What is Vestibular Dysfunction?
The main symptoms are vertigo, dizziness and imbalance. These symptoms often lead to physical, emotional and cognitive challenges which can include depression and anxiety. Many patients find they have difficulty performing activities of daily living. Cognitive abilities can be impacted as symptoms progress.
Vestibular/balance rehabilitation assists individuals who are experiencing difficulties with balance or dizziness in improving function and preventing falls by thoroughly evaluating each individual’s needs and providing a treatment plan to address their specific concerns.
What causes dizziness?
A variety of central and peripheral neurologic and orthopaedic diagnoses can contribute to dizziness and imbalance and may be effectively treated through vestibular/balance rehab.
• Falls or vehicle accidents
• Effects of aging
• Inner ear disorders (e.g., benign paroxysmal positional vertigo, ototoxicity, labyrinthitis)
• Brain injury and post-concussion syndrome
• Stroke and other neurologic conditions
• Vertigo and disequilibrium
• Motion sensitivity
• Orthopaedic injuries and conditions
• Heart conditions
How can Physical Therapy help?
Vestibular Therapy can help patients restore function, control symptoms, and improve quality of life. A thorough evaluation with a vestibular therapist involves an assessment of pertinent vestibular and neuromuscular system functions, including strength, range of motion, coordination and balance, head and eye movements, mobility, and risk for falls. The physical therapist will create an individualized treatment plan and a home exercise program to decrease dizziness symptoms and address musculoskeletal or neuromuscular problems that affect balance. Vestibular/balance rehab may also include gait training with an appropriate assistive device, patient education regarding safe home mobility, as well as other therapeutic exercises and activities.
We offer Vestibular Rehabilitation services at our Upper West Side and Midtown East locations
Upper West Side 248 West 80th Street, 5th Floor New York, NY 10024 Phone: 212-874-1550 Fax: 212-874-1599 Monday – Friday 7:00 am – 8:00 pm
Midtown East 575 Lexington Avenue (at 51st St) New York, NY 10022 Phone: 212-371-7869 Fax: 212-755-2030 Monday – Friday 7:00 am – 8:00 pm
For more information, please contact: Elizabeth Lamontagne: or Nina Kansagra:
Kinesiology taping has gained popularity among athletes and trainers, but it isn’t without its skeptics. So how does taping really work? There are 3 main proposed effects of kinesiology tape: 1. decrease pain, 2. tissue decompression, and 3. neurosensory input to improve body awareness.
Wu et. al. looked into the kinesiology taping method and found evidence to support the immediate effects of mechanical decompression on blood and lymph circulation. Other studies have supported that there is a significant elevation and separation of fascial layers of skin and its underlying tissue. The increase in blood and lymph flow aides in reduction of swelling and aids in recovery post-injury. This effect additionally allows for pressure relief, corresponding to less pain as pressure is relieved from compressed free nerve endings.
An additional effect of taping is on joint position sense, or proprioception. Seo et. al. looking into effects of taping on adults who have experienced ankle sprains and have found improvement of joint position sense with application of the tape. Callaghan et. al. used magnetic resonance imaging (MRI) to investigate whether taping had any influence on brain activity and found that use of tape while performing a task resulted in increased brain activation in regions responsible for control of motor movement. Kinesiology taping can also provide a facilitation or inhibition effect for muscle contraction as it provides a stimulus for specific cells in the muscle responsible for sensing muscle tension. This regulates muscle function, promoting better biomechanics and potentially preventing future injury. As such, the use of kinesiology tape could be used as an adjunct to treatment of a wide variety of issues including ankle sprains, patellofemoral pain syndrome, and shoulder impingement.
Wu WT, Hong CZ, Chou LW. The Kinesio Taping Method for Myofascial Pain Control. Evid Based Complement Alternat Med. 2015;2015:950519.
