Does It Hurt When I Do This?

An Irreverent Guide to
Understanding Injury Prevention and Rehabilitation

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 “owners manual” for the human body. Far from a dry guide, this
entertaining read teaches readers how to maintain and restore good health,
and can be referenced again and again when injuries arise”—Provided by
publisher.
Identifiers: LCCN 2020048565 (print) | LCCN 2020048566 (ebook) | ISBN
9781538149027 (cloth) | ISBN 9781538149034 (epub)
Subjects: LCSH: Wounds and injuries—Treatment. | Wounds and injuries—
Prevention.
Classification: LCC RD131.S25 2021 (print) | LCC RD131 (ebook) | DDC
617.1—dc23
LC record available at https://lccn.loc.gov/2020048565
LC ebook record available at https://lccn.loc.gov/2020048566

The paper used in this publication meets the minimum requirements of

American National Standard for Information Sciences—Permanence of
Paper for Printed Library Materials, ANSI/NISO Z39.48-1992.
For my brother, who had to take his leave too soon
 CONTENTS

Cover
Half Title
Title
Copyright
Dedication
Contents
Introduction

Part I: How a Healthy Body Works

1 The Parts List
2 The Mind-Body Connection

Part II: Keeping the Body Healthy

3 Nutrition
4 Sleep
5 Strengthening
 6 Stretching
7 Endurance Training
8 The Aging Body

Part III: The Injured Body

9 Types of Injuries
10 The Healing Process
11 Solving Mysteries
12 Peripheral Neuropathy: A Case Study

Part IV: Treatments for Injuries

13 Alternative Therapies
14 Specific Injuries
15 Foot and Ankle Injuries
16 Knee Injuries
17 Hip Injuries
18 Low Back Injuries
19 Neck Injuries
20 Shoulder Injuries
21 Elbow Injuries
22 Wrist and Hand Injuries

