Tag Archives: strengthening

Low Back Pain (LBP) Top 5 Exercises to Reduce Back Pain

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How to Reduce Low Back Pain
Over time, we develop arthritic changes in our back due to normal wear and tear. Below is a list of low back pain exercises that can help reduce lower back pain. These exercises will help you, in time, return you to your normal activities and improve your quality of life.

Top 5 Exercises to Reduce Back Pain

1. LOWER TRUNK ROTATION

Lie on your back with your knees bent.
Keep your feet and knees together and lightly rotate your spine.
Stop the stretch when you feel your hips coming off of the table. Only rotate to approximately 45 degrees and rotate back and forth like a windshield wiper.
Repeat for 2 minutes.
Low back pain

2. ABDOMINAL BRACING

Lie on your back with your knees bent. Slightly elevate your hips but not high enough to where it comes off of the table. Simultaneously, squeeze your abdominal muscles down towards the table. Continue to breathe.

Hold this for 10 seconds and rest for 10 seconds. Repeat for 2 minutes.

Low back pain
Low back pain

3. SINGLE KNEE TO CHEST

Bring one knee to your chest.

Hold for 5-10 seconds. Repeat alternating legs to your chest for a time of 2 minutes.
Low back pain

4. FIGURE 4 STRETCH

Cross one ankle over to the opposite knee and press down on the resting leg. You should feel the stretch in your hip.

Hold this stretch for 30 seconds if you can tolerate it. Repeat for 3 repetitions, then switch legs.
Low back pain

5. PIRIFORMIS STRETCH

Cross one ankle over to the opposite knee. Pull the resting knee across your body and up towards your chest. (You should aim for your opposite shoulder as a reference). This stretch should be felt over the crossed leg buttock.

Hold for 30 seconds if you can tolerate it. Repeat for 3 repetitions on each leg.
Low back pain

Written by Laura Cifre, OTR/L, PT, DPT, Director at Green Oaks Physical Therapy – Irving, Texas.
To learn more about Green Oaks Physical Therapy click here.

 

For more information about back pain, physical therapy click the links below.

beware bed rest for back pain  chronic back pain  low back pain relief

athletic trainer

Who is an Athletic Trainer?

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athletic trainer

Athletic trainers hold at least a four year degree from a BOC (Board of Certification) accredited institution. They are licensed, certified health professionals working with athletes on and off the field. Generally they are the first responders when injuries occur during sporting events.

Athletic trainers work closely with coaches and parents and will refer athletes to other health care professionals such as physicians, physical therapists and surgeons when needed.

Athletic trainers hours are determined by sports schedules. Typically they are available after school and stay until sporting events have concluded.

IN THE TRAINING ROOM ATHLETIC TRAINERS

  • Prepare athletes for competition by taking preventative measures such as equipment fitting, taping and bracing
  • Assess athletes with acute and chronic injuries to determine their participation status
  • Perform sport-specific rehabilitation on injured athletes
  • Provide opportunities for strengthening and conditioning
  • Work with sports staff on proper warm up, game day preparation and on/off season conditioning
  • Educate athletes, coaches and parents on sports medicine strategies, nutrition and sports psychology

running back

DURING THE GAME ATHLETIC TRAINERS

  • Support athletes during sporting events
  • Manage any type of musculoskeletal issues including:
  • Shoulder, hip, knee, elbow, hand and ankle injuries
  • Facial injuries
  • Neck and back injuries, spinal cord injuries and traumatic brain injuries like concussions
  • Triage and wound care
  • Heat-related illnesses
  • Fractures and dislocations
  • Catastrophic injuries

This information was written by the Center for Physical Rehabilitation, an outpatient physical therapy group with five locations in Western Michigan. The Center specializes in all inclusive physical therapy services, such as: Sports Medicine, Orthopedic Post-Surgical and McKenzie Therapy. Our state-of-the-art facilities are conveniently located around Grand Rapids with extended hours. Independent and locally owned since 1994, we have the freedom to work with the most qualified healthcare professionals. For more information click here.

seniors start exercising

Seniors: It’s Never Too Late to Start Exercising

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seniors start exercising

For years, seniors have attributed their aches, pains, and illnesses to the normal aging process. Age is often used as a reason to avoid exercise. But a regular exercise program can improve the quality of your life and help you avoid illness, including heart disease, stroke, and diabetes. As always, you should consult with your health care provider before starting any exercise program.