Seo HD, Kim MY, Choi JE, et al. Effects of Kinesio taping on joint position sense of the ankle. J Phys Ther Sci. 2016;28(4):1158-60.
Callaghan MJ et al… Effects of patellar taping on brain activity during knee joint proprioception tests using functional magnetic resonance imaging… Physical Therapy… 2012; 92(6): 821-830.
Falls occur when there is a loss of balance with an inability to control one’s posture. Sensory input, the external information received from our surroundings, influences our balance.
Three types of sensory input received include:
-visual input (i.e., vision),
-proprioceptive input (i.e., joint position, related to standing surface),
-and vestibular input (i.e. head positioning).
These, together with postural reflexes, help with postural control.
As we age, there are declines in the sensory and motor function that affect balance. When balance is affected, this can lead to falls, or a fear of falls, which may lead to decreased participation in the home and community, isolation, inactivity, and possibly decreased independence.
One study looked at how these three sensory variables can affect balance, specifically, postural sway. Postural sway is the movement of the center of mass while standing, and postural control is the ability to maintain the center of mass within the base of support with minimal postural sway . Pociask, et. al. (2016) explored the involvement of head position, along with vision and standing surface, and their contributions to postural sway in older adults. They assessed this in a group of community-dwelling older adults 60 yrs or older, free from physical/medical difficulties that would influence balance. Participants were required to stand and try to maintain their balance under eight different condition combinations of: eyes open or closed, on a firm or foam surface, and head neutral or extended.
Significant results showed postural sway increased: 1) On both firm and foam surfaces, with eyes closed, 2) On both firm and foam surfaces, with head extended, 3) With eyes open and eyes closed, with head extended; and the most postural sway occurred: 4) On a foam surface with eyes closed and head extended. These findings aligned with their initial hypothesis, that head extension increased sway for all visual-surface conditions.
The results of this study indicate that head position is relevant to address when assessing functional tasks involving head extension, as this may put older adults at risk for loss of balance, resulting in falls. Furthermore, this risk increases when on a soft surface with vision occluded.
The Philadelphia Eagles faced off against NFC rival Los Angeles Rams in a contest that many think could be a potential NFC Championship preview. The Eagles came out with a victory, winning 43-35 but suffered a more important loss. In the third quarter, the Eagles star quarterback Carson Wentz dived forward for what was initially thought was a touchdown but took a big hit to both of his legs. The touchdown was called back on a holding penalty but Wentz went on to complete the drive with several hand offs and a great throw in the pocket to receiver Alshon Jeffery for a touchdown. Wentz left the field on his own volition after the drive and walked back to the locker room amid the long faces of the Eagles support staff. It was reported later that Wentz had torn his left ACL which will end his potential MVP season. This is devastating for the Philadelphia Eagles who were super bowl favorites and currently own a 11-2 record, best in the NFC.
Anterior Cruciate Ligament injuries are a very common orthopedic injury in all sports but most notably in sports played on grass/turf due to the high level of cutting required. ACL injuries are frequently non-contact such as when pushing off or pivoting during which the distal aspect of the lower extremity is pushed laterally causing the knee to buckle inwards (known as a Valgus Stress) which places a large amount of stress on the ligaments of the knee most notably the ACL and the Medial Collateral Ligament. ACL injuries can also be from contact or blunt force trauma as in the case of Wentz. A blow to the lateral side of the knee can cause a large valgus force that can lead to an ACL tear.
The ACL is one of the key stabilizing ligaments of the knee along with the posterior cruciate ligament, medial collateral ligament and the lateral collateral ligament. The ACL’s primary function is to control anterior translation of the lower leg(Tibia) on the upper leg(Femur). When one or more of the knee ligaments are not intact, the knee becomes inherently unstable and can cause the knee to buckle or suffer additional soft tissue injuries. For athletes, this is especially problematic as they will not be able to confidently cut or pivot on their affected knee. When a high level professional athlete suffers a complete rupture of the ACL, reconstruction of the ligament is necessary if the athlete wishes to return to sport.
