DOES BAD POSTURE = BACK PAIN?

First thing's first:

Bad posture does not necessarily imply back pain.  Some people are naturally born with protracted, rounded shoulders, hyperlordosis, or hyperkyphosis (excessive curvatures) of the spine. When this happens, the body makes adjustments to accommodate the forces that act on it during daily activities, such as sitting, standing, and lying down. 

Next question:

Without any physical limitations or deficiencies, however, bad posture being correlated with back pain brings a question similar to that of "what came first - the chicken or the egg?"  You must decide which scenario better fits your situation.

Back pain can cause a negative shift in posture to accommodate and relieve the pain - back pain comes first.

OR

Poor posture, including slouching, rounded shoulders, head and neck, cause increased stress on the muscles of the back, causing pain. 

Thirdly:

Bad posture, without any anatomical limiting factors, is typically caused tightness of certain muscles, mixed with weakness of others.  In addition to muscular deficiencies, there are likely going to be some joints that are misaligned within the spine.

Let's start with the muscles.

A mixture between hip flexor tightness and pectoral tightness, along with scapular weakness and core weakness are 8/10 musculoskeletal cause of poor posture.

Tightness in these areas are more likely to come from more stagnant lifestyles; which doesn't necessarily mean sedentary, more along the lines of many activities may cause similar positions. 

For example: a business man who works a desk job is also an avid cyclist. Sitting in a desk chair all day, then cycling many miles in a hunched position, then come home to eat dinner seated, unwind seated, would mean their lifestyle is positionally stagnant. 

In other words, you may be an active person living an decently active lifestyle, but if you sit and think about it, many of the activities you partake in involve the same anatomical positions. Keep in mind, some are more prone to problems related to this than others. 

Misaligned Joints:

Almost every single muscle of the body inserts onto a bone. Keep in mind, your skeleton is simply a lever system controlled by the muscles. Your bones don't move, your muscles pull on your bones to make them move. 

So with that in mind, picture a person with half of their muscles tight, and half of their muscles weak. All of those tight muscles are pulling hard on their bony insertion points, and when their muscular counterparts are too weak to keep the bones in place, the joints will become misaligned. This can cause over-stretching of the weaker muscles, and nerves to get pinched underneath the tighter muscles.

Ergo, how bad posture can lead to back pain. 

Lastly: 

How do you naturally combat this?

1. Ensure good joint alignment.

When you bend down to put a dish away, make sure you lower your body with your legs, and activate those glutes.  They're relatively speaking to strength, some of the most influential muscles in your body. Keep your knees over your ankles, and shoulders over your knees when squatting down.

2. Ensure good core activation.

Make sure when lowering your own body down into a squat, picking/lifting any objects, and even sitting and standing, that you are keeping your core tight. Not sure what this means? Lay down on your back, look down at your belly button. Next, find your hip bones - these mark the start of the front of your thighs. Place two fingers just on the inside of each of those hip bones and say "SSS" short and quick.  Feel that contraction? That's your core. Keep it contracted. The stronger it is, the less back pain you'll have. 

3.  Work on your movement.

Be very aware of the movements you perform on a daily basis that cause pain or discomfort. Your physical therapist will want to know, and they'll give you exercises to relieve the tension on some muscles, and to strengthen others. 

4.  Vary your posture. 

Mix it up! Sit at a desk 8 hours per day? Stand every couple.  It's best for brain function to take a 5 minute break every hour, and it's best for musculoskeletal function to change positions every 20 minutes or so.  This does not mean sitting to standing, maybe just sitting back in your chair to sitting forward with your hands or elbows on your desk. Most people slouch in their chairs without even noticing, so make sure to adjust your position frequently if you plan to stay seated throughout most of your day. Another option that helps from slouching is avoiding using the backrest of the chair. 

Questions? Call or set up an appointment with our wonderful staff - we're all specialized in problems such as this!

LATERAL EPICONDYLITIS (TENNIS ELBOW)

Tennis elbow, or lateral epicondylitis, is a painful condition of the elbow caused by overuse. Not surprisingly, playing tennis or other racquet sports can cause this condition. However, several other sports and activities can also put you at risk.

Tennis elbow is an inflammation of the tendons that join the forearm muscles on the outside of the elbow. The forearm muscles and tendons become damaged from overuse — repeating the same motions again and again. This leads to pain and tenderness on the outside of the elbow.

There are many treatment options for tennis elbow. In most cases, treatment involves a team approach. Primary doctors, physical therapists, and, in some cases, surgeons work together to provide the most effective care.

Anatomy

Your elbow joint is a joint made up of three bones: your upper arm bone (humerus) and the two bones in your forearm (radius and ulna). There are bony bumps at the bottom of the humerus called epicondyles. The bony bump on the outside (lateral side) of the elbow is called the lateral epicondyle.

Muscles, ligaments, and tendons hold the elbow joint together.

Lateral epicondylitis, or tennis elbow, involves the muscles and tendons of your forearm. Your forearm muscles extend your wrist and fingers. Your forearm tendons — often called extensors — attach the muscles to bone. They attach on the lateral epicondyle. The tendon usually involved in tennis elbow is called the Extensor Carpi Radialis Brevis (ECRB).

Cause

Overuse

Recent studies show that tennis elbow is often due to damage to a specific forearm muscle. The extensor carpi radialis brevis (ECRB) muscle helps stabilize the wrist when the elbow is straight. This occurs during a tennis groundstroke, for example. When the ECRB is weakened from overuse, microscopic tears form in the tendon where it attaches to the lateral epicondyle. This leads to inflammation and pain.

The ECRB may also be at increased risk for damage because of its position. As the elbow bends and straightens, the muscle rubs against bony bumps. This can cause gradual wear and tear of the muscle over time.

Activities

Athletes are not the only people who get tennis elbow. Many people with tennis elbow participate in work or recreational activities that require repetitive and vigorous use of the forearm muscle.

Painters, plumbers, and carpenters are particularly prone to developing tennis elbow. Studies have shown that auto workers, cooks, and even butchers get tennis elbow more often than the rest of the population. It is thought that the repetition and weight lifting required in these occupations leads to injury.

Age

Most people who get tennis elbow are between the ages of 30 and 50, although anyone can get tennis elbow if they have the risk factors. In racquet sports like tennis, improper stroke technique and improper equipment may be risk factors.

Lateral epicondylitis can occur without any recognized repetitive injury. This occurence is called "insidious" or of an unknown cause.

Symptoms

The symptoms of tennis elbow develop gradually. In most cases, the pain begins as mild and slowly worsens over weeks and months. There is usually no specific injury associated with the start of symptoms.