Appendix I: Strength Training for Those Who Hate Exercise

Appendix II: Hormones

Acknowledgments

Notes

Bibliography

About the Author

 INTRODUCTION

O n a winter morning in 2010, a fifty-five-year-old former college

football player named Frank Ward showed up on my schedule for a
physical therapy evaluation. He had not yet agreed to use a cane, and he
walked with a pronounced limp as he struggled to move his 6-foot-4, 270-
pound frame across the clinic to the exam room. He told me the story of
how he developed a condition called peripheral neuropathy as the result of
an adverse reaction to a medication. He had been an elite athlete in his
youth and had continued to work out at a high intensity level until very
recently. He loved to run, cycle, lift weights. These activities fueled him,
made him feel alive. Now he could not walk up a flight of stairs without
help, and one of his many doctors told him that he would likely end up in a
wheelchair.
I will talk more about Frank’s story later, but for now I will give up the
ending: Frank did not end up in a wheelchair. In fact, he now competes in
three-mile road races. I was Frank’s physical therapist for the better part of
two years, and I wish I could boast that I was single-handedly responsible
for his success, but I cannot. Frank had the force of personality to conquer
the grueling test of endurance known as the American healthcare system.
He worked with his treating clinicians—and willed them to work with him
—as a team. He asked a thousand questions. He took control of his
situation. He did the things that separate those who achieve great outcomes
from those who suffer poor outcomes.
A patient like Frank comes around once or twice in a physical
therapist’s career, but his lessons apply to everyone, not just those with
devastating medical conditions. You and I are more likely to sustain injuries
that are not nearly as overwhelming. I spend most of my days helping the
competitive weight lifter who strained his back attempting to pick up a
paper clip, the retired NASA engineer who injured his knee chasing his self-
propelled lawn mower across his backyard, or the young mother who
accidentally used olive oil to make homemade bath oil and got so slippery
that she fell on her shoulder trying to get out of the bathtub. These are the
everyday people who summon the courage and fortitude needed to publicly
admit how they were injured and enter a system where the treatment you
receive depends largely on what type of doctor you happen to see. A family
doctor will give you drugs, a surgeon will cut you open, a chiropractor will
crack your back, a physiatrist will stab you with needles, and a naturopath
will try to sell you $1 trillion worth of supplements. With so many options
to choose from, it is not always easy to decide which treatment sounds the
least damaging.
Most people start with their primary care physician, or family doctor.
Primary care physicians are trained to refer you to the specialist that will
maximize the number of subsequent specialists you will need to see. If you
bypass this step and stumble around on your own, you may accidentally
land on the right specialist on the first try and deprive yourself of several of
the above character-building experiences.
Even if you make this novice mistake, our system has backup measures
that prevent your out-of-pocket costs from falling dangerously low. These
protocols ensure that even if you only go to one doctor, you will be
subjected to a battery of tests such as X-rays, MRIs, CAT scans,
ultrasounds, urine analyses, blood tests, and palm readings. These miracles
of modern technology can detect just about anything abnormal, so chances
are the results will come back and your doctor will say something like,
“Everything looks normal, so I have no idea why it hurts.”
When this happens, there is a good chance that your doctor will send
you to physical therapy, because that’s where many doctors send patients
when they have no idea what to do with them. That is where I come in. As a
trained physical therapist, I use gentle modalities to reduce tension and
relieve pain. A typical session might involve a soothing hot pack, a relaxing
massage, deep-breathing techniques, cocktails, and a bedtime story. At least
that is what I tell patients in order to convince them to come to their first
appointment. Then, when they are at my mercy on the exam table, I
confront them with the grim reality that the real world of physical therapy
involves me grabbing their extremities and bending them into positions they
have not been in since their trip down the birth canal. Patients are often
surprised to learn that these maneuvers have actually been shown to reduce
pain and relieve tension. After I administer this type of discomfort all day, I
come home totally relaxed with absolutely no urge to argue with my wife or
yell at my kids. I feel blessed to live in a country where it is legal to obtain
a license and earn a salary to torture people. These patients typically thank
me with a level of enthusiasm that is in direct proportion to the amount of
pain that I inflict. They often bring me home-cooked meals or gift
certificates to expensive restaurants. One patient tried to give me a bike. So
as you can see, one of the best ways to relieve stress and lead a healthy life
is to become a physical therapist. At times, physical therapy also benefits
the patients as well.
An additional bonus is that physical therapy, unlike pharmaceuticals,
doesn’t cause dry mouth, constipation, dizziness, weight gain, nausea,
hives, bulging eyeballs, oily discharge, memory loss, or erections lasting
more than four hours. The downside, however, is that physical therapy can
be expensive. If you don’t have insurance coverage, the cost is usually
about $75 per visit. If you are lucky enough to have coverage, your out-of-
pocket cost might run you only $75 per visit. But at a fraction of that price,
you can buy this book and learn how to perform most of your physical
therapy at home. Think of it as an Ikea instruction manual that teaches you
to put together a piece of furniture every bit as elegant as a handmade piece.
You don’t have to be MacGyver. Anyone can do this. In today’s healthcare
environment you have to be your own advocate, and often you have to also
be your own doctor, nurse, pharmacist, nutritionist, and yes, physical
therapist. It took me three years of graduate school to learn how to be a
physical therapist, but quite honestly most of that time was spent learning
how to impress people at parties by saying words like
“dysdiadochokinesia.” You really don’t need to know how to do this in
order to inflict basic physical therapy on yourself, so you should be able to
learn the fundamentals in just a few weeks.
 WHY I WROTE THIS BOOK

