Lymphedema can be defined as an abnormal accumulation of protein rich fluid, usually in the extremities, secondary to insufficient lymphatic circulation, which causes reactive fibrosis and chronic inflammation. In other words, lymphedema is a type of chronic “swelling” that is caused by damage or removal of lymphatic tissues and can cause hardening of the skin and various other conditions.

Primary lymphedema can be present at birth, also known as congenital lymphedema. Many people suffering from this disease are unaware because it often goes misdiagnosed and even when it is diagnosed many people are unaware that it can be treated and managed. Secondary lymphedema is caused by radiation therapy or surgical removal of lymph nodes, especially during the treatment of cancer.

Lymphedema is treated in three ways, which are manual lymph drainage, bandaging/compression and exercise. The treatment of lymphedema can only be performed by a therapist who is credentialed as a “CLT” or Certified Lymphedema Therapist. This therapist will perform manual lymph drainage (a soothing and relaxing “massage” of the superficial skin) in order to push the fluid from areas of accumulation to areas where the lymph nodes are working normally. Bandaging is performed in order to provide a consistent compression that will move the excess fluid from the areas of pooling to free and healthy lymph nodes. Exercise is then performed to create an active muscle contraction that assists in moving the fluid out of areas of accumulation to areas that are free.

Manual lymph drainage, bandaging and exercise are not only helpful for the treatment of lymphedema but are also the gold standard, “non-surgical” treatments for chronic venous insufficiency (CVI) and can also be used to manage and treat post-surgical swelling.

Certain research studies estimate that up to 85% of patients who receive cancer treatment suffer from different stages of lymphedema. In order to better understand and treat this disease, Recovery Physical Therapy has sent a Physical Therapist for thorough training in the diagnosis and treatment of lymphedema. In our continued effort to provide comprehensive care for our patients, Recovery Physical Therapy is now proud to offer treatment of Lymphedema as well as Chronic Venous Insufficiency. Please contact Richard Brooks PT,DPT,CLT at (212) 953-9494 or visit our Grand Central office at 200 Park Ave (MetLife building).

Further information about Lymphedema can be found at the website of the National Lymphedema Network. The address is www.lymphnet.org

We Mamas tend to favor one side or the other when holding, carrying and breast feeding our babies, putting extra strain on our bodies and tendons.

I quickly consulted one of our physical therapists when the pain set in.  Recent research has shown that the way tendon pain has been treated in the past, by treating the inflammation, may not be effective.  Tendon pain may mean something is wrong with the tendon and inflammation may not have anything to do with the pain.  Cortisone shots treat inflammation and provide only short term results. 

Rest, another protocol of the past is also ineffective.  Once the rest period is over and the tendon is back in use, very often the pain returns.  In my case, rest sounds delightful, but is not possible.  I’m not that skilled at caring for my 6 month old or 4 year old with one arm, while the other one just relaxes.  Oh, but rest is such a lovely concept, can you write me a prescription Dr?

Physical therapy provides the best results and in my case, my only choice.  My physical therapy home exercise program is a combination of “active rest” with progressive and functional strengthening exercises.   Together, the exercises strengthen the areas around my tendon while increased blood flow heals the tendon. 

A friend recently forwarded me Jane Brody’s article, “For Tendon Pain, Think Beyond the Needle”, which further confirmed the latest research and my experience.

http://www.nytimes.com/2011/03/01/health/01brody.html?_r=1&emc=eta1#

At RPT, our home exercise program is on-line; the exercises are demonstrated using 3-D animation.  This is fabulous, as my “Mama activities” keep me moving from dawn until late in the evening and I can do my exercises at odd hours.  Because of the animation, I know I’m doing them correctly and for some reason, viewing them on the computer holds me accountable.

I’m happy to report that just the other day, during a rare quiet moment, I noticed that my arm didn’t hurt anymore.  No pain!  A true miracle.  Should you find yourself with tendon pain, talk to a physical therapist first and get moving.  The pain will be gone before you realize it.