Common signs and symptoms of tennis elbow include:

• Pain or burning on the outer part of your elbow
• Weak grip strength

The symptoms are often worsened with forearm activity, such as holding a racquet, turning a wrench, or shaking hands. Your dominant arm is most often affected; however both arms can be affected.

Doctor Examination

Your doctor will consider many factors in making a diagnosis. These include how your symptoms developed, any occupational risk factors, and recreational sports participation.

Your doctor will talk to you about what activities cause symptoms and where on your arm the symptoms occur. Be sure to tell your doctor if you have ever injured your elbow. If you have a history of rheumatoid arthritis or nerve disease, tell your doctor.

During the examination, your doctor will use a variety of tests to pinpoint the diagnosis. For example, your doctor may ask you to try to straighten your wrist and fingers against resistance with your arm fully straight to see if this causes pain. If the tests are positive, it tells your doctor that those muscles may not be healthy.

Tests

Your doctor may recommend additional tests to rule out other causes of your problem.

• X-rays. These tests provide clear images of dense structures like bone. They may be taken to rule out arthritis of the elbow.
• Magnetic resonance imaging (MRI) scan. If your doctor thinks your symptoms are related to a neck problem, an MRI scan may be ordered. MRIs scans show details of soft tissues, and will help your doctor see if you have a possible herniated disk or arthritis in your neck. Both of these conditions often produce arm pain.
• Electromyography (EMG). Your doctor may order an EMG to rule out nerve compression. Many nerves travel around the elbow, and the symptoms of nerve compression are similar to those of tennis elbow.

Treatment

Nonsurgical Treatment

Approximately 80% to 95% of patients have success with nonsurgical treatment.

Rest. The first step toward recovery is to give your arm proper rest. This means that you will have to stop participation in sports or heavy work activities for several weeks.

Non-steroidal anti-inflammatory medicines. Drugs like aspirin or ibuprofen reduce pain and swelling.

Equipment check. If you participate in a racquet sport, your doctor may encourage you to have your equipment checked for proper fit. Stiffer racquets and looser-strung racquets often can reduce the stress on the forearm, which means that the forearm muscles do not have to work as hard. If you use an oversized racquet, changing to a smaller head may help prevent symptoms from recurring.

Physical therapy. Specific exercises are helpful for strengthening the muscles of the forearm. Your therapist may also perform ultrasound, ice massage, or muscle-stimulating techniques to improve muscle healing.

Brace. Using a brace centered over the back of your forearm may also help relieve symptoms of tennis elbow. This can reduce symptoms by resting the muscles and tendons.

Steroid injections. Steroids, such as cortisone, are very effective anti-inflammatory medicines. Your doctor may decide to inject your damaged muscle with a steroid to relieve your symptoms.

Extracorporeal shock wave therapy. Shock wave therapy sends sound waves to the elbow. These sound waves create "microtrauma" that promote the body's natural healing processes. Shock wave therapy is considered experimental by many doctors, but some sources show it can be effective.

Surgical Treatment

If your symptoms do not respond after 6 to 12 months of nonsurgical treatments, your doctor may recommend surgery.

Most surgical procedures for tennis elbow involve removing diseased muscle and reattaching healthy muscle back to bone.

The right surgical approach for you will depend on a range of factors. These include the scope of your injury, your general health, and your personal needs. Talk with your doctor about the options. Discuss the results your doctor has had, and any risks associated with each procedure.

Open surgery. The most common approach to tennis elbow repair is open surgery. This involves making an incision over the elbow.

Open surgery is usually performed as an outpatient surgery. It rarely requires an overnight stay at the hospital.

Arthroscopic surgery. Tennis elbow can also be repaired using miniature instruments and small incisions. Like open surgery, this is a same-day or outpatient procedure.

Surgical risks. As with any surgery, there are risks with tennis elbow surgery. The most common things to consider include:

• Infection
• Nerve and blood vessel damage
• Possible prolonged rehabilitation
• Loss of strength
• Loss of flexibility
• The need for further surgery

Rehabilitation. Following surgery, your arm may be immobilized temporarily with a splint. About 1 week later, the sutures and splint are removed.

After the splint is removed, exercises are started to stretch the elbow and restore flexibility. Light, gradual strengthening exercises are started about 2 months after surgery.

Your doctor will tell you when you can return to athletic activity. This is usually 4 to 6 months after surgery. Tennis elbow surgery is considered successful in 80% to 90% of patients. However, it is not uncommon to see a loss of strength.

New Developments

Platelet-rich plasma (PRP) is currently being investigated for its effectiveness in speeding the healing of a variety of tendon injuries. PRP is a preparation developed from a patient's own blood. It contains a high concentration of proteins called growth factors that are very important in the healing of injuries.

Current research on PRP and lateral epicondylitis is very promising. A few treatment centers across the country are incorporating PRP injections into the nonsurgical treatment regimen for lateral epicondylitis. However, this method is still under investigation and more research is necessary to fully prove PRP's effectiveness.

GROWTH PLATE FRACTURES

The bones of children and adults share many of the same risks for injury. But because they are still growing, a child's bones are also subject to a unique injury called a growth plate fracture. Growth plates are areas of cartilage located near the ends of bones. Because they are the last portion of a child's bones to harden (ossify), growth plates are particularly vulnerable to fracture.

Approximately 15% to 30% of all childhood fractures are growth plate fractures. Because the growth plate helps determine the future length and shape of the mature bone, this type of fracture requires prompt attention. If not treated properly, it could result in a limb that is crooked or unequal in length when compared to its opposite limb. Fortunately, serious problems are rare. With proper treatment, most growth plate fractures heal without complications.

Anatomy

Growth plates are found in the long bones of the body—the bones that are longer than they are wide. Examples of long bones include the femur (thighbone), the radius and ulna in the forearm, as well as the metacarpal bones in the hands.

Most long bones in the body have at least two growth plates, including one at each end. Growth plates are located between the widened part of the shaft of the bone (the metaphysis) and the end of the bone (the epiphysis). The long bones of the body do not grow from the center outward. Instead, growth occurs at each end of the bone around the growth plate. When a child is fully grown, the growth plates harden into solid bone.

This diagram of a femur (thighbone) shows the location of the growth plates at both ends of the bone.

Reproduced with permission from Sullivan JA: Introduction to the Musculoskeletal System, In Sullivan JA, Anderson SJ (eds): Care of the Young Athlete, Rosemont, IL, American Academy of Orthopaedic Surgeons and American Academy of Pediatrics, 2000, pp 243-258.

Description

Most growth plate fractures occur in the long bones of the fingers. They are also common in the outer bone of the forearm (radius) and lower bones of the leg (the tibia and fibula).

