a variety of symptoms. These may appear right away, or may be delayed for several days after the injury. Some symptoms are physical, such as drowsiness. Others are cognitive, like memory loss. In many cases, people with concussions are more emotional than usual.

The most common symptoms of concussion include:

• Drowsiness
• Headache
• Loss of consciousness
• Memory loss
• Irritability
• Confusion
• Balance problems, dizziness
• Difficulty speaking and communicating
• Depression
• Nausea and vomiting
• Changes in sleep patterns

Doctor Examination

During the evaluation, your doctor will ask questions about the injury and how it occurred. He or she may ask how severe the force was and whether you lost consciousness or had memory loss after the blow. It is especially important that you tell your doctor about any previous concussions you have had.

Your doctor will most likely perform a neurological examination, which tests for balance, coordination, vision, hearing, and reflexes.

Neurological Examination.

Imaging Tests

Magnetic resonance imaging (MRI) and computed tomography (CT) scans provide doctors with detailed images of the skull and brain. As stated above, results from MRI scans and CT scans are most often normal in concussion patients, so these tests are not usually helpful in diagnosing the injury.

If the neurological examination indicates problems, such as trouble with your vision, your doctor will order imaging scans. Also, if your symptoms worsen over time, CT and MRI scans are important for guiding treatment.

Neuropsychological Assessment

Neuropsychological testing helps to measure the effects of concussion on mental capabilities. This kind of assessment can be done using computerized tests, or during a session with a neuropsychologist.

The testing provides valuable information on a range of mental functions, such as short-term and long-term memory, attention and concentration, problem-solving, and speech.

Balance Assessment

Many athletes are unsteady on their feet for several days following a concussion. Balance testing is a way for doctors to assess how well the part of the brain that controls movement is functioning.

There are several balance tests your doctor might use, as well as more sophisticated force plate technology. Force plates are instruments that measure the forces of stepping, running, jumping and other actions. They are typically rectangle-shaped and may be used in a stand-alone device, or inserted in machines that resemble exercise equipment, like treadmills or stair steppers.

Treatment

The key to healing from a concussion is complete rest. This includes not just physical rest, but mental rest, as well. Reading, computer work, video games — even television — should be limited until all symptoms have resolved. This typically takes 7 to 10 days, although some people have symptoms for weeks or months after the injury.

Once you are free of symptoms, you can gradually return to physical and mental activity. It is important to slowly return to daily activities because being symptom-free does not mean the brain injury has fully healed. Your doctor may recommend a step-by-step program: first add an activity, then monitor your symptoms. If your symptoms do not return, you can continue increasing the challenges.

This slow, steady approach typically reduces the time spent away from school, work, and athletics because it provides enough time for the injury to heal. Diving back into activities as soon as your symptoms have resolved can bring them back on and require a return to complete rest.

Return to Play

Getting back into the game too soon puts you at risk for another concussion.

If you suffer a repeat concussion before your first concussion has healed, it may take much longer for your symptoms to resolve and you may have long-term problems, such as learning difficulties or chronic headaches. Although it rarely happens, repeat concussion can cause permanent brain damage and even death.

New Recommendations

In 2010, the American Academy of Pediatrics recommended that young athletes with concussions be evaluated and cleared by a doctor before returning to sports. The American Academy of Neurology issued a similar statement, and stressed that doctors who clear athletes for return to sports should be trained in managing and assessing sports concussions.

Baseline Evaluations

Because it is difficult to determine when a concussion has fully healed, baseline neurocognitive evaluation is an important tool for assessing whether it is safe for an athlete to return to play. Before the sports season starts, each athlete takes a computerized test that measures brain functions, such as memory and reaction time. If an athlete later has a concussion, post-injury tests can be compared to the baseline evaluation to measure the severity of the concussion and help doctors monitor healing.

In addition, pre-season evaluations can help identify athletes who have had previous, unrecognized concussions and who are at risk for repeat concussions. For example, past injuries to the face or neck may have been accompanied by an unrecognized concussion.

Prevention

Although injury prevention begins with proper equipment, there is no such thing as a concussion-proof helmet or mouthguard.