Reed was a difference-maker in this weekend’s matchup against the Texans but landed hard on his left hip in the first half, and in the next to last play of the game rolled his left ankle. Though x-rays of the ankle were negative, and Reed claims he’ll be good to go, he isn’t likely to be feeling too great about now… hopefully only a Grade I ankle sprain and a mild hip contusion.

Giants safety Deon Grant passed concussion tests after leaving the field in the third quarter in the contest against Green Bay. Awaiting further reports…

John Kuhn, Packers’ fullback, suffered an unspecified knee injury in the third quarter and did not return. Unfortunately for Green Bay, he will have plenty of time to recover. A less than impressive performance by a team that deserved the spotlight all season long, and a surprising demonstration by the Giants, a team that has been peaking at the perfect time…

A healthy New England put the clamps on Denver, and the absence of the Broncos’ prized wide receiver, Eric Decker, (knee) wasn’t likely the cause. Some reports claim the loss was in part due to the fact that starting safety Brian Dawkins was out with a neck injury, while other starting safety, Quinton Carter, left the game in the first half, also with a neck injury. Denvers’ strong safety David Bruton and DT Brodrick Bunkley exited mid-game as well (in the third), both with concussions. The game was long over by then… The number of concussions in the NFL remains a particularly scary issue.

The Patriots suffered fewer in-game losses, with only TE Aaron Hernandez leaving the game in the fourth, also with a head injury after absorbing a hard hit.

Somehow, I don’t think an intact Broncos team would have had a chance against the Pats the way New England played on Saturday. A disappointing game, especially after all the hype that preceded it…

What drama in San Francisco – the game was riveting! Niners’ TE Delanie Walker didn’t play against the Saints because of a fractured jaw, sustained in late December. AP reports he is hoping to play for the NFC Championship. As with other playoff teams, several players were inactive or questionable at game time. Those suffering mid-game injuries included Niners’ center Jonathan Goodwin who hurt his left lower leg in the second quarter but returned to the game shortly thereafter. Receiver and kick-return man Ted Ginn Jr. wasn’t certain to start due to a prior ankle sprain. Though he was out there, he was hurting enough by mid game (with either an ankle flare-up or a new ankle injury) to merit some time on the bench. Though Ginn returned for a brief time, he was removed again in the third quarter after sustaining a knee injury. I would be very surprised to see him return for the NFC Championship.

New Orleans was missing WR Lance Moore, who was inactive due to a hamstring injury, and had several other players dealing with prior injuries not thought serious enough to keep them from playing. In-game losses included Saints RB Pierre Thomas who had a head injury in the first quarter and Jimmy Graham, who scored a touchdown after returning to the game in the second quarter after suffering a lower extremity injury earlier in the game. The injured Saints, along with those banged up on the Packers, Broncos and Texans will have the next six months to heal.

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Do you think Ed Reed will be hampered by his injuries this weekend?

The ACL is the primary stabilizer of the knee, while the MCL protects the medial (inner) compartment of the knee. Both ligaments attach to the femur (of the thigh) and the tibia (of the lower leg). The medial and lateral (outer) menisci are the pieces of fibrocartilage that lie between these two bones. They serve to create a better fit at the joint, and act as secondary stabilizers as well as shock absorbers.

These three structures are oftentimes injured together because the nature of the trauma forces the joint into a position that stresses the ligaments beyond their capacity to check the motion and simply tears these stabilizing structures. According to Wheeless’ Orthopaedics, the mechanism of injury most often involves internal rotation of the femur on the tibia with the knee in flexion (bent). The femur tends to position the medial meniscus toward the back of the center of knee joint, catching the posterior portion between the femur and tibia. When the joint is suddenly extended, the meniscus tears along its length.

The medial meniscus is affected more often than the lateral both because of the way in which the knee is generally stressed and because it is attached to the deep fibers of the MCL. Thus, stress to the medial collateral also pulls on the medial meniscus. The lateral meniscus is not anchored to the lateral collateral on the outer side of the knee.