Classification of Growth Plate Fractures

Several classification systems have been developed that categorize the different types of growth plate fractures. Perhaps the most widely used by doctors is the Salter-Harris system, described below.

Type I Fractures

These fractures break through the bone at the growth plate, separating the bone end from the bone shaft and completely disrupting the growth plate.

Type II Fractures

These fractures break through part of the bone at the growth plate and crack through the bone shaft, as well. This is the most common type of growth plate fracture.

Type III Fractures

These fractures cross through a portion of the growth plate and break off a piece of the bone end. This type of fracture is more common in older children.

Type IV Fractures

These fractures break through the bone shaft, the growth plate, and the end of the bone.

Type V Fractures

These fractures occur due to a crushing injury to the growth plate from a compression force. They are rare fractures.

Cause

Growth plate fractures are often caused by a single event, such as a fall or car accident. They can also occur gradually as a result of repetitive stress on the bone, which may occur when a child overtrains in a sports activity.

All children who are still growing are at risk for growth plate injuries, but there are certain factors that may make them more likely to occur:

• Growth plate fractures occur twice as often in boys as in girls, because girls finish growing earlier than boys.
• One-third of all growth plate fractures occur during participation in competitive sports such as football, basketball, or gymnastics.
• About 20% of all growth plate fractures occur during participation in recreational activities such as biking, sledding, skiing, or skateboarding.
• The incidence of growth plate fractures peaks in adolescence.

Symptoms

A growth plate fracture usually causes persistent or severe pain. Other common symptoms include:

• Visible deformity, such as a crooked appearance of the limb
• An inability to move or put pressure on the limb
• Swelling, warmth, and tenderness in the area around the end of the bone, near the joint

Doctor Examination

Because a child's bones heal quickly, a potential growth plate injury should be examined by a doctor as quickly as possible, ideally within 5 to 7 days. It is important that the bone receives the proper treatment before it begins to heal.

After discussing your child's symptoms and medical history, your doctor will perform a careful physical examination of the injured area.

Your doctor will likely order an x-ray to determine whether a growth plate fracture has occurred. X-rays provide clear images of dense structures, such as bone. If greater detail is needed, your doctor may order other diagnostic imaging tests that can better show the soft tissues, or a cross-sectional view of the injured area. These types of scans include magnetic resonance imaging (MRI) scans and computed tomography (CT) scans.

Treatment

Treatment for growth plate fractures depends on several factors, including:

• Which bone is injured
• The type of fracture
• How much the broken ends of the bone are out of alignment (displaced)
• The age and health of the child
• Any associated injuries

Nonsurgical Treatment

This Type III fracture of the thighbone (femur) goes through the growth plate and down into the knee joint. The fracture is fixed with screws. This restores normal joint alignment.

Many growth plate fractures can heal successfully when treated with immobilization: a cast is applied to the injured area and the child limits some types of activity.

Doctors most often use cast immobilization when the broken fragments of bone are not significantly out of place. A cast will protect the bones and hold them in proper position while they heal.

Surgical Treatment

If the bone fragments are displaced and the fracture is unstable, surgery may be necessary. The most common operation used to treat fractures is called open reduction and internal fixation.

During the procedure, the bone fragments are first repositioned into their normal alignment (called a reduction). The bones are then fixed into place with special implants like screws or wires, or by attaching metal plates to the outer surface of the bone.

A cast is often applied to protect and immobilize the injured area while it heals.

Complications

Although most growth plate fractures heal without any lasting effect, complications can occur.

Rarely, a bony bridge will form across the fracture line, stunting the growth of the bone or causing the bone to curve. If this occurs, your doctor may perform a procedure to remove the bony bar and insert fat or other materials to prevent it from reforming.

In other cases, a growth plate fracture may actually stimulate growth so that the injured bone ends up longer than its opposite, uninjured limb. If this occurs, surgery can help achieve a more even length.

Recovery

A child's bones heal quickly, but a growth plate fracture can still take several weeks to heal. If cast immobilization is used, the length of time the cast is worn will vary depending on the severity of the fracture.

After the bone heals, your doctor may recommend specific exercises to strengthen the muscles that support the injured area of bone and improve the range of motion of the joint.

Long-Term Outcomes

Growth plate fractures must be watched carefully to ensure proper long-term results. Regular follow-up visits to the doctor should continue for at least a year after the fracture to make sure that the growth plate is growing appropriately.

More complicated fractures, as well as fractures to the thighbone (femur) and shinbone (tibia), may require follow-up visits until the child reaches skeletal maturity.

ACL RECONSTRUCTIONS

ACL tears are beginning to get more and more prevalent in today's society.  Many people believe it's in regards to the athletes getting bigger and stronger, younger, and the duration a body must endure physical exhaustion between the start of a career and the end. Then there's the discussion of the shoes, and the courts changing from the old hardwoods to the new, more athletically-inclined sport courts, to the strength of the athletes becoming more sport specific and less functionally based.  For example, a dual-sport athlete who practices both sports year-round still may get winded from walking up a set of stairs, simply because this isn't a part of their routine. This would be considered a functional deficit. 

PREVALENCE

Between winter and spring are when most of our ACL tears come into the clinic, and that usually correlates with those sport-specific seasons. Why not during the fall, you ask?

1.  ACL tears are due to a non-contact injury 70% of the time;

Meaning 70% of the time, the ACL will tear without someone else crashing into the knee joint and causing a rupture due to outside forces.

2.  ACL tears are almost 3x more prevalent in women than in men;

This is due to a number of reasons, including anatomical additives, such as the Q angle (read up on our blog post titled Q Angle), bone structure, hormonal balance, and musculoskeletal relationship that differs between men and women. 

3.  Sport-specific seasons;

Looking at sport seasons in the Kansas City metro area, the fall has football, volleyball, cross country, Men's soccer, etc. which, except volleyball, all fall under the less-at-risk categories.  Football is a contact sport, where ACL tears are just over 2x less likely to occur during a contact sport, and are just over 3x less likely to happen to males - which also decreases the risk for men's soccer.  Distance runners are usually less likely to tear their ACL as compared to sprinters and short distance runners because their stride involves a lesser knee flexion stride, and the majority of the hits the ACL will take is while the knee is extended, or in a nonthreatening position in regards to the ACL. 

Once you get into the winter and spring, where men/women's basketball become the main focus, competitive volleyball takes off, baseball practices start, as does track and field and women's soccer, the risk increases as each of these sports have a higher risk of ACL tears than do those in the fall. 

