When should I see a physical therapist?

Many of the patients I treat are extremely active, though few make their living playing sports professionally. They are passionate about their lifestyle and sport of choice, and take their health very seriously.  With many sports and hobbies, aches and pains are likely to occur.  Athletes quickly get used to sore muscles and minor injuries, often considering these a normal part of an active lifestyle.

But should these be treated more seriously?

Many of the patients with whom I work initially ignored what seemed to them to be minor injuries, yet have since become more frequent or more intense.

At what point should you visit a physical therapist?

Read more for quick tips to decide if what you’re feeling needs a closer look.

1. Immediately after a specific injury.

A number of recent studies have shown support for early physical therapy for lower back pain.  The studies show that physical therapy within 2-4 weeks of a lower back injury leads to a decreased risk of surgery and injections, fewer doctor visits, faster recovery, and fewer incidents of chronic pain.

Clinically, I have seen even earlier physical therapy provide excellent results. I am a strong advocate of patients developing a relationship with a physical therapist as a practitioner on their medical team.  I also believe that patients should have email access to their physical therapists in order to communicate updates and ask general questions.  Often, a patient will email or call our office within the first few days of an injury and we will schedule them that day.  Earlier this year, I worked with a triathlete who developed intense back pain after a weekend race.  We saw her the next day and within a week she reported an 80% decrease in her symptoms. The following week she reported a 95% improvement and was able to race again exactly one month later. The sooner we can see a patient post-injury, the faster their recovery from the painful, acute stage.  This allows us to move to more advanced stages of physical therapy earlier, in order to address the root cause of their injury.

2. If an old injury has reappeared or never disappeared!

As I was getting ready to graduate one of my runners from physical therapy the other day, she asked, “but…how will I know if I need to come back?”  It was a great question, yet one without a definitive answer.  Runners, especially, are subject to occasional minor aches and pains.  At what point should they take these more seriously and seek help?

In general, you should reconnect with your physical therapist when:

You feel pain during an activity that gets worse as you continue the activity.  This is a sign that something is not right.

Your pain changes the way you perform the activity.  If you are running down the street with foot pain and you have to limp to avoid it, go home and call your PT.  Remember, the faster the painful symptoms are addressed, the more likely the root cause will be identified and other related injuries are less likely to occur.

You feel pain during three consecutive workouts or activities Often pain will be present at the start of an activity, but will disappear within a few minutes.  Does that mean it should be ignored?  No.  If you are consistently feeling the same or similar symptoms, even if they go away during the activity, schedule an appointment.  Pain is a sign of tissue fatigue or too much stress on a particular part of the body, likely related to an underlying movement dysfunction.  In English?  You’re likely not moving as well as you could, an area of your body is doing more than its fair share of the work, and it needs some help.

3. For an annual check up.

Physical therapists can be, and should be, the medical practitioners of choice for a musculoskeletal wellness/fitness screen, an assessment with a physical therapist to identify risk factors for developing a particular injury.  Much like we visit the dentist on a regular basis, we believe that everyone should schedule an annual preventative visit to their physical therapist to identify and address areas of dysfunction (that tight neck you’ve been complaining about, poor posture, or the shoulder that occasionally hurts in your bootcamp class).  Left undetected, these will likely get worse over time.  We would much rather see you once a year to revise your exercise program and keep you healthy, than have you wind up in our office as our newest patient!

Remember, you shouldn’t try to tough it out or wait until an injury becomes more severe before visiting your physical therapist.  You will wind up suffering needlessly and make our jobs even harder!

If you’re still not sure you should come in for an assessment, feel free to email us:  hello@therapydiasf.com.

In your email, please provide the following:

-where is the location of pain?

-how did the injury occur?

-how long has have you had the pain?

-what makes it hurt?

-what makes it feel better?

We will review the information and advise you on the best option for your injury.  This may include advice for self-management, the need to schedule a physical therapy assessment, or a physician contact, if necessary.

Lindsay Haas, PT, DPT, OCS


We are excited to welcome Lindsay Haas to the TherapydiaSF team!  Sydney and Lindsay worked together several years ago when Lindsay was in her last year of physical therapy school at UCSF/SFSU.  Since earning her DPT, Lindsay has practiced physical therapy in San Francisco, gaining quite the following of loyal clients!  We are happy that she will now be working with us at TherapydiaSF.  Lindsay joins the team this Monday, June 2 and will be treating patients daily, from 9:30-6:30.

 A little more about Lindsay in her own words:

“The foundation of my practice as a physical therapist comes from my certification as an Orthopedic Clinical Specialist, and my ten years combined experience working as a PT in San Francisco and as a trainer for Division I college athletes at UCLA.  My background in sports medicine and therapeutic exercise helps ensure my clients return to activity as soon as possible, and my knowledge in and passion for biomechanics – for which I use manual therapy techniques and neuromuscular re-education – helps them avoid future injuries.

