Return to Sport after ACL Reconstruction

Many people in Durango know someone who has had an anterior cruciate ligament (ACL) injury of their knee if they have been lucky enough to have not had one them self. Much of the time, these injuries end up needing a surgical reconstruction depending on the severity of the sprain or tear to the ligament. One of the most common questions that we hear after an ACL reconstruction is when returning to sport activities is safe. The surgeon will often give strong recommendations to wait as long as possible, especially depending on the type of sport that the individual is getting back into. This is especially true in sports that require any twisting or pivoting of the knee, such as soccer, skiing, and football. In general, most people don’t love hearing this and I have often encountered patients who push back into their sport fairly quickly. 

A recent study published in one of my favorite peer-reviewed PT journals, the Journal of Orthopaedic & Sports Physical Therapy (JOSPT), sought to find out what the implications are of returning to sport too soon.(1) The study specifically looked at young athletes (late teens to early and mid-20s) in regards to how quickly they returned to sport and how this impacted their rate of re-injury to the affected ACL.(1) Ultimately, this study found that “returning to knee-strenuous sport before ACL reconstruction was associated with an approximately 7-fold increased rate of sustaining a second ACL injury.”(1) “Knee-strenuous sports” included baseball, snowboarding, skiing, volleyball, basketball, football, soccer, and ice hockey” among others.

Something also very interesting that the researchers found was that the risk of re-injury was unaffected by whether or not the person achieved symmetrical muscle function or quadriceps muscle strength.(1) So, even if the person did everything they could to get strong and their strength of the surgical leg was equal to the non-surgical leg, they still had a significantly higher chance of reinjuring their ACL if they returned to sports before that 9 month mark.(1) The take away from all of this: if it is at all possible, you should WAIT to return to sport after an ACL reconstruction if you are a young athlete. Even though this study was not performed in older athletes, the argument may be made that this advice applies to them as well. If you have experienced an ACL injury and subsequent surgery and you want more information about when and how to safely return to sport, make sure you talk to your PT and surgeon about this timeframe. 

  1. Beischer S, Gustavsson L, et al. Young Athletes Who Return to Sport Before 9 Months After Anterior Cruciate Ligament Reconstruction Have a Rate of New Injury 7 Times That of Those Who Delay Return. J Orthop Sports Phys Ther 2020;50(2):83-90. doi:10.2519/jospt.2020.9071

Sleep and Its Relationship to Pain

I recently attended the annual American Academy of Orthopedic Manual Physical Therapy conference in Orlando, Florida, where I got to learn from a lot of leaders in the field of physical therapy on a variety of topics. One of the presentations that I was eager to attend was one regarding a topic that is very near and dear to my heart these days: the importance of sleep and how Physical Therapist’s play a role in discussing sleep with our patients!

The presenters did a great job outlining the role that sleep plays for our health, especially the relationship between sleep deprivation and increased risk of cardiovascular disease. Furthermore, and strongly related to what we deal with each day in physical therapy, the relationship between sleep and pain was discussed. There are multiple research studies performed in the past couple of decades attempting to find out the relationship between sleep and pain. For example, a 2015 study of over 10,000 participants found that impaired sleep (reports of insomnia more than once a week, sleep latency greater than one hour, or decreased sleep efficiency) was associated with increased pain sensitivity.(1) Another study that was published this year (2019) showed that baseline sleep disturbance negatively affects pain response to treatment of chronic pain, even with the use of opioid and nonopioid medications.(2) Things that qualified as “sleep disturbance” in this study included difficulty falling asleep and trouble staying asleep.(2)

Ultimately, the research shows that sleep- or rather, difficulty sleeping- has a relationship with multiple bodily functions, including our pain experience. For anyone who has experienced a poor night’s sleep (or experiences this frequently), this isn’t surprising news. The big question to ask is, “How can I improve my sleep?”. The presentation that I attended in October gave some great suggestions for better sleep hygiene:(3)

  • Consistent timing: plan to go to bed and wake up around the same time every day
  • Limit bedroom activity: the bedroom should be for sleep and intimacy only (not reading, work, watching TV, etc.)
  • Eliminate pre-bedtime stimulation
  • Try not to exercise within 2 hours of bedtime
  • Eliminate caffeine at least 4 hours before bedtime
  • Avoid large meals, spicy food, and liquid 2-3 hours before bedtime
  • Eliminate electronics at least 30 minutes before bedtime
  • Create a dark, cool environment
  • No sleeping pills
  • No naps
  • Refrain from alcohol 3-4 hours before bedtime

If you’re struggling with sleep, start by looking at this list of suggestions and identify areas where you currently do things differently. Think about one to two changes you can make in your pre-bedtime habits to start to work toward better sleep and, ultimately, better function. Remember to mention disturbed sleep to your health providers, including physical therapists, to get further individualized suggestions to help your sleep hygiene.