Rehabilitation for an athlete undergoing ACL reconstruction generally takes about 6-8 months to return to sport but can sometimes take over a year. It is important to make sure that the graft that is used to replace the deficient ACL is as strong as it needs to be to tolerate the extreme stresses at the knee of high level sports. It is also important for the athlete to regain as much knee/hip strength (most notably the hamstring which assists the ACL in preventing anterior translation of the tibias) as possible to regain stability at the knee. The athlete must also gain the confidence to compete at a high level on their affected knee which can often be the limiting factor in returning to sport. Early ACL rehab focuses on the athlete regaining full knee range of motion as well as volitional quadriceps strength to allow them to fully straighten the knee. Focus in the first few months is placed on strengthening all of the muscles of the knee/hip/ankle as well as working on balance and proprioception to help return the knee to its pre-injured state. Once the new graft has been given ample time to set (10-12 weeks) more high level strengthening and some sports specific training can begin.
Bears Tight End Zach Miller has Emergency Vascular Surgery Following Knee Dislocation by Sean Sullivan, PT DPT
While orthopedic injuries tend to dominate the headlines in professional sports leagues such as the NFL, neurological or vascular injuries can occur in conjunction and often can be limb/life threatening. Chicago Bears tight end Zach Miller caught a pass in the end zone during their game against the New Orleans Saints when he landed awkwardly on his left leg and came up lame in obvious pain/distress.
His injury was initially diagnosed as a fracture of his leg but was later diagnosed as a knee dislocation. A dislocation the bones that make up that joint are separated often times due to trauma. In Miller’s case, his Femur(thigh bone) and Tibia(shin bone) were separated. It is not known at this time whether Miller suffered any fractures along with this dislocation but it is likely that he will require surgery to repair any soft tissue(ligament) damage that occurred.
What happened in conjunction with Miller’s dislocation turned out to be the more pressing concern for the NFL veteran. Miller also suffered a rupture of his popliteal artery. Miller’s leg was stabilized by on field medical personnel and was rushed to the University Medical Center of New Orleans where he underwent emergency vascular surgery to repair the damaged blood vessel. He is currently being monitored to ensure proper healing/blood flow following his surgery.
The popliteal artery originates from the femoral artery which runs from our groin down the front/inside of our thigh. The Popliteal artery can be found on the posterior aspect of our knee and branches into its various divisions below the knee where it supplies blood flow to our entire lower leg. It is not difficult to see why a rupture of this artery( or any for that matter) is an emergency medical condition. When an artery is damaged, the blood flow to the areas of the body that are supplied by that vessel is impaired which leads to tissue ischemia. Prolonged ischemia of 6-8 hours can lead to irreversible tissue death and can result in amputation being the only means of preserving a limb.
While Miller’s injury is a very rare case, it is important for all medical personnel (on or off the field) to properly evaluate neurovascular integrity of a patient’s limbs following trauma. This means checking all pulses distal to the injury sight and assessing sensation to rule out any nerve or blood vessel damage. Making sure to not forget this crucial step can ensure that patients do not endure long term health ramifications due to late detection of neurovascular damage.
The 2017-18 NBA season tipped off last night with a rematch of last years Eastern Conference Finals pitting the Cleveland Cavaliers against the Boston Celtics. Just minutes into the first quarter Celtic small Forward Gordon Hayward went up for an alley-oop dunk from guard Kyrie Irving when came down awkwardly on his left ankle. The photo below shows Hayward in the air before landing on his left leg. The next photo shows Hayward sitting on the court in visible pain and gives a great view of how his ankle looked after the fall. Those who are squeamish, scroll down with caution.