Peterson will have a challenging rehab ahead of him, but he is young and motivated. Willis McGahee did even more damage to his knee in the Fiesta Bowl in 2002 and continues to be a very productive running back, even in spite of a string of new injuries. Don’t count Peterson out. If he’s not back for the start of the season, he will likely join the Vikings midway.

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Arizona Cardinals’ rookie, and second round draft pick, Ryan Williams, has been sitting out the entire 2011 season with a right patellar tendon rupture that he sustained during a pre-season game. Only 20 years old at the time of his injury, Williams is missed on a Cardinals team that has been rebounding from a rough start and might be playoff bound if he’d been out there.

Last year’s victims of a torn right patellar tendon included Nate Allen, a rookie safety on the Eagles who was injured in December of 2010, and Clint Sintim, NY Giants linebacker, who was sidelined during a pre-season game.

Interesting that all the injuries were on the right side…

The patellar tendon is a part of the extensor mechanism of the knee and it serves to connect the patella (kneecap) to the tibia (larger bone of the lower leg). The extensor mechanism acts to straighten (extend) the knee, and is also comprised of the four quadriceps muscles of the front of the thigh, the quadriceps tendon (which attaches the quads to the patella), the ligaments that help to stabilize the patella (by providing a connection to the femur (thigh bone) above and to the tibia below), and also by other soft tissues on either side that help stabilize the patella and other structures of the knee.

Patellar tendon ruptures are relatively rare and they occur most often in people younger than 40 (most are in their teens or twenties). Ruptures can either be partial or complete. Complete ruptures should be surgically repaired quickly in order to enable the tendon to be sutured end-to-end. This also optimizes outcome. Waiting would result in retraction of the tissue and make a repair more difficult. The upper (proximal) portion of the patellar tendon ruptures more often than the lower. Some of these proximal ruptures pull a piece of bone away from the lower part of the patella; this type of injury is called an avulsion of the patella. It has been noted that African Americans have a greater predominance of patellar avulsions than other groups.

A complete rupture of the patellar tendon renders the quadriceps helpless, making it impossible to straighten the knee. A partial rupture makes extension difficult and is likely to make it impossible to straighten the knee through the end-range of motion.

Post-operative rehab is (as coaches say about almost everything), a process. Controlling pain and swelling in the initial phase, while also addressing mobility of the scar and surrounding soft tissue is crucial. Care must be taken to protect the repair and avoid stretching the sutured tendon too quickly, while ultimately restoring full range of motion – thereby enabling the knee to bend. Weight bearing is gradually resumed and assistive devices (crutches and canes) are eliminated once the extensor mechanism is strengthened sufficiently to fully support ambulation without significant gait abnormalities. Muscle strengthening, flexibility and endurance, as well as overall mobility and agility are all a part of rehabilitation.

A study on the recovery of NFL players who suffered patellar tendon ruptures concluded that the injury occurs most often with eccentric overload* of the extensor mechanism. It also noted that anterior cruciate ligament (ACL) tears occasionally accompany patellar tendon ruptures in the NFL, and that players without complications from other injuries generally return to play the following season. The study also found that players who’d been chosen earlier in the draft were more successful in returning to play.

• An eccentric muscle contraction is one when the muscle is actually lengthening while it is working. An example would be the second phase of a biceps curl when the elbow is straightening, thereby lengthening the biceps while the muscle works against gravity (and added weight) to slowly return the arm to its resting position.

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Leinart isn’t the first quarterback to fracture his clavicle this season. That honor went to Jason Campbell, of the Oakland Raiders, who landed on his shoulder after being hit on October 16th. Campbell had surgery the following day to repair his fracture, and this week attempted, unsuccessfully, to begin a throwing program. It’s been written that Leinart’s treatment will be more conservative and simply entail wearing a sling and undergoing physical therapy.

Mid-Shaft Displaced Clavicle Fracture

So, why the difference in treatment?