  1. Sivertsen B, Lallukka T, et al. Sleep and pain sensitivity in adults. Pain Journal. 2015;156:1433-1439.
  2. Koffel E, Katz AM, et al. Sleep Disturbance Predicts Less Improvement in Pain Outcomes: Secondary Analysis of the SPACE Randomized Clinical Trial. Pain Medicine. Doi: 10.1093/pm/pnz221
  3. Shepherd M, Dickerson C. Sleep Quality Assessment and Intervention in OMPT. American Academy of Orthopaedic Manual Physical Therapists Annual Conference. Orlando, FL. October 26, 2019.

PT First for Low Back Pain

You’ve heard the news: our country has an opioid epidemic. This history of this epidemic is not a pretty one, and it is one that our country is attempting to take steps toward fixing. From policy-makers trying to affect change via rules and regulations for prescribing providers to trying to get physical therapists included on national loan repayment programs for underserved and rural communities in our country, there are a lot of people putting their heads together to try and figure out how to solve this national problem. One such group of people is the American Physical Therapy Association, or APTA, that recently co-sponsored a very large study to assess the effects of which provider someone sees first for low back pain on the use of opioids both in the short- and long-term.

When I say very large, I mean it: the study analyzed more than 200,000 insurance claims from adults with a new onset of low back pain.(1) The researchers were looking to see if the type of provider seen at the initial visit (specifically primary care physicians versus PTs, chiropractors, or acupuncturists) affected the patient’s use of opioids either short-term (filled their prescription within 30 days of the initial visit) or long-term (filled their prescription within 60 days of the initial visit and continued taking opioids over the next 4-12 months).(1) Here are the key take-aways from the results of the study:(1)

  • Of all of the patients looked at, about 18% filled an opioid prescription within 3 days of their initial visit, and 22% filled a prescription within 30 days of their initial visit. 1.2% of the entire group studied fit the criteria for long-term use.
  • Looking at the patients with short-term opioid use, those who saw a PT first had 85% less chance of filling an opioid prescription within the first 30 days of their visit versus patients who saw a primary care physician first.
  • Furthermore, the patients who saw a PT first for their back pain had 73% decreased odds of long-term opioid use versus patients who saw a primary care physician first.
Low Back Pain in Durango CO | Tomsic Physical Therapy
As PTs, we have many tools – including manual therapy- to treat low back pain

This study provides strong evidence for patients who are experiencing a new onset of low back pain to come to PT first.(1) After all, we are the musculoskeletal specialists, and low back pain a condition we treat frequently. Ultimately, if you come to PT first to get a thorough evaluation and treatment for your low back pain, your likelihood of taking opioids is significantly decreased. If you are experiencing low back pain and not sure where to go, make sure you give our office a call so we can get you in to see one of our specialized physical therapists for a timely evaluation and get you on the road to feeling better without delay.

1. Kazis LE, Ameli O, et al. Observation retrospective study of the association of initial healthcare provider for new-onset low back pain with early and long-term opioid use. BMJ Open. 2019;9:e028633. doi:10.1136/bmjopen-2018-028633

CBD Use and Musculoskeletal Pain

There has been a lot of buzz around the use of cannabidiol (CBD) lately, as more states have made CBD legal for use both with and without medical prescription. I have many patients that ask me about the use of CBD for their aches and pains, and have even more that tell me that they already use it and find relief with it. Just yesterday, a patient came in and reported that her sleep, which used to be interrupted 3-4 times per night because of hip pain, has significantly improved since she started using oral CBD before bed. Based on these stories, I wanted to learn more about the research behind CBD use when it comes to musculoskeletal pain, and I was pointed to a great research review titled, “Cannabinoids in the Management of Musculoskeletal Pain: A Critical Review of the Evidence”.(1) I’ll share with you what the research says, but I do want to remind you that you should always consult with your primary care physician when considering taking any new medication.

The review by Madden et al looked at 33 studies looking at the use of cannabinoids, including CBD (the form that does not have THC in it) as well as cannabis (which does have THC, a psychoactive property, in it), in regards to treating orthopedic pain.(1) This included pain from arthritis, post-operative pain, back pain, and trauma-related pain.(1) Overall, the quality of these studies was not very high, as they were mostly observational and did not control for other variables. Essentially, it is best to take this information with a grain of salt, and there is a lot of room for research to dive further into this topic in order to gather more quality information on its effectiveness. However, the researchers reported that 22 of the 33 studies (67%) indicated that cannabinoids were effective in treating musculoskeletal conditions.(1) Furthermore, these studies were looking more at the use of cannabis, with limited information on how CBD can be effective as a treatment.