While further details are still to come on the specifics of Hayward’s injury, what we do know is that he sustained a fracture of his left Tibia(Shin Bone) and a dislocation of his ankle joint. He is set to have surgery on that ankle Wednesday back in Boston. He will likely require a plate/screw/nail fixation(Open reduction with internal fixation) to keep his ankle joint stable and possibly a repair of the ligaments that work to stabilize his ankle. Luckily the Celtics medical staff were able to reduce/relocate his ankle on the court before placing it in an air cast which helped to reduce his pain. He also likely avoided any nerve/blood vessel damage that can occur with this type of injury as this would require immediate surgery.
Rehab for this type of surgery is likely to be at least 3-4 months but possibly longer depending on the degree of soft tissue damage that Hayward sustained. This is important because when a joint is dislocated, often times the surrounding ligaments become compromised, as they work passively to stabilize the joint. As discussed in my post on high ankle sprains, soft tissue such as ligaments do not heal as quickly as bone due to their poor blood supply. If the damage to the surrounding ligaments of Hayward’s ankle is severe, this will likely add months to his recovery and will make his return this season very unlikely.
The NFL suffered another painful blow to their star power when Aaron Rodgers left during the 1st quarter of the Green Bay Packers game against the Minnesota Vikings after suffering a fracture of his right clavicle. Rodgers was tackled by Vikings linebacker Anthony Barr and was drilled into the ground. Barr was not penalized for the hit and while deemed legal by NFL rules many felt the roughness of the tackle was unnecessary. Rodgers will have surgery to repair the fracture which will likely end his regular season.
The mechanism of injury for Rodgers is typically how a clavicle fracture occurs which is a direct blow or fall onto the lateral shoulder. The most common area of the clavicle to be fractured is the middle third of the clavicle and these types of fractures typically heal well without surgery if the fracture is not complex or displaced. These type of fractures can heal with a period of immobilization in a sling. If the fracture is at the distal end of the clavicle or is a complex fracture, this will almost always require surgical treatment.
It has not come out what type of fracture Aaron Rodgers suffered but what we do know is that he will require surgical treatment which likely will involve an open reduction internal fixation. This means that the surgeon will need to perform an open surgery to allow them to put the fracture back in place and then use some type of fixation(Screw, nail, plate) to hold the fracture in place while it heals. Since the clavicle does move slightly with shoulder elevation, it is important to limit overhead activity for the first few weeks. Rodgers will likely be in a sling for the first 4-6 weeks and will not be able to start throwing until at least 3 months.
Week 4 of the NFL season just concluded on Monday night following the Kansas City Chiefs last second win over the Washington Redskins. As with just about every week of NFL games comes a host of injuries to key players on contending teams, often times of the season ending variety.
Rookie running back Chris Carson of the Seattle Seahawks suffered a season ending left leg injury during the Seahawks win over the Colts on Sunday night. What was originally diagnosed as a fracture of his left lower leg turned out to be more severe. In addition to the fracture that he suffered in his fibula, Carson suffered a severe syndesmosis tear otherwise known as a “High Ankle Sprain”.
The syndesmosis is a series of ligaments that connect the ends of the two lower leg bones, the tibia and the fibula. A tear of one of these ligaments is a common injury in American football and is generally caused when the athlete’s foot/ankle is pushed into extreme external rotation. It can also be caused by a blow to the lateral aspect of the knee/lower leg with the foot planted which causes the syndesmosis to be over stretched which is what happened in Carson’s case as seen in the picture below.
The words “High ankle sprain” are words an athlete never wants to hear. Unlike a typical lateral ankle sprain which is a tear of one of the lateral ankle ligaments, a syndesmosis tear takes more time to heal. If there is a disruption of the any of the syndesmosis ligaments, these ligaments are stressed any time the athlete tries to bear weight on that limb as the athlete’s body weight and gravity put stress through the lower leg and tries to separate the tibia and fibula. This is the primary reason why recovery from a high ankle sprain can take longer to heal and are prone to reoccurrence.