THE TEAR

Now, ACL tears can either be partial or complete, and the typical orthopedic surgeon is going to perform some type of repair if the tear is >50% (where a complete tear is a 100% tear.) Many physicians will require pre-operational therapy to increase functional strength to help an athlete's chances in recovering successfully. This is dependent upon the athlete, but pre-operational therapy will likely last anywhere from 2-6 weeks. 

SURGERY

Surgical procedures are going to range from 45-180 minutes, depending on the type of reconstruction and the surgeon - and of course - whether or not there are any complications. The surgical risks are minimal, as risks decrease with age and overall health. Since usually these ACL tears are more prevalent with athletes, they are typically younger in age and in excellent health. 

The surgical procedure chosen between the patient and their surgical team is likely to differ based on the surgeon, and the patient's condition. 

For example, we currently have a patient, who is also a close friend of our staff, who is here recovering from his third ACL rupture. This is the second tear on the knee he's currently working on, so the procedure chosen was going to be a different approach than the first. 

TYPES

Allograft v. Autograft

An autograft is going to be harvesting the necessary portion of the tendon and using the host as a donor. In other terms, the hamstring graft will be harvested from the patient the ACL reconstruction is being performed on - or using their own hamstring tendon.  

An allograft is harvesting a portion of the hamstring tendon from a separate, nonliving donor, or a cadaver. 

Allograft repairs have a lesser recovery time, as only the knee joint and ACL have to heal, whereas an autograft would likely be slightly more painful, as well as take longer to heal.  Allografts, however, have had recent research come out that states the likelihood of a second rupture is increased by almost 60% in comparison to an autograft tear. The reason behind this is usually because the body recognizes the new ACL as it's own, and therefore, heals faster. 

Hamstring Graft

There are 4 hamstring muscles on the back side of the thigh. Their primary function is going to be flexion (bending) at the knee, and extension at the hip, and they insert on the knee joint via a tendon, on both sides. A surgeon would take a portion of one of these hamstring tendons, typically the semitendinosus for increased stability and recreate an ACL with that graft.  Doubling over the tendon by folding it in half is proven to increase tensile strength, but does require harvesting a larger portion of the tendon, but is associated with greater range of motion discrepancies, as well as a slower recovery. 

BTB Patellar Graft

A BTB, or Bone-Tendon-Bone, Patellar Graft would be taking a portion of the patellar tendon, as well as portions of the bony attachments. The patellar tendon is the distal half of the quadriceps tendon. The quadriceps, more commonly known as the "quads", are a group of 4 muscles on the front of thigh that extend (straighten) the knee, and assist to flex the hip (i.e. doing high knees). The insert on a common tendon, the quadriceps tendon, and head distally. This tendon envelopes the patella, or the knee cap, a sesamoid bone that is otherwise not attached to the body. Distal to the patella, the quadriceps tendon now becomes the patellar tendon before inserting on the shin bone.  This portion of the quadriceps tendon will be the graft.  Bone-tendon-bone means the surgeon will not only harvest the middle 1/3 of the patellar tendon, but will also harvest small pieces of the patella and shin bone to serve as bony attachments to enhance recovery, as the small pieces of the bone will start to regrow into the bone they're going to be surgically attached to. 

Hamstring v. Patellar Tendon

Both surgical procedures have a 90-95% success rate, meaning the likelihood of a second rupture is only around 5-10%. Done correctly and given no extraneous circumstances, either option is going to be enough to get back to doing what you love.  Hamstring repairs are now done in Kansas City entirely arthroscopically, meaning the incisions are going to be very minimal - and recovery is faster, and less painful because the incisions will heal before the patient is out of the post-surgical brace. Patellar tendon repairs, however, are typically a little stronger, but take longer to recover from. The incision is typically about 4 inches long, which will take weeks to heal properly - potentially even after the post-surgical brace is removed. 

When an athlete decides, it will be up to them to choose a surgeon to will give them the best chance of a successful surgery, whilst limiting them to as little time as possible out of the game. Hamstring tendon repairs typically get patients back to doing what they love a little faster, by maybe a few weeks, but do come with a slightly higher risk, inching closer to that 90% success rate, respectfully, compared to the impressive 95% success rate of the patellar tendon repair. Both will take around 6 months to be cleared from therapy and return to sports, and will take around 12 months for the patient to feel back to 100%.  Surgeons will likely recommend athletes wear an ACL supporting brace, but are worn at the discretion of the athlete. 

EXERCISING WHILE PREGNANT: SAFETY, BENEFITS, & GUIDELINES

Exercising While Pregnant: Safety, Benefits & Guidelines

There are usually many questions that come to mind when planning how to exercise during pregnancy. Physical exercise is bodily activity that improves or maintains physical fitness and overall health and wellness. This type of exercise during pregnancy is important and can help with some common discomforts of pregnancy and even help prepare your body for labor and delivery.

Is exercise during pregnancy safe?

Overall and in most cases, exercise is safe during pregnancy. You will usually find it is even recommended. Typically, the first rule of thumb is if you were physically active before you were pregnant, it is likely safe to remain active during pregnancy. More than likely, your healthcare provider will tell you to remain active, as long as it is comfortable and there are no other health conditions suggesting otherwise.

Find a Prenatal Exercise Class in your area

Now is not the time to exercise for weight loss, however, proper exercise during pregnancy will likely help with weight loss after the delivery of your baby. Exercise does not put you at risk for miscarriage in a normal pregnancy. You should consult with your health care provider before starting any new exercise routine. We have more information at exercise warning signs.

What are the benefits of exercise during pregnancy?

Exercising for 30 minutes on most, or all, days can benefit your health during pregnancy. Exercising for just 20 minutes, 3 or 4 days a week, is still beneficial, as well. The important thing is to be active and get your blood flowing.

To have success in completing exercises during pregnancy, it is a good idea to plan the days and times during the week when you will exercise. As shown in the photo above, prenatal yoga is a great, low impact exercise that can be highly beneficial for pregnant women.

Here are some of the benefits from exercise during pregnancy you may experience:

• Helps reduce backaches, constipation, bloating, and swelling
• May help prevent, or treat, gestational diabetes
• Increases your energy
• Improves your mood
• Improves your posture
• Promotes muscle tone, strength, and endurance
• Helps you sleep better
• Regular activity also helps keep you fit during pregnancy and may improve your ability to cope with labor. This will make it easier for you to get back in shape after your baby is born.

You can visit this page for more information about the effects of exercise on pregnancy.

Guidelines for choosing an exercise during pregnancy

If you participated in a regular exercise activity prior to becoming pregnant, it is probably fine to continue to participate during your pregnancy. There are many exercises that are safe to do during your pregnancy, but it is important not to overdo it and to use caution.