Ultimately, when asking the question, “Is CBD something that can help with my musculoskeletal pain?”, the answer is, “Maybe”. There is currently not enough information to make an evidence-based recommendation regarding the use of CBD, but you should certainly discuss this with your primary care physician if you are considering the use of it either orally or topically. Hopefully, as the use of CBD becomes more popularized across the nation as an alternative to other medications, further research using higher-quality standards can be performed so that clinicians can make better evidence-informed recommendations.

1. Madden K, van der Hoek N, et al. Cannabinoids in the Management of Musculoskeletal Pain: A Critical Review of the Evidence. JBJS Review. 2018:6(5):e7.

Physical Therapy Bike Fit

For many of us, biking is a way of life in Durango. Whether it’s just for fun, for exercise, or for commuting, biking is enjoyed in many ways and on many kinds of bikes. As fun as biking can be, the unfortunate reality is that it can sometimes cause aches in pains in our body. Common complaints related to cycling can include pain of the neck, back, wrists, or knees. Many times, these aches and pains can be remedied by adjustments made to the positioning of your bike to accommodate your body. This type of assessment is something we offer here with the help of our own Dr. Josh MacNaughton, PT.

Josh has been certified to perform Physical Therapy Bike Fits, where he takes a holistic approach to making your bike fit to your body. The two hours that he spends with you includes these components of the in-depth assessment and fitting:

  • Functional Movement Systems (FMS) Assessment
  • Physical Therapy Assessment of any current problems
  • Custom Bike Fit and Measurements
  • Video Analysis (Before and After comparisons)
  • Home Interventions/Exercises for on and off the bike
Functional Movement Analysis in Durango CO | Tomsic Physical Therapy
Dr. Josh MacNaughton performing a functional movement assessment on local biking legend, Ned Overend
Functional Movement Analysis in Durango CO | Tomsic Physical Therapy
The squat is an integral part of the functional movement screen to assess your flexibility and strength off the bike
Bike Fit in Durango CO | Tomsic Physical Therapy
Making sure that our very own Dr. Ellen Tomsic has the best bike fit

Josh’s main goal is to analyze your individual movement patterns and identify any limitations in flexibility, weakness, and posture. He takes this information and transfers it to how you fit on your bike to make sure that you get the most comfort and efficiency while riding. Josh has experience with bike fitting for any level of rider: from amateur cyclists riding for fun to professional cyclists looking to make their competitive edge stronger while remaining injury-free. If you’re interested in a Physical Therapy Bike Fit, whether or not you are currently dealing with an injury, reach out to us today to learn more information about these in-depth assessments.

Exercise for Health During Pregnancy

I found it fitting to write a blog about health and exercise during pregnancy given that I’m 39 weeks pregnant and getting ready to welcome baby girl any day now! The good news is that there is a lot of content to pull from out there, as researchers continue to find more and more benefits of exercise whether or not you are growing another human inside of you. One of the latest research studies, a randomized controlled trial out of Brazil, confirms some of these benefits.(1)

The researchers split up 456 pregnant women into two groups: one was the “control group” that received standardized obstetrics care, and general nutrition and physical activity counseling, while the other was the “exercise group” that participated in a structured and supervised hour-long exercise program three days per week from weeks 8-10 of pregnancy until the the end of their third trimester right before having their babies.(1) This supervised exercise program consisted of a gradual warm-up, aerobic exercises, light muscle strengthening, coordination and balance exercises, stretching exercises, pelvic floor strengthening, and relaxation at the end.(1)

Exercise for Health During Pregnancy in Durango CO | Tomsic Physical Therapy
Sneaking in a little exercise between patients on my second to last day before maternity leave!

The research looked at two main outcomes, maternal weight gain and gestational diabetes diagnosis, to try to compare the two groups and to see if there were any positive effects of the structured and supervised exercise, and here is what they found(1):

  • The women in the exercise group had significantly lower weight gain, within normal amounts
  • The amount of women diagnosed with gestational diabetes was lower in the exercise group

Given all that is known about the positive effects of exercise in general, those results should not be surprising to anyone. However, it’s nice to see that just three hours of low- to moderate- exercise per week- which can feel tough for some women to accomplish during pregnancy depending on how they are feeling on any given day- can make such a positive difference in health. I feel fortunate that I’ve been able to use the daily movements and tasks of my job as my main exercise program throughout this pregnancy, and I definitely credit a lot of my ability to maintain good health throughout these past 39 weeks to my sustained activity levels even if I haven’t felt up to my usual exercise regimen of hiking, running, and biking during this time. If you are pregnant, make sure you talk with your care provider to ensure that exercise is safe for you and make sure to reach out to physical therapist if you need help establishing a well-rounded and safe exercise program to help as your body changes.