WHAT WE KNOW
Most people know that with age, come certain physiological changes. Studies show that we lose the following as we age:
• Lean muscle tissue—Most of us will lose muscle mass as we get older. We usually hit our peak muscle mass early—around age 20—and begin losing muscle mass thereafter.
• Aerobic capacity—The aerobic capacity is the ability of the heart and the body to deliver and use oxygen efficiently. Changes in the heart and decrease in muscle tissue decrease aerobic capacity.
• Balance—As we age, our ability to balance decreases, making falls and injuries more likely. The loss of muscle is a major contributor to losses on balance.
• Flexibility—Our joints and tendons lose some of their range of motion with age, making it difficult to bend and move around comfortably.
• Bone density—Most of us reach our peak bone density around age 20. After that, bones can become gradually thinner and weaker, which can lead to osteoporosis.

Fortunately, regular exercise can help delay some of these changes and give you the energy you need to do everyday activities like walking, shopping, and playing with your grandchildren. Exercise may even help decrease depression and stress, improve mood and self-esteem, and postpone age-related cognitive decline.

By adding endurance, strength, flexibility, and balance training into your routine, you will be healthier, happier, and more energetic.

senior push ups

ENDURANCE
Decades ago, doctors rarely recommended aerobic exercise for older people. But we now know that most people can safely do moderate exercises. Studies have shown that doing aerobic exercise just a few days a week can bring significant improvements in endurance.

Aim to get 30 minutes of moderate exercise—such as brisk walking, bicycling, or swimming—at least 5 days a week. You do not have to do 30 minutes at once—you can break these sessions up into two 15-minute sessions or three 10-minute sessions. Moderate exercise will cause your heart rate to rise and your breathing to be slightly elevated, but you should still be able to carry on a conversation.

STRENGTH
It is not just aging that makes people lose muscle. One of the main reasons older people lose muscle mass is that they stop exercising and doing everyday activities that build muscle.

Building stronger muscles can help protect your joints, strengthen your bones, improve your balance, reduce the likelihood of falls, and make it easier for you to move around in general. Even small changes in your muscle size and strength—ones that you cannot even see—will make things like walking quickly across the street and getting up out of a chair easier to do.

Aim to do strength exercises (eg, weight lifting) every other day, or at least twice a week. For each exercise, do three sets of 8-12 repetitions.

FLEXIBILITY
Increasing your overall activity level and doing stretching exercises can markedly improve your flexibility.

To improve the flexibility—or range of motion—of your joints, incorporate bending and stretching exercises into your routine. A good time to do your flexibility exercises is after your strength training routine. This is because you muscles will already be warmed up. Examples of exercises that you may enjoy include Tai chi, yoga, Pilates, and exercises that you do in the water.

By regularly stretching, you will be able to move around easier. You may also feel less stressed, and your posture will improve.

BALANCE
Just becoming more physically active will improve your balance and decrease your risk of falling. If you add some basic balancing exercises to your exercise routine, you will begin feeling more stable on your feet. Balance exercises can be done just about anywhere and usually require no more equipment than a chair.

Keep in mind that if you are having severe problems with balance, a fall prevention physical therapy program can be a great way to regain your balance, increase strength or improve flexibility.

GETTING STARTED
To avoid injury, start slowly. Add one or two sessions a week at first and progress from there as you begin to feel stronger. A physical therapist, or other health professional, can help develop a program that will be both safe and effective. Check with your local fitness or community center, which may offer exercise classes designed especially for older adults. Check with your primary health care provider if you are planning to participate in vigorous activities.

Remember, it is never too late to start exercising. The sooner you start, the sooner you will start feeling healthier, more energetic, and less stressed.

RESOURCES:
American Heart Association
http://www.heart.org

The President’s Council on Physical Fitness, Sports, and Nutrition
http://www.fitness.gov

CANADIAN RESOURCES:
Health Canada
http://www.hc-sc.gc.ca

Public Health Agency of Canada
http://www.phac-aspc.gc.ca

REFERENCES:

Effects of aging. American Academy of Orthopaedic Surgeons website. Available at: http://orthoinfo.aaos.org/topic.cfm?topic=A00191. Updated September 2009. Accessed April 4, 2016.