Young athletes must be trained in safe sports technique and to follow the rules of the game. In addition, rule changes should be considered in sports where force is delivered head first. This not only promotes fair play, but also protects both participants.

In order to get back into the game, most athletes will downplay their symptoms. Understanding the long lasting consequences of repeat concussion is an important part of prevention. Several medical and sports organizations have recently developed concussion awareness programs for athletes, coaches, and parents. These educational programs play a critical role in helping to recognize concussions and prevent repeat injury.

ICE v. HEAT

Many people have this question when coming in for therapy - which is better for my injury, specifically - ice or heat? 

The truth is, neither have the research behind them proving that they do much good, longterm. Regardless of whether you ice, your injury will still swell immediately, and regardless of whether you use heat, your chronic pain will return.  Neither are permanent solutions to the underlying problems, but they can, however, be used as short term solutions to help minimize pain. Ice will partially numb a painful area, whereas heat will partially relax the muscles surrounding or leading to pain in a specific area. 

The scientific community still debates on the validity of information reporting that ice and heat will change anything or improve the status of your injury, but heres the deal: it usually doesn't hurt to try.

Below are some simple guidelines, the recommended do's and don't's as far as what injury you  have and whether or not you should ice or heat. Ice is for injuries, and heat is for muscles - in most cases.

Ice is for injuries — calming down damaged superficial tissues that are inflamed, red, hot and swollen. The inflammatory process is a healthy, normal, natural process … that also happens to be incredibly painful and biologically stubborn. Icing is mostly just a mild, drugless way of dulling the pain of inflammation. Examples would include a recently torn ACL, a knee or ankle that hurts from walking in heels all day, or a rolled/strained joint. 

Heat is for muscles, chronic pain, and stress — taking the edge off the pain of whole muscle spasms and trigger points, or conditions that are often dominated by them, like back pain and neck pain), for soothing the nervous system and the mind (stress and fear are major factors in many chronic pain problems, of course).

What are Ice/Heat NOT for?

Heat can make inflammation worse, and ice can make muscle tension and spasms worse, so they have the potential to do some mild harm when mixed up.

Both ice and heat are pointless or worse when unwanted: icing when you’re already shivering, or heating when you’re already sweating. The brain may interpret an excess of either one as a threat — and when brains think there’s a threat, the pain will likely increase. 

But heat and inflammation are a particularly bad combination. If you add heat to an fresh injury, watch out: it’s likely going to get worse. Pain and swelling will double, as the heat dilates the arteries, increasing blood flow to the area.  As inflammation/swelling occurs as the body's natural defense to protect the injured area, the increase of blood from arterial dilation will therefore, increase swelling. 

If you ice painful muscles, be careful: it might get worse! Ice can aggravate sensations of muscle pain and stiffness, which are often present in low back and neck pain. Trigger points (painfully sensitive spots) can be surprisingly intense and easily mistaken for “iceable” injury and inflammation. But if you ice trigger points, they may burn and ache even more acutely. This mistake is made particularly often with low back pain and neck pain — the very condition people often try to treat with ice. If in doubt, please see the links below in the “More information” section.

What about an injured muscle?

If you’re supposed to ice injuries, but not muscle pain, what do you with injured muscles (a muscle tear or muscle strain)? That can be a tough call, but ice usually wins — but only for the first few days at most, and only if it really is a true muscle injury. A true muscle injury usually involves obvious trauma during intense effort, causing severe pain suddenly. An example would be an achilles tendon rupture in the calf, or a biceps tendon rupture in the arm. In these cases, ice is going to be your best bet.  After surgical repairs or intense therapy in the case of a partial tear, you'll likely continue with ice to help decrease the swelling and numb some of the pain until you're further along in therapy to where the muscle is cramping.  For an achilles tendon rupture and repair, that'll likely be as far as 4-5 months out from the date of the initial injury. If the muscle is truly torn, then use ice to take the edge off the inflammation at first. Once the worst is over, switch to heat.

Which is better?

Ice packs and heating pads are not especially powerful medicine: some experiments have shown that both have only mild benefits, but sometimes, any little bit helps.