  1. Barakat R, Refoyo I, et al. Exercise during pregnancy has a preventative effect on excessive maternal weight gain and gestational diabetes. A randomized controlled trial. Braz J Phys Ther. 2019;23(2):148-155.

Running Distance Changes and Running-Related Injury

Spring is kicking into full gear with warmer temperatures, drier trails, and increased outdoor activity! With many Durango folks trading their ski boots for running shoes these days, it’s important to talk about safe increases in running distance in order to set up for an injury-free season.

Running-related Injury in Durango CO | Tomsic Physical Therapy
A nice preview of what running on the trails will look like when all of that snow melts up high!

A recent article in one of my favorite sources for quality research reports, the Journal of Orthopaedic and Sports Physical Therapy, touched on this topic by specifically looking to find out if there is an association between change in weekly running distance and running-related injury.(1) The researchers studies over 250 non-injured runners of a period of 14 weeks as they followed a running schedule that was either focused on distance increases or pace increases.(1) The main finding of this research article was that significantly more runners were injured if they increased their weekly running distance by greater than 20%, with this association more commonly occurring in the first few weeks of the training program.(1) This falls in line with a previous articles on this topic, where activity increases greater than 10-30% were associated with higher risks of injury.

This current article does make a point to mention that there are many other variables besides schedule and weekly increases that can lead to injury in runners.(1) As physical therapists, we are uniquely qualified to assess you, whether or not you have a current injury, and help with ensuring that you have as good of a running season as you can with guidance on specific exercises and training plans to work with as you increase hit the roads, paths, or trails around town this year. Don’t hesitate to contact us if you want to do everything you can to minimize your risk of injury or reduce the effects of a current injury if you have one!

1. Damsted C, Parner ET, et al. The association between changes in weekly running distance and running-related injury: preparing for a half marathon. J Orthop Sports Phys Ther. 2019;49(4):230-238.

Second ACL Injury Risks

Back when I was doing my Doctorate training at the University of Utah, I performed an extensive review of risk factors for repeat injuries or injuries on the opposite side after having an ACL-reconstruction surgery for my final doctorate project. Since then, researchers have continued seeking for answers to the question of why people who have had an ACL injury and surgery have a risk of re-injuring the same knee or injuring the opposite knee, which occurs in anywhere from 3 to 37% of people depending on their activity level, type of sport, and other factors such as age.(1)

Second ACL Injury Risks in Durango CO | Tomsic Physical Therapy
Brad, Ellen’s husband, skiing some deep and steep snow in Canada this January! Skiing is a sport many folks like to return to after ACL injuries.

Second ACL Injury Risks in Durango CO | Tomsic Physical Therapy

In an attempt to reduce the risk of further injury, especially with people who are returning to sports that might put their ACL at risk (such as soccer, football, and any other running/cutting sports), researchers and clinicians have created many “Return to Sport” tests to try to prepare their patients to getting back to their usual activities as safely as possible. These tests are typically looking to see how symmetrical the legs of the patient are with comparing the surgical side with the non-surgical side, as well as with trying to gauge how confident the patient is during the tests as there is more and more information coming out about how confidence in movement can affect quality of movement and, potentially, their risk of further injury. A recent systematic review, which is a grouped analysis of multiple studies, sought to find out whether passing these return to sport tests are associated with actual decreases in the chance of a second ACL injury.(1)

Within the four studies that the researchers were able to look at in this review, approximately 42% of the patients were able to pass the return to sport testing performed.(1) Of those patients that passed their tests, 14% of them went on to have either a re-injury of the originally injuried knee or a new injury of the opposite knee.(1) Unfortunately, the researchers found that experiencing a “passing” grade of the return to sports tests only led to a 3% reduction in risk of injury- which is not a significant amount.(1) The results of this study show that there is still much work to be done in terms of trying to better identify what might place someone at a higher risk of a second ACL injury as well as trying to create tests that are more sensitive so that we can more confidently send patients back to their sport and activities of choice with reduced risk of a further injury. Here at Tomsic PT, we create a very individualized program for each patient to work toward the goal of getting them back to their activities as strong and safe as possible. If you have experienced an ACL injury, either just recently or further in the past, don’t hesitate to see one of our physical therapists for further evaluation on how to best decrease your risk of a second ACL injury.