Several years ago, I was treating a patient for a low back injury. He was
lying facedown on the treatment table while I ground my knuckles into the
muscles surrounding his spine. This treatment melted away his tension and
caused him to utter a variety of expletives at a gradually increasing decibel
level. When other patients started to sneak out the back door, this was my
usual sign that the therapy had reached its maximal benefit, so I decided to
conclude the treatment. The patient then sat up and said to me, in all
seriousness, that he was afraid to have the back surgery that he needed
because his cousin had back surgery and the surgeon accidentally touched
the wrong nerve in his back and his eyeball popped out.
This is an example of what I have to listen to all day. So during a typical
shift, I might get five or six minutes when I don’t have to explain things like
why you don’t have to worry about your eyeball popping out, or your heart
shaking loose, or your nose hair bursting into flames. I use this time wisely
so that I don’t fall behind on the most important part of patient care:
electronic record keeping. If you have been to a doctor recently, you know
all about this. A typical doctor visit starts with a fun-filled hour at the front
desk where you fill out forms similar to those needed for a mortgage, only
longer. You spend the next hour in the waiting room reading every issue of
People magazine dating back to the Renaissance. A medical assistant with a
laptop then escorts you to the treatment room and immediately starts typing
your entire medical history starting with your first bowel movement. This is
the same history you filled out at the front desk, but the highly trained
assistant knows that there is no way you will remember having done
something that long ago.
The medical assistant then hands you a gown and leaves you alone to
undress and figure out how to tie the gown. There is no instruction because
the medical assistant has no idea how to tie the gown. Heart surgeons have
no idea how to tie the gown. Is this the front? The back? The top? The
choice of which private part of your body to leave exposed to the world is
entirely up to you.
At some point, usually after about forty-five minutes, a physician
assistant barges into the room, glances at the tangled mess you are wearing,
asks you why you came, and types with blistering speed on the same laptop
the story of your life that would rival in length the entire Harry Potter
series. When this is complete, the physician assistant assures you that the
actual physician will be with you momentarily.
Sometime during this wait the night cleaning crew comes in and dusts
the cobwebs off your stiffening body and freshens you up before the
cheerful doctor comes in and asks, “So, what brings you here today?” While
you talk, the doctor resumes the competitive speed-typing started by the
assistant. When this is complete, the doctor sends you on your way because
your injury has long since healed on its own.
If you are lucky enough to still have an injury after your doctor visit,
you may be referred to me for physical therapy. If this happens, I will start
your first session with a detailed evaluation. I will ask you to describe
exactly what happened. I will ask you about your medical history and all
medications. I will ask you what you do for a living, what you do for fun,
and how your injury affects these activities. I will examine your injured
body part. I will measure your strength and range of motion. I will analyze
the way you walk. I will instruct you in exercises and perform hands-on
stretching techniques. And after all this, when you come back for your
second visit, even if it is the very next day, there is a good chance that I will
look at you and not remember anything about your injury.
Some people call this “having a senior moment,” but this type of thing
has been happening to me since I was five, and I’m a little tired of all these
“seniors” getting all the special treatment. So I propose that we change the
official terminology to “idiot moment” to be more inclusive of people like
me.
At this point, you may be asking yourself, “Why did I buy a book
written by such a moron?” Trust me, you will probably have this thought
more than once. And when you do, I want you to remember my earlier
words of wisdom: This book is way cheaper than your copay.
But the point is, it’s not the doctor’s fault that your appointments take
six hours, and it’s not my fault that I can’t remember anything about your
injury. It’s the insurance company’s fault! They force all of this electronic
documentation upon us, and it takes up 90 percent of our time and brain
space. I too have this computer that I wheel around with me, and I have to
use every spare second to type in every detail of every patient visit. It is
impossible to keep up without world-class typing skills and, more
importantly, macros. Macros are to record keeping what nail guns are to
house building. If I program enough macros into my computer, I can type
eight thousand words per minute. The trick is to get these macros to make
sense when they are all strung together, so the note looks like it was written
by an actual human being. I see chart notes that look like this:
She states the pain is moderate. She is currently experiencing. Physical therapy referral
evaluation and treatment. Right foot. Hold for—scheduling requested for. Follow up visit in.
ICE. Comfortable shoe. Patient referred for. STOP physical therapy. Patient to continue
physical therapy.