The choice of how to address a fractured collarbone depends on several factors, including: the location of the fracture (whether it is toward one end of the bone or the other, or whether the injury is mid-shaft), whether the portions of the bone remain aligned or if they become displaced, or whether there are other complications from the trauma, such as a fractured scapula (shoulder blade), or injury to the brachial plexus (a network of nerves in the neck that extend to the underarm area). Plexus injuries are most likely to occur if the trauma forces the head away from the shoulder, putting the nerves on extreme stretch, or if a portion of a broken clavicle causes direct injury to the nerves.

Conservative (non-operative) treatment of mid-shaft fractures has been shown to have poor results, though there is risk of non-union (incomplete bone mending) with non-operative management of other types of clavicle fractures as well. Though there is often a deformity of the bone after conservatively managed clavicular fractures, healing is generally rapid and the deformity is not generally symptomatic. Of course, disuse of the upper extremity during the initial protective phase of healing (whether post-operatively or not) results in loss of strength, and therapy to restore strength, full range of motion in the shoulder and flexibility of the musculature is also necessary.

At it’s inner end, the clavicle forms a joint with the sternum (breastbone), and at its outer end, it forms a joint with the scapula (shoulder blade). The latter, known as the AC joint (acromioclavicular joint), is often separated due to falls onto the shoulder.

There are several muscles that attach to the clavicle and these can exert forces on the fractured bone that pull the fragments apart, contributing to non-union. The central portion of the collarbone is least covered by muscle and is the region where these issues most often occur.

Here is a link to the summary of a study involving the management of middle-third clavicle fractures in the NFL. It discusses variable courses of care and length of time to return-to-play. After comparing cases over a five-year period, researchers concluded that displaced middle-third clavicle fractures were best treated surgically in order to “enable a successful clinical outcome in a predictable time frame.” I am assuming that Leinart’s fracture was non-displaced, without complications and possibly not mid-shaft, thereby allowing him to avoid surgery.

On an unrelated note, and for the record, it bears mentioning that CBS.Sports.com lists 46 players as having hamstring injuries. Yikes! Just thought you’d like to know…

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Peyton Manning (Colts) should probably consider shutting it down permanently after his third neck surgery, and Matt Cassel (Chiefs) just had surgery to address a “serious injury” to his throwing hand, suffered last week Though many reports have team management hoping Cassel will make a miraculous recovery and return this season, it isn’t likely. The specific nature of his injury remains a mystery to me, as reports are vague.

With a bye in week 11, the Texans are simply listing Matt Schaub as out for week 12. Schaub was diagnosed with a Lisfranc Injury and, though surgery seems probable, even if it is avoided, Schaub clearly won’t be back this year.

Other starting QBs not practicing this week include: Michael Vick (Eagles), resting the cracked ribs he played with for most of last Sunday’s contest, and Jason Campbell (Raiders), out since leaving the game on 10/16 with a fractured clavicle (collarbone).

Those who participated in limited practice and are listed as questionable for this weekend include: Tarvaris Jackson (Seahawks) who’s been out since exiting a game on 10/9 with a torn pectoral muscle, and Kevin Kolb (Cardinals), who hasn’t played since sustaining a turf toe injury on October 30th.

Able to rest his newly fractured thumb with a bye this week, Ben Roethlisberger (Steelers), is probable for week 12 after taking part in practice. Also likely suffering, though taking part in full practices and listed as probable for week 11, is Sam Bradford (Rams), out since suffering a high ankle sprain on 10/16.

Mathew Stafford (Lions) played last week with a fractured index finger in his throwing hand, an injury sustained in the game the week prior. The injury clearly limited Stafford’s effectiveness, yet he too is probable for week 11.

Rookie Christian Ponder (Vikings), took a beating in a big Monday night loss this week and, despite the need for x-rays of his left hand, is also reportedly likely to start.