Many people were uneasy when they discovered that Olympic volleyball player Kerri Walsh Jennings had received the “OK” from her obstetrician to play competitive volleyball while pregnant. The American Pregnancy Association would have cautioned against this because of the vulnerability of impact with another player, the ground, or parts of the surrounding court area. However, it is important to highlight a key truth in the counsel her healthcare provider gave.

Your baby is surrounded by fluid in the amniotic sac, which is nestled inside the uterus, which is surrounded by the organs, muscles and your physical body. This actually creates a rather safe environment for your developing baby. However, even with this protection, it is recommended you avoid high-impact exercise .

You will probably want to avoid these types of exercises during pregnancy:

• Activities where falling is more likely
• Exercise that may cause any abdominal trauma, including activities that with jarring motions, contact sports or rapid changes in direction
• Activities that require extensive jumping, hopping, skipping, or bouncing
• Bouncing while stretching
• Waist twisting movements while standing
• Intense bursts of exercise followed by long periods of no activity
• Exercise in hot, humid weather
• Do not hold your breath for an extended period of time
• Do not exercise to the point of exhaustion

You may want to include these basic guidelines in planning exercise during pregnancy:

• Be sure to wear loose fitting, comfortable clothes, as well as, a good supportive bra.
• Choose well-fitting shoes that are designed for the type of exercise you are doing.
• Exercise on a flat, level surface to prevent injury.
• Eat enough healthy calories to meet the needs of your pregnancy, as well as, your exercise program.
• Finish eating at least one hour before exercising, see also pregnancy nutrition.
• Drink plenty of water before, during and after your workout.
• After doing floor exercises, get up slowly and gradually to prevent dizziness.

Which exercises during pregnancy are beneficial

Before you begin exercising, remember it is important to talk to your health care provider. If you typically get little or no activity, walking is a great exercise to start with. Walking is usually safe for everyone, it is easy on your body and joints, and it doesn’t require extra equipment. It is also easy to fit into a busy schedule.

Squatting during labor may help open your pelvic outlet to help your baby descend, so practice squatting during pregnancy. To do a squat, stand with feet shoulder width apart and slowly lower into a squat position. You should keep your back straight, heels on the floor and your knees shouldn’t protrude in front of your feet. Hold the squat for 10 to 30 seconds; you can rest your hands on your knees.

Then slowly stand back up, pushing up from your knees with your arms, if you need to. Repeat this 5 times working up to more.

Pelvic tilts strengthen the muscles in your abdomen and help alleviate back pain during pregnancy and labor. To do pelvic tilts get on your hands and knees. Tilt your hips forward and pull your abdomen in. Your back should slightly round. Stay in this position for a few seconds then relax without letting your back sag. Repeat a couple of times, working up to 10.

Body changes that affect exercise during pregnancy

There are many changes happening in your body during pregnancy.  First, joints are more flexible from the hormones which cause certain muscles to relax during pregnancy.  Your center of gravity or equilibrium is shifted from the extra weight in the front, as well as, your shifting hips.

This can affect your balance as you near your due date. The extra weight will also cause your body to work harder than before you were pregnant.

All of these factors may affect how you exercise and what exercises you choose to do.  Remember, it is always recommended you consult your healthcare provider about exercises for your specific situation.

DO'S OF THE GYM

As far as Do's go, they'll be different for everyone so we're going to give you some tips as to how to make your workout as efficient, and beneficial for your body as possible.

Fat Loss

Many people are going to tone their body differently - but the first thing you'll want to do is increase your fat loss during your workouts. The way to do this is to position your heart rate at such a pace that your body is maximally efficient at breaking down grams of fat. One gram of fat is equivalent to 9 kcals, whereas one gram of carbs or protein is only equivalent to 4 kcals. This is why it's so much easier for your body to burn through sugars and carbs, as it takes more energy (comes out in the form of heat, as a kcal - the reason your body temperature increases) to burn through fat. 

1. Your heart rate should be anywhere from 55-65% your MAX HR* to spark fat loss, 
2. Your workouts should last anywhere from 45 - 60 minutes per day, 
3. Your workouts should span on average for 4-5 days per week, for best results,
4. Circuit training or interval training works best. 

Toning

First thing you'll want to do is increase your fat calorie loss, by aiming for your workouts to stay, on average, within that fat - loss HR zone. Most of the time people assume doing 1,000 abs per day is going to give you a "6-pack" and that's not the case. If you do any kind of consistent workout whatsoever, you likely have toned muscles underneath a layer of adipose tissue (fat). This isn't saying you're fat by any means, most people have it - especially women. Increasing your fat calorie loss will help.  The case is the same for all those thigh machines - no amount of pushing those leg holsters in is going to give you a thigh gap - it comes from fat calorie burning. A couple tips include:

1. Walk-run intervals on the treadmill,
2. Multi-joint weight lifting as opposed to isolated weight lifting,
3. Mixing up your workouts to keep your body on it's toes.

Multi-joint weight lifting would be considered doing squats, lunges, or deadlifts as opposed to using machines to isolate certain groups of muscles.  Not only does this increase your hormonal and metabolic responses, both short and long term, but increases the efficiency at which you're toning and strengthening. 

Know What You're Doing With Weights

It is a common mistake to believe that high weight/low rep weight lifting is going to be the best for you to burn calories and tone; this isn't necessarily the case. 

1. Development of Muscles/Power: High weight/low repetitions

Power: Amount of force you are able to act on relative to your body weight and the rate you can move it at, or in other words, how much weight you lift and how fast you lift it

2. Joint Strength/Stability, Toning: Low weight/high repetitions

Joint Stability: the muscles surrounding a joint capsule are all strengthened equally to provide balance and support

Developing your muscles and power is going to increase your body weight by increasing your lean muscle mass, whereas joint stability and toning is going to increase your lean muscle mass slightly, but is also performed at a HR that falls within the fat-loss zone.  When done correctly, major lifts performed for power should increase the HR near it's maximum, or within the performance zone.  Performance zone is anywhere from 80 - 100% of your MAX HR. 