1. Losciale JM, Zdeb RM, et al. The Association Between Passing Return-to-Sport Criteria and Second Anterior Cruciate Ligament Injury Risk: A Systematic Review with Meta-Analysis. J Orthop Sports Phys Ther. 2019;49(2):43-54.

Cross Country Skiing and Strength Training

Some of our snow dances must have worked in this past month with a decent start to 2019 including some plentiful snow storms! When the snow started coming down on January 1st, I’m fairly certain that I could feel the warmth of Durango’s large, collective smile as we all were anxious to see some of the white stuff fall after experiencing the negative effects of a dry year in 2018. One of the best parts about seeing all of the snowfall was the added potential for outdoor opportunities like downhill skiing, snowshoeing, and cross country skiing.

Living in Durango, you’re bound to either have some experience cross-country skiing or know someone who has experiences cross-country skiing. I’ve only tried skate skiing a handful of times, but I could tell from my short experience with it that it’s a great workout and way to enjoy the beautiful outdoors! For those of you who enjoy cross-country skiing, I wanted to share some info on how to maximize your ability to utilize your upper body strength for exercise and competitiveness based on a research article that came out of Norway last year.(1)

Strength Training in Durango CO | Tomsic Physical Therapy
Photo Source: Popular Mechanics – How to Start Cross-Country Skiing

The researchers set out to find how 8 weeks of added strength training helped cross-country skiers’ strength adaptations and double poling performance.(1) Double poling requires greater upper body demands and allows you to assist your legs in the workload of cross-country skiing, which is helpful whether you are a novice or competitive racer. The strength training used in the study included three days per week of three exercises- a standing “double poling”, seated pull-down, and triceps press- with progressive increase in weights and decrease in reps throughout the 8 weeks.(1) When comparing the groups that added strength training to their regimen to the group that did not, the strength training group had improved double poling performance as well as longer “time to exhaustion”.(1) This was a smaller study with some limitations, so you have to take the information with a grain of salt, but the results found reinforced the importance of added upper body strength training for improving athletic performance, especially with endurance activities.(1) So, whether or not you are a competitive cross country skier or just like to do it as a fun way to exercise outdoors in our beautiful backyard, you might consider performing specific upper body strengthening exercises a few days per week to improve the time you spend out on the snow. If you have specific questions about exercises you should or shouldn’t do based on your specific needs and current or past injuries, make sure to contact us to work with one of our specialized PTs to ensure an individualized program that works for you!

1. Øfsteng S, Sandbakk Ø, et al. Strength training improves double-poling performance after prolonged submaximal exercise in cross-country skiers. Scand J Med Sci Sports. 2018;28:893-904.

Let it Snow – and how to Stay Safe with Snow Shoveling

Maybe I’m just trying to be optimistic, or am desperately hoping to avoid a repeat of this past summer’s fire, but I have been busy doing some snow dancing for the past month! In hopes of more snow coming down in and around the Durango area, I wanted to share some tips on snow shoveling that I recently came across in an article from the American Physical Therapy Association’s (APTA) website, Move Forward PT1:

With fresh snow comes lots of playing and… snow shoveling!
  • Lift smaller loads of snow, rather than heavy shovelfuls.
  • Be sure to take care to bend your knees and lift with your legs rather than your back.
  • Use a shovel with a shaft that lets you keep your back straight while lifting.
  • A short shaft will cause you to bend more to lift the load. Using a shovel that’s too long makes the weight at the end heavier.
  • Step in the direction in which you are throwing the snow to prevent the low back from twisting. This will help prevent “next-day back fatigue.”
  • Avoid excessive twisting because the spine cannot tolerate twisting as well as it can tolerate other movements. -Bend your knees and keep your back as straight as possible so that you are lifting with your legs.
  • Take frequent breaks when shoveling. Stand up straight and walk around periodically to extend the lower back. Backward bending exercises while standing will help reverse the excessive forward bending of shoveling: stand straight and tall, place your hands toward the back of your hips, and bend backwards slightly for several seconds.

Another tip that I would add is to make sure that you have shoes on that have good traction so that you are not slipping and sliding around on any packed snow or ice. You might even invest in a pair of traction “cleats” that you can slip over your current shoes to make sure you feel extra steady on the snow and ice while you are pushing snow around.

If you do have any issues or concerns related to shoveling, any of our specialized PTs can assist you with any pain you are currently experiencing or to learn prevention techniques if you are not currently injured!

1. American Physical Therapy Association. (2018). 6 Tips to Shovel Snow Safely. [online] Available at: [Accessed 21 Dec. 2018].