Finally, Josh Freeman (Bucs), who like Stafford, played with an injury (thumb) is again likely to play in week 11. Both Ponders and Freeman threw a lot of interceptions last week, so for all the macho of the league, playing hurt doesn’t seem to be paying big dividends – for the injured players, the teams or for fantasy enthusiasts.

Many QBs on the current injury report made earlier appearances on the list this season with other ailments, as did some of their back-ups. It is likely that these injuries remain somewhat of an issue, though to a lesser extent (Stafford’s ankle, Schaub’s hip, Romo’s rib, Vicks other fractured ribs, Bradford’s finger amongst them).

Exposed in the quarterback shuffle and in the push for starters to play through significant injury is the thinness of the rank at the QB position. How effective will the walking wounded be on Sunday?

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New York is a Direct Access state, which means that patients can go to a physical therapist without a Doctor's prescription.

Although many conditions, especially those that require a more in depth diagnostic workup, should be managed through a physician, there are a number of instances where seeing a physical therapist through direct access makes very good economic sense without compromising outcomes.

For more information about this study, visit:

 http://www.apta.org/PTinMotion/NewsNow/2011/10/14/DirectAccess/#.TrhAVfT_2XQ.email

What makes McGahee’s accomplishments even more remarkable is that he played less than two weeks after surgery to repair a fractured fourth metacarpal in his right hand. McGahee had suffered the impact injury against a defenders mask versus the Dolphins on October 23rd.

The procedure performed on McGahee reportedly entailed stabilizing the fracture in his ball-carrying hand with a plate and five pins.  Originally casted, he reportedly wore only padding over his incision during practice last week and was absent that at game time. McGahee was quoted as saying that he  ”suffered what doctors call a boxer’s fracture.” but could now ”bend my hand without it hurting or anything”.  Improbable but we’ll take him at his word.

McGahee is no stranger to an accelerated return to action.  Having ended his college career in the 2003 Fiesta Bowl with devastating tears of his left ACL (anterior cruciate ligament), PCL (posterior cruciate ligament) and MCL (medial collateral ligament), he was drafted in the first round after an early return at the combines, and went on to a brilliant rookie season with Buffalo.

So what are the Metacarpals, and what is a Boxer’s Fracture?

The metacarpals (MCs) are the long bones in the hand that extend from the small carpal bones (that comprise part of the wrist) to the base of the fingers. Each metacarpal has a base near the wrist and a head at the knuckle (forming a joint with the lower bone of the finger – the proximal phalange) and a shaft and neck in between.

The MCs are most often fractured due to impact with a closed fist.  I know of too many people who’ve had this injury from punching a wall in anger.

Some metacarpal fractures can be treated conservatively with splinting. Others, like McGahee’s, require surgery, either because they are displaced (the segments of the bone no longer line up) and involve the joint, because more than one MC is fractured, or due to soft tissue that is in the way, preventing the bone from being set. I have not seen reports of the specific nature of McGahee’s fracture, but it is likely his falls into one of the first two categories.

Fractures can occur at any point in the metacarpals, though the very common  Boxer’s Fracture  is technically considered one that occurs at the “neck”of the fifth metacarpal, which is the MC leading to the little finger.  Therefore, with his fourth MC injured, McGahee may have been misinformed.

Typically the union (mending) of a metacarpal fracture occurs in six weeks.  Indeed, that is considered to be the response time for the healing of many fractures. Generally, due to splinting of the injury, whether managed conservatively or surgically, some loss of motion is expected, and rehab to restore mobility, strength and muscle flexibility is important. Inflammation must also be managed to control swelling. McGahee’s return in less than two weeks and his effectiveness is doing so is astounding.  His hand can’t be feeling too good right now though.

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Congratulations to our patients who completed Sunday's NYC Marathon. 

We were happy to be a small part of a huge accomplishment.  Great job runners!

• David T.
• Josephine M.
• Rupert M.
• Marina K.
• Jason P.
• Harvey R.
• Robin V.
• Brian P.
• Matthew W.
• Eric T.