Body Weight

Your body weight is going to be just as efficient as machines, if not even more so. If you don't have time to run to the gym during the day for whatever reason, I'd suggest doing a circuit of body weight strengthening and agility movements. Something along the lines of:

30 seconds high knees, as fast as you can
10 military-style push-ups
30 seconds butt kicks, as fast as you can
20 squats
30 seconds jog in place

2 minute break

30 seconds high knees, as fast as you can
10 squat jumps
30 seconds jog in place
30 seconds plank, arms extended
20 squats
10 scissor jump lunges, per leg
30 seconds high knees, as fast as you can

2 minute break

30 seconds high knees, as fast as you can
30 squats
30 seconds wall-sits
10 military-style push ups
30 seconds jog in place

3x through, but take your time with the strengthening exercises (squats, pushups, etc.) to help decrease your HR while strengthening. Increase sets over time as you get more confident in the workout. NOTE: the breaks are just as important as the actual exercise. Take that time to get some water, and catch your breath. They're important because they decrease your HR, and these decreases in HR ensure that your average HR for the entirety of the workout stays within that fat burning zone. 

*Make sure to talk to your doctor or physical therapist before engaging in any exercise more engaging than your body is used to, as they could increase symptoms of an underlying issue, such as heart problems, or blood pressure. 

DIRECT ACCESS V. SELF PAY

We've recently had a number of patients inquire about the new laws regarding Direct Access v. Self-pay. Within the last couple of years, the law has changed for the State of Kansas concerning the necessity for a physician's prescription to begin physical therapy. 

Direct Access is the ability for a patient to be treated by a physical therapist for muscle or joint pain without a prescription written and signed by their referring physician (primary care or orthopedic), while still being able to use their insurance plan for payment as opposed to paying the entirety out-of-pocket.

Direct Access is not available to certain insurance plans, including some from Cigna and Humana- OrthoNet, as well as government-issued Medicare, or medicare replacement plans via a private company (such as Humana-Medicare, Coventry Advantra, etc.) For further information regarding whether or not your insurance allows for Direct Access, please call the customer service line noted on your insurance card. 

Direct Access is also not available at most physical therapy clinics for those patients who are beginning therapy on a body part immediately following a surgical procedure on said body part. Following operations, patients have a specific set of guidelines they are required to follow, including treatment precautions that must be abided by to heal properly.  Without operation notes from the procedure and a written prescription, physical therapists do not have access to the information necessary to treat a patient without significantly increasing the risks to the patient and liability of the treating therapist.

Self-Pay is the ability to pay for your own physical therapy visits under a number of circumstances:

• When your insurance coverage has expired,
• When you have already used your annual allotted physical therapy sessions pre-determined by your insurance company or specific insurance plans, 
• When you need to save your allotted sessions for a pre-scheduled surgery later in the coverage period (many times Jan 1 - Dec 31).

For example: Some insurance plans only allow 25 or 40 covered physical therapy sessions per year. 

Self-pay still may require a prescription issued by the referring physician, dependent upon the insurance coverage a patient has. Again, for further information, contact your insurance company via the customer service line noted on your insurance card. 

GOT 5 REASONS WHY THE GYM ISN'T AN OPTION FOR YOU?

Give me your best shot - I've probably heard it all.  Everybody has reasons why they can't get to the gym, why something else takes precedence, why they hate exercise and working out.  Truth is: it's good for you. Any exercise, any improvements to your lifestyle can help you live a longer, healthier life with more energy and a better emotional state.

The trick is efficiency. Being efficient in your workout requires that you know what constraints you have, or what prevents you from getting exercise or to the gym in the first place.
Some examples would include:

• Limited time due to work or family
• An injury or chronic problem that makes exercise difficult or painful
• Inability to stay motivated on your own
• Financial Instability
• Lack of confidence

Time Constraints

Limited time is a problem almost everyone you see at the gym suffers from; whether it be work related and your hours don't condone a scheduled exercise routine (popular in the medical field), or family and the number of children you have running around your home. The thing is - you can always make time.  Whether it be a quick workout at home, getting up early to run to the gym, or arranging to let the kiddos stay at a friends in the afternoon and alternating with another family, it is possible. There are multiple gyms around the Kansas City area that are open 24 hours/day, or that offer classes as early as 5:30 in the morning, or as late as 8 at night. The benefits of exercise not only improve your physical health, but emotional, as well.  Exercise activates your body's "happy" hormone production, which can lead to overall reduced stress. Not to mention - parent's, I'm looking at you - we all know how impressionable kids can be. The more active you are, the more active your children will want to be, and they carry those traits with them throughout their entire lives. 

Injuries and Chronic Problems

Injuries can make it difficult to exercise when you've been able to do a number of different workouts for so long, and now are limited to a fair few. We'd suggest asking for a referral to an athletic trainer or personal trainer at your gym, or asking your physical therapist who they'd recommend to get you back to performing those higher level activities.  There are a number of ways to see the same results with different exercise routines, you just have to find them! 

Chronic problems such as arthritis can make exercise seem very, very painful. The trick is to know what aggravates those symptoms, and what doesn't. Activities such as swimming are wonderful for arthritis, as they release the pressure surround the joint cavities in the body. Other non-impactful exercise routines can give you the burst of cardio without the hard impact on the joints, such as elliptical or a stationary bike. It is beyond crucial that any exercise routine include strengthening, whether it be resistance-based or weight-based. Weight lifting, resistance band training, or yoga are great additives to a workout sculpted around arthritic joints because the stronger those muscles, the stronger they pull on their boney insertion points, which naturally gives the joint cavity a little more room to breathe. 

Motivation

Struggle to maintain motivation? Getting into a workout routine can be very, very difficult. It's hard to go expend so much energy to not see changes overnight; but there are things you can do to help improve your chances of success.

Firstly - any habit implementation takes 3 weeks or around 21 days for the brain to accept and change it's default settings. This essentially means the first 3 weeks are going to be the hardest to drag yourself to the gym, but if you can make it through the first 3 weeks, it'll get easier.  

Secondly - any habit implementation is easier when it can be added into your daily routine at a specific time, as opposed to random time selections throughout your day. For example, I take my daily vitamins each morning immediately after brushing my teeth. When I found out I needed to take an iron supplement because I was borderline anemic (low iron in the blood), I added my iron supplement to my daily vitamin - and presto! After the first few days, it was habit already to be taking two supplements every morning instead of one.  The same concept applies here. If you add going to the gym before or after work each morning, and packing your gym back each night while laying out your work clothes, you may be able to trick your brain into adjusting to the change a little bit faster. 

Lastly - the easiest way to hold yourself accountable is to enlist someone else to help do it with you.  For the first few weeks while you're adjusting to your schedule, set up appointments with a personal trainer, enroll in workout classes and PRE-PAY (no one likes to waste their money) or recruit a friend to workout with you who already works out consistently. Not only can they help you brainstorm ideas that may be more conducive to the exercise you're looking for, but having someone else hold you accountable helps a lot.