Exercise and physical activity: your everyday guide from the National Institute on Aging. National Institute on Aging website. Available at: http://www.nia.nih.gov/health/publication/exercise-physical-activity-your-everyday-guide-national-institute-aging-1. Updated February 16, 2016. Accessed April 4, 2016.

Physical activity: glossary of terms. Centers for Disease Control and Prevention website. Available at: http://www.cdc.gov/nccdphp/dnpa/physical/terms/index.htm#Moderate. Updated June 10, 2015. Accessed on April 4, 2016.

EBSCO Information Services is fully accredited by URAC. URAC is an independent, nonprofit health care accrediting organization dedicated to promoting health care quality through accreditation, certification and commendation.

shin splints

7 Ways Physical Therapists Treat Shin Splints

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shin splints

Here are 7 ways a physical therapist can help treat pain and symptoms associated with shin splints:

Pain Reduction: The RICE principle is the first step to recovery (rest, ice, compression, and elevation). Manual therapy and Kinesiotaping may also be used to speed up recovery and reduce swelling.

Gait and Footwear Analysis: An analysis of how a person walks and runs in an important part of treatment. The wrong mechanism of walking can transmit a great deal of force through the shin to the knee and hip. In such situations, physical therapists will correct gait patterns and recommend footwear with shock absorbing capacity.

Muscle Stretches and Strengthening: The tibial and peroneal muscles are attached to the shin and must be stretched adequately before any form of exercise. Physical therapy includes various stretches of the goot that will help stretch and warm up these muscles. Strengthening damaged muscles can also help.

 Activity Modification:  Physical therapists may suggest alternative activities to minimize stress on the shinbones. These can include swimming and cycling.

Increase Range of Motion (ROM): Exercises for the hip, knee, ankle and foot improve blood circulation, reduce inflammation and relieve pain. A home exercise program may also be implemented.

Arch Support:  The absence or collapse of a normal foot arch can lead to shin splints. Physical therapists will recommend appropriate orthotics that can be custom made for the patient and provide the appropriate amount of arch support.

Return to Sport: If you are an athlete, your therapist may tailor exercises that are specific to strengthening the areas needed to perform your sport. Modified use of your muscles may also be discussed and implemented. Return to your sport may be gradual to prevent re-injury.

To learn more about shin splints please visit our PT & Me injury center on this website by clicking here.

National Athletic Training Month

March is National Athletic Training Month

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March is National Athletic Training Month

Why We ATC?

ATHLETIC TRAINERS are highly qualified, multi-skilled health care professionals who collaborate with physicians to provide preventative services, emergency care, clinical diagnosis, therapeutic intervention, and rehabilitation of injuries and medical conditions. They can work in a variety of settings, including high schools, middle schools, universities, professional sports teams, hospitals, clinics, performing arts, club sports teams, and more. Athletics trainers decrease the liability on coaches, ensure a quicker and safer return to play, and reduce the risk of injuries for athletes of all ages. To learn more about the great things our ATC’s do — search for one of our PT & Me athletic training locations by clicking here!

Game & Practice Coverage:

• Early injury detection and intervention
• Quick referral process to local specialists if required
• Concussion safety injury screenings:
• Evaluation of injury
• Recommendation on immediate care
• Quicker return to play

March is National Athletic Training Month

WHAT IS NATIONAL ATHLETIC TRAINING MONTH?
March is National Athletic Training Month, a time to celebrate the positive impact athletic trainers have on work, life and sport. National Athletic Training Month is sponsored by the National Athletic Trainers’ Association (NATA), the professional members association for certified athletic trainers and others who support the athletic training profession. NATA represents more than 45,000 members worldwide.

ATC SPORTS STATS
All statistics taken from www.atyourownrisk.org

90% of student athletes report some sort of sports-related injury in their athletic careers.
54% of student athletes report they have played while injured.
12% report they have sustained concussions and head injuries from their time on the field.
163,670 middle or high school athletes were reported being seen in the emergency room for a concussion.
300 sports-related deaths of youth anything to prevent injuries.
37% of public high schools employ a full-time athletic trainer.
54% of athletes said they have played while injured.

PT News

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This Month in PT News. Featuring articles from PTandMe partnering clinics!