MRIs are the gold standard for diagnosing a high ankle sprain. Depending on the grade of the tear, a patient may or may not be instructed to bear weight following the injury. Upon imaging, if there is no widening of the space between the tibia/fibula, the fracture is considered stable and are treated conservatively with rest/rehab and can weight bear as tolerated. If there is mild widening of less than 4cm, then the athlete is generally immobilized in a walking boot. If there is significant widening of the mortise of greater than 4cm, this will require surgical treatment which unfortunately is what will end Carson’s season. Following surgery, Carson will likely be immobilized in a plaster cast for 2 weeks and transferred to a cast boot for another 4-6 weeks during which he will be non weight bearing to avoid stress to the healing fracture/ligaments.
Angels outfielder Cameron Maybin, sustained a Grade 1 right knee MCL sprain in a stolen base attempt on Tuesday. Also on Tuesday, Stephen Vogt, Brewers backup catcher, sprained his left MCL in a collision at the plate with Pirates pitcher Chad Kuhl. Kuhl remained in the game. The Grade of Vogt’s injury was not reported.
Some MCL Anatomy
A Medial Collateral Ligament, or MCL, is a ligament that stabilizes the inner (medial), aspect of joints such as at the knee and elbow. At the elbow, it is the ligament that is reconstructed when pitchers undergo Tommy John surgery. It is a fibrous band of tissue and – in the case of the MCL at the knee – it has both a superficial and deeper layer, each of which has different attachments. For more detail on the medial knee and origins and insertions of the ligament take a look here, or here.
The superficial MCL serves as the primary restraint to check against forces to the outer knee that would result in the knee collapsing inward. This is known as a valgus stress. The superficial portion of the MCL has both anterior (front) and posterior (rear) fibers and the degree to which they are effective in this role depends in large part on the position of the knee when the stress occurs. When the knee is almost extended, the ligament contributes somewhat less to the stability of the joint. Therefore, testing for the integrity of the MCL is done with the knee flexed to 30 degrees, an angle at which the ligament is most effectively isolated.
The deep layer of the MCL is often separated from its superficial counterpart by a bursa, which allows for a greater mechanical advantage and smoother gliding of tissues. A point of note with regards to the deeper layer of the MCL is its attachments to the meniscus both from the femur above and the tibia below (it also inserts directly into the top of the tibia at the tibial plateau). Because of its meniscal attachments, MCL injury can result in meniscal injury as well. Though the deeper layer does not contribute much as a restraint against valgus stress, it does serve as a secondary check to anterior translation of the tibia (which would result in knee hyperextension). The Anterior Cruciate Ligament (ACL) serves as the primary restraint to this motion. The relationship between the two ligaments is the reason that ACL injuries are often accompanied by those to the MCL.
Diagnosis and Treatment
Ligament sprains are graded from Grade 1 – which is a mild tweak causing less damage – to a Grade 3, or complete rupture. Time lost to competition depends on the severity of the injury, the specific location of the tear and the individualized nature of the healing process. Pain can be very localized or more diffuse depending on where the tear occurs. MCL tears at the attachment to the femur can result in a portion of the bone being avulsed, while tears more central to the ligament can cause significant soft tissue damage. Tears at or near the tibial attachment may cause pain to run down the shin and it is also possible to experience an MCL tear deep to the pes anserinus, a site of attachment of several muscles/tendons below the knee at the medial aspect of the tibia.
MRI can be helpful in identifying the location of the tear and the degree of damage. Treatment is generally non-operative with a healing response time for significant tears of six weeks. However, because remodeling of the scar tissue involved in the healing process can take up to a year, the tensile strength of the tissues can be compromised during that extended time. Interestingly, studies have noted that even though mature scar tissue has only 60% of the strength of a normal MCL, the fact that there is a proliferation of this tissue compensates sufficiently so that “the ultimate load to failure is unchanged”.
Surgical intervention may be indicated when a significant gap occurs in the MCL at the area of a tear or when a portion of bone is avulsed.