Financial Instability

We understand that money can get very tight, so gym memberships may take a backseat when you're already stretching your dollar to the end of the month.  As easy as it would be to tell you what you already know, to really take a hard look at your expenses and where your money is going, it's best that we stick to our area of expertise.  What we suggest you do is start doing some research on your own, but in the meantime, do your best to improve your lifestyle with the little things. Go for a walk while you eat your sandwich over lunch, walk your dog instead of just letting him out into the yard (and bring your kids!), take advantage of the timeframes your children have practice/school and go for a jog around the neighborhood, take the stairs! There are a number of small changes you can do to help you get used to the exercise and increase your overall energy.  Another option would be getting a single personal training session, and explaining your situation; that you'd like basically an info session on what you can do to get the same workout at home without all the equipment of a gym. Most gyms don't require that you be a member to have a single personal training session.

Lack of Confidence

Body Image

As a person who, at one point, really struggled with their body image, I can honestly tell you that now, sitting on the other side of it, no one is judging you.  Most people go to the gym, put their headphones on, and work up a sweat without caring who's on the next machine over - myself included. Consistent gym members go for a number of reasons, but to increase their self confidence by looking down upon others is definitely not one of them. Please don't forget - if you continue to hide, your body image will never change.  At some point, you need to stop caring whether or not someone looks at you - changing your lifestyle to improve the way you view yourself and your body has nothing to do with anybody else.  Not only can exercise improve your body image by helping you change your body, but exercise allows your brain to flood your body of hormones that induce good moods, a decrease in stress, and lessen anxiety. 

Lack of Knowledge

If you're self-conscious because you've never really been a gym-goer, and aren't sure what you're doing or how to work the equipment - ask the staff! You can either set up a personal training session at your local gym just for some general information on how everything works, or ask a specialist who's on the floor if you're interested in trying something you've never tried before. If you're less bold and would rather observe, sit down on a machine you do recognize, and watch someone else use the machine you're interested in. 

AC JOINT SEPARATION

Introduction

A shoulder separation is a fairly common injury, especially in certain sports. Most shoulder separations are actually injuries to the acromioclavicular (AC) joint. The AC joint is the connection between the acromion (a bony process) on the scapula (shoulder blade) and the clavicle (collarbone). Shoulder dislocations and AC joint separations are often mistaken for each other, but are not the same.  Surprisingly enough, I had a Grade II/III AC joint separation as a result of snowboarding accident in which my outstretched arm got caught when trying to prevent the fall.

This guide will help you understand:

• what the AC joint is
• what happens when the AC joint is separated
• how an AC joint separation is treated.

Anatomy

What is the AC joint, and how does it work?

The shoulder is made up of three bones: the scapula (shoulder blade), the humerus (upper arm bone), and the clavicle (collarbone).

The part of the scapula that makes up the top of the shoulder is called the acromion. The AC joint is where the acromion and the clavicle meet. Ligaments hold these two bones together.

Ligaments are soft tissue structures that connect bone to bone. The AC ligaments surround and support the AC joint. Together, they form the joint capsule. The joint capsule is a watertight sac that encloses the joint and the fluids that bathe the joint. Two other ligaments, the coracoclavicular ligaments, hold the clavicle down by attaching it to a bony knob on the scapula called the coracoid process.

AC joint separations are graded from mild to severe, depending on which ligaments are sprained or torn. The mildest type of injury is a simple sprain of the AC ligaments. Doctors call this a grade one injury. A grade two AC separation involves a tear of the AC ligaments and a sprain of the coracoclavicular ligaments. A complete tear of the AC ligaments and the coracoclavicular ligaments is a grade three AC separation. This injury results in the obvious bump on the shoulder.

Causes

How does AC joint separation happen?

The most common cause of an AC joint separation is falling on the shoulder. As the shoulder strikes the ground, the force from the fall pushes the scapula down. The collarbone, because it is attached to the rib cage, cannot move enough to follow the motion of the scapula. Something has to give. The result is that the ligaments around the AC joint begin to tear, separating (dislocating) the joint.

Symptoms

What symptoms does this condition cause?

Symptoms range from mild tenderness felt over the joint after a ligament sprain to the intense pain of a complete separation. Grade two and three separations can cause a considerable amount of swelling. Bruising may make the skin bluish several days after the injury. 

In grade three separations, you may feel a popping sensation due to shifting of the loose joint. Grade three separations usually cause a noticeable bump on the shoulder.

Diagnosis

What tests will my doctor run?

Your doctor will need to get information about your injury and a detailed medical history. You will need to answer questions about past injuries to your shoulder. You may be asked to rate your pain on a scale of one to 10.

Diagnosis is usually made by the physical examination. Your doctor may move and feel your sore joint. This may hurt, but it is very important that your doctor understand exactly where your joint hurts and what movements cause you pain. 

Your doctor may order X-rays. X-rays can show an AC joint disruption, and they may be necessary to rule out a fracture of the clavicle. In some cases, X-rays are taken while holding a weight in each hand to stress the joint and show how unstable it is.

Treatment

What treatment options are available?

Nonsurgical Treatment

Treatment for a grade one or grade two separation usually consists of pain medications and a short period of rest using a shoulder sling. Your rehabilitation program may be directed by a physical or occupational therapist.

The treatment of grade three AC separations is somewhat controversial. Many studies show no difference whether a person is treated with surgery or conservative treatment. Even with surgery, a bump may still be present where the separation occurred. And a significant portion of people who undergo surgery will need another operation later.

Several studies have looked at what happens to the AC joint after this injury. It appears that many people, whether they had the joint repaired surgically or not, will need an operation at some time in the future. The injured joint degenerates faster than normal. Over time it becomes arthritic and painful. This process may take years to develop, but sometimes it happens within one or two years.

If you don't need surgery, range-of-motion exercises should be started as pain eases, followed by a program of strengthening. At first, exercises are done with the arm kept below shoulder level. The program advances to include strength exercises for the rotator cuff and shoulder blade muscles. In most cases, the pain goes away almost completely within three weeks. Full recovery can take up to six weeks for grade two separations and up to 12 weeks for grade three separations. Since there is little danger of making the condition worse, you can usually do whatever activities you can tolerate.

Surgery

Some surgeons prefer to repair severe grade three AC separations, especially in high-level throwing athletes.

The surgery is usually done through a four-inch incision over the AC joint. The surgeon starts by putting the joint into its correct position. A screw or some other type of fixation may be used to hold the clavicle in place while the ligaments heal.

To fix the joint using a screw, the surgeon inserts the screw through the top of the clavicle and into the coracoid process.

Some surgeons use surgical tape to connect the clavicle and coracoid. A small drill hole is made in the clavicle and corocoid. The surgical tape is looped through each hole and pulled snugly.