1. How to Deal with Chronic Joint and Muscle Pain
Written by the Therapy Team at Cornerstone Physical Therapy – Gahanna, OH

All of us have experienced pain and discomfort in the muscles and joints at some point, especially with age. In most cases, the use of over the counter medications, hot/cold packs and rest help resolve the problem. Read more

2. Pain at the Mall
Written by the Therapy Team at the Jackson Clinics – Northern Virginia

As the outside temperatures drop, people contemplating undertaking an exercise program often consider walking at the mall. Benefits include a controlled climate, an absence of traffic, security and easily available restrooms and water. Read more

3. Quality of Care in Rehab
Written by the Ian M. Campbell, DPT at Intermountain Physical Therapy – Boise, ID

What does quality care mean in rehabilitation? One can drive through their city and likely notice multiple physical therapy (PT) clinics. Some may be privately owned and operated, others run by local hospitals. Read more

lumbar physical therapy

The Phases of Cervical, Thoracic and Lumbar Physical Therapy

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A great cervical, thoracic and lumbar physical therapy program is very important for patients who have experienced surgery. Rehabilitation will be modified based on body region and type of surgery.

Pre-Operative Phase
Prior to surgery, your physical therapist will perform a comprehensive evaluation to assess your mobility, strength, coordination, and function in order to create a customized home exercise program to perform in preparation for your surgical procedure. This program will be important for you to perform until you have surgery to help improve your recovery after surgery.

NON-FUSION PHYSICAL ACTIVITY PROGRAM

Phase 1 Post-Operative (0 – 4 Weeks Post-Op)
During this phase, you will undergo light activities, like walking. During this time, it is imperative that you perform the home exercise program your physical therapist taught you to improve muscle function, and help improve healing. During this time, you may exhibit pain and soreness due to the surgery. This is a normal part of the healing process.

  • Immediately following your surgery, you will be allowed to perform very light, gentle, activities of daily living around your home. However, do not lift more than 10 pounds (a milk jug), and go slowly when bending or twisting.
  • Walking is important to perform consistently as well. Move around your house, ensuring that the area is free of any obstacles which can cause you to fall. Walking around the block should be the limit to what you do in the first 2 weeks. This duration can be increased but should stay under one quarter of a mile for the first 4 weeks.

  • Healing is most important during this phase and post-surgical pain and soreness is normal.

Phase 2 Post-Operative (4 – 6 Weeks Post-Op)
During this phase, you will start physical therapy. Physical therapy during this phase will involve exercises to improve your mobility, strength, and stability. Due to an increase in activity during this time, it is normal to exhibit increased muscle soreness with physical therapy. The soreness will resolve as your muscles get stronger.

  • Formal physical therapy as prescribed by your surgeon will start.
  • Physical therapy will include a comprehensive evaluation to determine the appropriate treatment to improve mobility, strength, stability, and coordination.
  • It is normal to experience muscle soreness during this time with your program. Each person’s body has a different activity threshold that needs to be reached to make physical improvements and muscular soreness is a healthy, safe response to working in this threshold.
  • As your activity threshold level improves, the soreness will resolve.

Phase 3 Post-Operative (7 – 10 Weeks Post-Op)
During this phase, physical therapy will focus on dynamic exercises and activities emphasizing multiple planes of motion. During this time, you can expect more complicated exercises to challenge your coordination and stamina for reaching your goals.

  • During this phase, physical therapy will increase intensity in regards to your appropriate activity threshold.
  • Exercises and activities will become more challenging, more dynamic, and will involve multiple planes of motion to simulate and retrain muscles to complete your daily or recreational activities.
  • Your custom physical therapy program will include specific activities and exercises to prepare you for return to your functional goals.

Information provided by PT and Me physical therapy partner, Rehab Associates of Central Virginia. R.A.C.V. has 13 locations throughout central Virginia. More information about Rehab Associates of Central Virginia can be found on their website at www.racva.com.

total knee replacement

Physical Therapy Following a Total Knee Replacement

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There are over 600,000 total knee replacements done each year in the U.S. As the workforce ages and as obesity levels continue to rise, this number is expected to increase.

Candidates for a knee replacement include patients experiencing difficulty doing simple daily activities, including walking or going down steps, and where conventional treatments are no longer helping. Common causes that lead to a replacement include pain with simple ADL’s (activities of daily living), pain at rest, chronic swelling, inflammation not improving with medication, knee deformity, knee stiffness, or trauma to the joint. When you are scheduled for a total knee replacement, ask to see your physical therapist for a pre¬surgical exercise and stretching program. This will help your knee recover its range of motion and strength.