Notes like these give lawyers erections that last way more than four
hours.
The other problem with macros is that I may type a perfectly normal
sentence, and part of a word just happens to be a macro that someone in
another office programmed into the system. So I type, “Patient did well
with gait training today with hemi-walker,” and what appears in the note is,
“Patient did well with gait training today with I applied cortisone cream
manually to relieve hemorrhoidal itching-walker.”
But back to the reason why I wrote this book. Like the man who was
afraid his eyeball would pop out, many of my patients do not understand
their injuries or why they were sent to physical therapy. Doctors and
therapists strive to look up from their computers long enough to explain
injuries using appropriate amounts of detail, and this is difficult. All patients
are unique, and they understand different levels of detail. Some patients ask
a lot of questions, others don’t ask any questions, and many believe they
understand when they really do not.
Some patients have already seen several doctors or therapists and report
that each gave a different explanation. And then there’s the internet, which
can further compound the confusion.
Clinicians have a responsibility to properly educate all patients. We
don’t always get it right, myself included. This is a problem. We should get
it right every time. My experiences and mistakes over the last twenty-five
years have taught me that when I use simplistic explanations, like “Your
back is really screwed up,” I get it wrong. When I use technical
explanations and medical jargon in an effort to appear more intelligent than
I actually am, I get it wrong. But when I focus on the basics, I get it right.
When I focus on the basics, I respect the patient’s intelligence and
ability to understand. When I focus on the basics, I explain in plain
language the anatomy, how each part functions, how the parts function
together, how the injury disrupts this system, and how physical therapy
helps. When I focus on the basics, I hear the following sentence with
incredible regularity: “That makes total sense; why didn’t anyone explain
that to me before?”
So this book is about the basics. You cannot fully understand what you
hear from a healthcare professional, what you read in the news, or what you
see on the internet without a solid understanding of the basics.
Frank never gave up until he understood the basics. He inspired me to
never give up until every one of my patients understood the basics. He
inspired me to write.
I will teach you how your body works. I will teach you how injuries
affect your body and how your body responds. I will teach you how your
body heals and how physical therapy improves healing. And I will teach
you the fundamentals of rehabilitation.
I know that some therapists will argue that it is irresponsible to suggest
that people follow physical therapy instructions from a book. They will say
that there is no substitute for hands-on evaluation and treatment by a
skilled, licensed therapist who can pick up details of each person’s unique
biomechanical structure and movement in order to prescribe the correct
treatment. I wholeheartedly agree, and I have two things to say in my
defense. First, this book is meant to enhance the patient-therapist
relationship, not replace it. I would consider it a blessing if every one of my
patients came to me having read a book like this. Second, and I know every
therapist out there has seen this, doctors sometimes choose not to send
patients to therapy, instead handing them a sheet of paper with exercises on
it and saying, “Go home and do these.” No instruction. No supervision. No
understanding of why or how the exercises work. If that happened to my
mother, I would want her to have, at the very least, a basic understanding of
the fundamentals that this book provides.
If you sustain an injury, do not use this book to treat yourself before you
see your doctor to determine the exact nature of your injury and what
restrictions you should follow. This is a very important step that is
necessary to avoid potentially dangerous medical complications, such as
you suing me. I previously mentioned the time needed to actually see your
doctor. To expedite this process, I recommend calling to set up the
appointment a couple of weeks before you get injured.
 WHY SHOULD YOU LISTEN TO ME?