In some cases, sutures are also used to repair and reinforce the torn coracoclavicular ligaments.

When a screw is used, it is usually removed six to eight weeks after the surgery. If it is not removed, the screw will probably break.

After Surgery

Your surgeon may have you wear a sling to support and protect the shoulder for a few days. A physical or occupational therapist will probably direct your recovery program. The first few therapy treatments will focus on controlling the pain and swelling from surgery. Ice and electrical stimulation treatments may help. Your therapist may also use massage and other types of hands-on treatments to ease muscle spasm and pain.

Therapists usually wait four weeks before starting range-of-motion exercises. You will probably begin with passive exercises. In passive exercises, the shoulder joint is moved, but your muscles stay relaxed. Your therapist gently moves your joint and gradually stretches your arm. You may be taught how to do passive exercises at home.

Active therapy starts six to eight weeks after surgery, giving the ligaments time to heal. Active range-of-motion exercises help you regain shoulder movement using your own muscle power. You might begin with light isometric strengthening exercises. These exercises work the muscles without straining the healing joint.

After about three months, you will start more active strengthening. Exercises will focus on improving strength and control of the rotator cuff muscles and the muscles around the shoulder blade. Your therapist will help you retrain these muscles to keep the ball of the humerus centered in the socket. This helps your shoulder move smoothly during all your activities.

Recovery from shoulder surgery can take some time. You will need to be patient and stick to your therapy program. Some of the exercises you'll do are designed get your shoulder working in ways that are similar to your work tasks and sport activities. Your therapist will help you find ways to do your tasks that don't put too much stress on your shoulder. Before your therapy sessions end, your therapist will teach you a number of ways to avoid future problems.

CAST AND DRESSING CARE

Cast Care Instructions 

Unless you have a waterproof cast, you should keep your cast dry. However, even waterproof casts should be dried out thoroughly after getting them wet. If you don't dry your cast out after getting it wet, the skin underneath stays damp and can become moldy and smelly. Also, don't swim with your cast on unless you have the waterproof kind. 

To keep your cast dry in the shower, you can enclose it in a plastic garbage bag. Tape the open end of the bag so that water can't get in. You can also buy a special cast protector.

Casts don't completely harden for about two days. Be especially careful with your cast during this time. Don't rest the full weight of the cast on a hard surface during these first two days. Doing so can dent the cast and can cause pressure sores on the skin under the cast. If the cast involves your foot, don't walk on it for forty-eight hours, even if you have what is known as a walking cast. Walking on a soft cast may cause it to crack or dent.

Keep the casted or splinted limb elevated (propped up) above the level of your heart when you're able to do so. This will reduce the swelling and help to keep the cast from becoming too tight.

Avoid too much activity and situations that may re-injure you or damage your cast. Remember your cast is there to help your arm or leg heal. It can't do its job without your cooperation.

Dressing Care

Following a surgical procedure, your surgeon and nursing staff will likely dress you prior to wheeling you into recovery. Until your next follow-up appointment where your surgeon will check on your sutures and swelling, your dressings will not be changed, and are not to be tampered with.  During these crucial few days, the sutures are going through the initial clotting and dermal regrowth phases, and keeping disturbance to a minimum is a requirement.  Your dressings are not to get wet, moved, or changed.  Do not add vaseline or lotion, or any other product around open wounds. 

At that initial follow-up appointment, you will likely either be cleared to shower, or be setting a date for a subsequent follow-up appointment that will determine when it is okay for you to shower and get your incision site wet. The reason it is important that you wait for clearance is because water from your shower is not sterile, and can force harmful bacteria into the open incision site. Dressings should be left alone for this same reason - they are sterile following surgery, and will no longer protect your incision site from bacteria once they are removed. 

Once you are cleared to shower, you will also be cleared to change your own dressings around your surgical incision sites. 

Changing a regular dressing over your incision

• Your doctor or nurse will tell you how to take care of your dressings.
  • Wash your hands before starting the dressing change.
  • Remove the old dressing by only touching the edges. Throw away the old dressing in the garbage.
  • Wash your hands again.
  • Open a sterile dressing package by holding the upper two edges of the package and pull sideways, rather than tearing the package open.
  • Keep the new dressing inside the sterile package until you are ready to put it over your incision.
  • Touch only the edges of the new dressing. Do not touch any part of the dressing that will be on the incision.
  • Tape all sides of the dressing securely.
  • Wash your hands when the new dressing is on.
• If there is a drainage tube, be sure to cover this area with the dressing.
• Follow any special instructions your doctor or nurse gives you.

Warning Signs

If you have any of the following warning signs after your cast is placed or changed, you should consult your doctor. 

Severe Pain

Your injury will probably cause some pain, but if the pain becomes steadily worse after the cast has been placed or changed, that may be a sign that the cast is too tight.

Bluish Nail beds

The area under the fingernails and toenails is called the nailbed. Normally the nailbeds are pink. When the nailbed is pinched and released, it turns white for a few seconds and then pink again. This is because small blood vessels under the nail are squeezed shut. When you release the pressure, the blood vessels quickly open back up, turning the nail bed pink once again. This is called blanching.If the nailbed has a blue color and doesn't turn pink again after being pinched and released, this may be a warning sign that the cast is too tight. 

Numbness or Tingling

You may feel some numbness after a broken bone has been straightened or fixed if any type of anesthesia (such as a regional block or local anesthesia) was used. This should wear off in a few hours. But if you feel constant numbness or tingling in the fingers or toes of the casted arm or leg, this may indicate that the cast is too tight or that a nerve has been injured.

Immobility of Fingers or Toes

Because of your injury, you may have pain that makes it difficult for you to move your fingers or toes. But if you have no ability to move the fingers or toes of the casted arm or leg, it may be a signal that the cast is too tight and the muscles or nerves aren't working properly.

Severe Coolness of Fingers or Toes

Many people notice a difference in the temperature of the casted arm or leg. Usually, this difference is minor. But if you have any other problems mentioned here that suggest that the circulation is not good, and the hand or foot is cool, it may be a sign that the cast is too tight.

Severe Swelling

If you have severe swelling above or below your cast, try keeping the casted limb propped up above the level of your heart. Most injuries cause at least some swelling. But if the swelling continues to get worse after the cast is put on, it may be either a sign that the cast is too tight or that something is going on under the cast that needs to be checked.

Dented or Cracked Cast

If your cast is dented or cracked, or starts falling apart before you are due for a checkup, this could lead to problems with healing. Small cracks are probably alright, but if the cast isn't doing what it is supposed to, it could affect the healing of the injury. You should also check with your doctor if you think the cast isn't holding the arm or leg still enough.