Surgery consists of resurfacing the knee’s damaged and worn joint surfaces with artificial parts made of metal or plastic. Most patients are in the hospital for an average of 3¬5 days. And more than 90 percent of people report significant decrease in pain and improvement in ability to perform ADL’s within one month after surgery. Currently, many knee replacements are lasting 20 years or more with appropriate activity modification. One of the most important factors in success after a total knee replacement is follow up with physical therapy and a lifelong exercise program. Physical therapy typically starts during the hospital stay with the goals being to get the individual up and walking decreasing swelling in the knee and increasing knee ROM (range of motion). Upon hospital discharge, patients either go home and receive home physical therapy for one to two weeks, or to an extended care facility to continue their therapy.

Typically, patients need outpatient physical therapy after therapy at home, which usually begins two to four weeks after surgery. Outpatient physical therapy is recommended for three times a week for up to three months. Therapy goals initially are to reduce swelling and pain, and improve knee range of motion in both directions. To achieve these goals, treatment may consist of soft tissue massage to increase circulation and decrease swelling, stretching to improve flexibility, patellar mobilization, range of motion exercises, and modalities such as ice and electrical stimulation to help decrease pain and swelling. Physical therapy will progress to lower extremity strengthening exercises, balance activities, and fine tuning the gait pattern. Various activities and techniques will be used to improve strength, balance, and gait. As patients reach the end of their course of physical therapy, a personalized home exercise program is developed with the focus on independence with all ADL’s and returning to activities such as walking, swimming, dancing, golf, and biking. It is important for patients to stay active and maintain strength, flexibility, and endurance.

childhood obesity

Treating Childhood Obesity With Activity

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When talk focuses on childhood obesity in the United States, words like “critical” and “epidemic” are often used. The tried-and-true prescription of more exercise and better nutrition still holds true, but overweight children face unique challenges when it comes to weight loss.

Why Has Childhood Obesity Increased and What Are the Effects?
The statistics are disturbing. Not only are the overall obesity rates increasing, the heaviest kids are heavier than they were 30 years ago. Why is this happening? Experts who have studied childhood obesity attribute it to a change in lifestyle. The active lifestyle of the past—walking to school, playing outside, and engaging in after-school activities—has been replaced by a sedentary lifestyle of watching TV, playing video games, and using electronic devices like phones, computers, and tablets. Eating habits have changed noticeably, with convenience foods that are higher in fat and calories replacing fruits and vegetables.

The consequences of obesity are significant. A child who is obese may develop high blood pressure, high cholesterol, and type 2 diabetes. These conditions can increase the risk of cardiovascular disease such as a heart attack and stroke. In addition, older teens who are obese may have an increased risk of death during adulthood.

Obesity can also affect emotional health. A child who is obese may have emotional problems in school, and struggle with low self-esteem and depression.

What Is One of the Best Solutions?
Exercise is one of the main tools to fight childhood obesity. The US Department of Health and Human Services encourages children of all ages to be physically active. If your child is overweight, obese, or even of normal weight, recommendations to improve your child’s health include:

  • Encouraging your young child (aged 1-4 years old) to actively play daily in a safe environment
  • Encouraging your older child (aged 5 years and up) to participate in moderate to vigorous activity every day—Your child should aim for at least one hour per day of moderate to vigorous activity. At least 3 days out of the week should be vigorous activity.

Since children often engage in shorter bursts of activity throughout the day, it is okay to count these times as exercise.

Examples of different types of physical activity include:

Moderate-intensity: Brisk walking, hiking, skateboarding, baseball, rollerblading, and bike riding
Vigorous-intensity: Jumping rope, running, and playing sports like basketball, hockey or tennis

The main difference between moderate- and vigorous-intensity exercises is the demand on the body. Vigorous activities force the body to work harder. The heart beats faster and breathing becomes more rapid, but energy is used up faster.

  • Rollerblading
  • Learning karate
  • Playing organized sports (field hockey, soccer, football)
  • Swimming
  • Gymnastics
  • Strength training with weights
  • Rock climbing
  • Cross-country skiing

Before your child jumps into a new fitness routine, it is important that you work with your child’s doctor. Being obese can put a strain on muscles and bones, possibly causing back pain and foot or ankle problems. The doctor can assess your child’s overall health and recommend safe exercises.