Over the years, I have found that one of the best places to find peace and
quiet and get things done is the men’s room. This was actually more true in
the old days. Back then, a public restroom was a simple place where the
most advanced technology was the indoor plumbing. It wasn’t a place for
lazy people. I had to push a lever attached to the toilet to flush, turn a faucet
to run the water, and actually crank this little handle to dispense paper
towels. Today, the restroom is a living, breathing work of modern
technology that does everything but send me alerts telling me when I have
to go. The joy of clanking around with my papers and duffle bag has been
replaced by neurotic fear that any wrong move will cause these modern
sensors to trigger a toilet-flushing, water-running, soap-squirting, towel-
dispensing, wind-blowing flurry of paranormal activity. Men throughout
America now tiptoe around restrooms like neurotic burglars, and I am no
exception. By the time I make it out of a modern men’s room, I’m a nervous
wreck. I once changed my shirt in a stall. The toilet flushed eight times.
And not just residential-grade flushes. I’m pretty sure I could have flushed a
bowling ball down that toilet.
So I sat in the restroom stall at the clinic one day, trying not to make any
sudden movements, and a doctor walked in and called out, “Mark, are you
in there?” Apparently, someone told him I was in there. I had to answer, just
in case he recognized my shoes. He said, “I just wanted to talk to you about
a patient when you get out.” I asked him the patient’s name so I could get
my thoughts together, and he told me, and I asked something else, and he
asked me something, and before I knew it, we were having a full-blown
conference as I sat there on the toilet.
After this conference I felt two things: stunned and awkward. Stunned
because this doctor managed to get out of there without setting off the paper
towel dispenser, and awkward because, well, it was just a little weird. But
the point is, I have learned that if I pay attention, I can learn something
anywhere. I earned a bachelor’s degree in mechanical engineering and a
master’s degree in physical therapy, passed the state board exam, and kept
up with the latest research. But for twenty-five years I have also treated
thousands of patients, listened to their stories, talked with doctors in men’s
rooms, watched them perform surgeries (not in men’s rooms), sat with
radiologists while they interpreted MRIs and X-rays, and treated my own
injuries.
That’s another advantage I enjoy as a physical therapist. When I sustain
injuries, I can treat myself. No referrals, no copays. Nobody poking me and
touching me. Some therapists like to treat each other’s ailments, but I prefer
self-treatments in the privacy of my own home. That is one of the reasons I
didn’t become, say, a proctologist.
I have learned a great deal from my own injuries. For example, several
years ago I had a painful condition called plantar fasciitis, which I will
discuss later in more detail, but for now let me just say that it felt like
someone was sticking a knife into my heel. I had always instructed patients
with plantar fasciitis not to run. So when I had plantar fasciitis, I decided, of
course, to run—every day, for six months. It took me this long to confirm
that running, in fact, was bad for plantar fasciitis. Just to be sure, I repeated
this experiment a couple of years later and came to the same conclusion.
(This book is way cheaper than your copay.)
In my defense, I am a healthcare professional, and healthcare
professionals suffer from a compulsive urge to scientifically prove that
everything they have ever learned was wrong. This is why it is so hard to
keep up with what is healthy and what is unhealthy. News outlets report the
results of the latest studies. A year later new studies show the exact
opposite. A year after that they’re back to the first ones. It is maddening,
and it causes many people to become cynical. “Eat what I want, do what I
want, and die when I’m supposed to” is a phrase I’ve heard from many
patients who have reached their wits’ end.
Accurate information is not readily available to the public. Critical
analysis of research is not part of news reports, and the best and most
important studies often don’t make headlines. News outlets report studies
that improve ratings, rarely scrutinizing methods, sample sizes,
interpretation of results, or the funding sources’ likely agendas. This tedious
chore is left to healthcare professionals, who are responsible for relaying
accurate information to their patients. I take this responsibility very
seriously and tackle it with a large dose of common sense. Healthcare is
scientific, but judgment and opinion still play a large part in every treatment
decision. I have yet to meet two healthcare professionals who agree on
everything, and it is often wise to seek a second opinion. This book contains
my opinions. I am not always right, but I back up what I say with evidence,
logic, and common sense.

WHY PHYSICAL THERAPY?

A book about physical therapy is more important now than ever because I
am not qualified to write about anything else. But if that’s not reason
enough, consider the state of healthcare in America. Costs are soaring, yet
more expensive treatments are not producing better results.1 Many people
do not have access to healthcare, and those who do often cannot afford the
out-of-pocket costs. Employers struggle to provide insurance for employees
and cover the costs for those who sustain injuries on the job. This system is
not financially sustainable, so the future of health-care must involve
treatments that are less expensive and produce better outcomes. Research
shows that physical therapy is one such treatment.
A 2015 study published in the Annals of Internal Medicine showed that
patients who had physical therapy for spinal stenosis had outcomes equal to
those who had surgery.2 Another 2015 study in the journal Health Services
Research showed that when physical therapy was the first line of treatment
for low back pain, overall costs for the first year were 72 percent lower.3
Data collected by the Bureau of Labor Statistics and MedRisk Industry
Trends Reports from 2003 to 2017 documented that increased physical
therapy utilization corresponded with decreased time away from work as a
result of injuries.4,5 Even the financial market industry published reports that
supported physical therapy, including reports from Capstone Partners
Investment Banking Advisors from 2016 and 2017 that stated that with “the
ever-increasing burdens on an already troubled healthcare system,
commercial carriers and government sponsored healthcare programs are
switching to value-based reimbursements and efficacious cost-effective
treatments such as physical therapy.”6
Physical therapy is not like taking a pill. Patient and therapist must work
together as a team and form a one-on-one partnership, because patients with
more knowledge and understanding have much better outcomes. Patients
who ask a lot of questions have much better outcomes. Patients who take
control of their recovery have much better outcomes.