What Else Can Be Done to Encourage Activity?
Another important piece to the puzzle is to focus on screen time. Screen time refers to how many hours per day your child spends in front of a screen—whether it be watching TV, playing video games, or using electronic devices. These are sedentary activities that contribute to obesity. The NHLBI recommends that screen time should be limited to less than 2 hours per day, which leaves more time for exercise. You can further encourage your child to be active by planning family outings, like going on a hike, riding bikes, or playing flag football. That way, the whole family can become healthier together.

by Patricia Kellicker, BSN and Rebecca J. Stahl, MA

RESOURCES:
American Council on Exercise
http://www.acefitness.org

Shape Up America
http://www.shapeupus.org

CANADIAN RESOURCES:
Health Canada
http://www.hc-sc.gc.ca

Healthy Alberta
http://www.healthyalberta.com

REFERENCES:
Aerobic, muscle, and bone-strengthening: What counts? Centers for Disease Control and Prevention website. Available at: http://www.cdc.gov/physicalactivity/basics/children/what_counts.htm. Updated June 5, 2015. Accessed March 2, 2016.

Chapter 3: Active children and adolescents. US Department of Health and Human Services website. Available at: http://www.health.gov/paguidelines/guidelines/chapter3.aspx. Accessed March 2, 2016.

How much physical activity do children need? Centers for Disease Control and Prevention website. Available at: http://www.cdc.gov/physicalactivity/basics/children/index.htm. Updated June 4, 2015. Accessed March 2, 2016.

Krul M, van der Wouden JC, Schellevis FG, van Suijlekom-Smit LW, Koes BW. Musculoskeletal problems in overweight and obese children. Ann Fam Med. 2009;7(4):352-356.

NCHBI integrated guidelines for pediatric cardiovascular risk reduction. EBSCO DynaMed website. Available at: http://www.ebscohost.com/dynamed. Updated February 12, 2013. Accessed March 2, 2016.

Obesity in children and adolescents. EBSCO DynaMed website. Available at: http://www.ebscohost.com/dynamed. Updated February 10, 2016. Accessed March 2, 2016.

Last reviewed March 2016 by Michael Woods, MD Last Updated: 3/2/2016

EBSCO Information Services is fully accredited by URAC. URAC is an independent, nonprofit health care accrediting organization dedicated to promoting health care quality through accreditation, certification and commendation.

Achilles Tendinitis

Treatment Options for Achilles Tendinitis

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The Achilles tendon is the largest tendon in the body. It connects your calf muscles to your heel bone and is used when you walk, run and jump.  Although the Achilles tendon can withstand great stresses from running and jumping, it is also prone to tendinitis, a condition associated with overuse and degeneration. Achilles Tendinitis causes pain along the back of the leg near the heel. If you suffer from Achilles Tendinitis – try these pain relief methods.

REST: Cut back your training by decreasing your mileage and intensity. Also avoid hills and speedwork. You may substitute running with swimming, running in water and biking to reduce the irritation.

ICE: Apply ice to the affected area for 10 to 20 minutes with at least one hour between applications. Do not apply ice directly to your skin – a pillowcase or dish towel works well as a protective barrier. Frozen peas or reusable gel packs are flexible and conform well to the injured area.

PROPER FOOTWEAR/ORTHOTICS: This situation can be corrected with arch supports or custom orthotics. Orthotics allow your foot to maintain correct position throughout the gait. Avoid walking barefoot and wearing flat shoes. If your pain is severe, your doctor may recommend a walking boot or to cast you for a short time. This gives the tendon a chance to rest before any therapy is begun.

NON-STEROIDAL ANTI-INFLAMMATORY MEDICATION: Drugs such as ibuprofen and naproxen reduce pain and swelling. They do not, however, reduce thickening.

PHYSICAL THERAPY: Achilles tendinitis can be painful, chronic condition if left untreated. Consult your physician to discuss physical therapy options. Licensed physical therapists coordinate with your physician to provide individualized care and treatment options for your specific needs.

CORTISONE INJECTIONS: Cortisone, a type of steroid, is a powerful anti-inflammatory medication. Cortisone injections into the Achilles tendon are rarely recommended because they can cause the tendon to rupture (tear).