By the end of physical therapy, I believe my clients should be experts on their own conditions and body.  Through working together, my goal is that they learn the root causes of their ailments, as well as gain the tools they need to play a proactive role in their own long-term wellness.  Being attentive and open-minded, I aim to listen to my clients’ words and bodies to create a rehabilitation and wellness plan that is catered to their goals.  I love building long-term friendships with my clients, engaging personally with them in support of both their injury recovery and their long-term wellness.

My desire to continue learning and improve my practice motivates me to seek out and absorb the latest research and continuing education opportunities.  My passion includes stopping injuries before they start, and I would like to see physical therapy grow to be not just about rehabilitation but also about injury prevention.  As our profession evolves, I get excited about using all the great tools available combined with ongoing education to ensure my clients remain active in the pursuits they love.”

Physical Therapists and Exercise

Why work with a physical therapist for fitness? 

PT’s are trained in movement:

We are healthcare professionals trained in optimal patterns of movement, posture, and form and will provide a safe and effective workout.

PT’s are experts in anatomy:

We will design a full body program to address strength, flexibility, cardiovascular health, and balance.

PT’s understand injury:

We will design a program that takes into consideration current and previous injuries, muscle imbalances, and current goals.

At TherapydiaSF, we offer a full selection of wellness services including:

  • Pilates
  • yoga
  • TRX training
  • general fitness training
  • small group classes
  • Fitness Screen: complete assessment of strength, flexibility, balance and independent program design.
  • RunRx: complete assessment of strength, flexibility, and video of running mechanics

An Open Letter to Well-meaning Physicians and Well-educated Patients: Volume 1, Pilates

pilates“My doctor said I need Pilates.”

“I have a prescription for Pilates.”

“I’ve been doing Pilates for months and I’m not getting any better.”

Well-meaning physicians and motivated, educated patients frequently make this assertion without a full understanding of what Pilates really is.  My hope with this post is to explain a bit more about Pilates and why the method may or may not be the best treatment for you.

1.  Pilates is an exercise method 

Joseph Pilates, a German medic who trained in boxing and gymnastics, developed Pilates as a form of exercise in the early 20th century.  As a child, he suffered from asthma, rickets and rheumatic fever. Though he had no formal training, Pilates was dedicated to improving his physical fitness and fascinated with the study of human movement.  He believed that postural dysfunction and inefficient breathing techniques contributed to poor health. Seems like he was onto something here, right? When he emigrated from Germany in the 1920s, Joseph and his wife Clara developed a following in the dance community in New York City.  As its  popularity grew,  The Pilates Method became mainstream, offered in gyms, studios and often taught as an adjunct in physical therapy clinics.

2.  Pilates is not synonymous with core stabilization

When physicians write “Pilates” on a prescription for physical therapy, it is likely that they are recommending core stabilization for their patient.  However, Pilates is too broad a term to use when making suggestions regarding a patient’s rehabilitation without a full understanding of all of the factors that may contribute to a person’s injury.  Not everyone with back pain has a weak core (GASP!) and not everyone has tight hamstrings…more on this in a future post.

3.  Pilates is not synonymous with rehabilitation  

Several years ago I sat in on a meeting of a group of local Pilates instructors to discuss forming a collective. During the meeting, I was surprised to hear such disagreement between instructors about what they actually do.  One in particular was adamant that she provided rehabilitation for her clients.  Another well-known instructor was equally vocal stating that Pilates instructors teach a method of exercise that may be helpful as clients work to rehabilitate an injury, but they do not, in fact, provide injury rehabilitation.  As a physical therapist who is Board Certified in Orthopedics, I use my Pilates training to enhance my educational foundation in anatomy, kinesiology, and pathology.  In the United States, there is a fairly large discrepancy in the training involved to qualify as a Pilates instructor.  Some instructors train with Master Trainers and participate in educational programs that include a basic study of anatomy with observation and practice hours.  These programs may also involve education about specific injuries and assessment of abnormal movement patterns and provide information on what types of exercises should be avoided.  Many instructors, like myself, are licensed physical therapists looking to expand their exercise instruction techniques.  On the other end of the spectrum are those who take a weekend class, or do some training on their own to teach Pilates. A physical therapist is best trained to perform a full physical examination to determine the most appropriate routine of core stability exercises, or whether stabilization is even the correct treatment for the patient.

4.  Pilates is not appropriate for everyone

Unfortunately, as its popularity has increased, Pilates as a method of exercise has become less defined over the years. Now, virtually any type of movement performed on a Pilates Reformer or mat can be labeled Pilates and without experience working with a qualified instructor, you may never know the difference.  When a physician recommends the method, a coworker suggests Pilates because, “it worked for me,” or you choose to do Pilates independently with a video, you are applying a very broad exercise method to a condition that may require a little more specificity and individualization.  In fact, many Pilates exercises, both mat-based and on the equipment, are flexion-based and not only inappropriate for some patients, but actually contraindicated (e.g. herniated disc, osteoporosis).  Exercises that promote strengthening the back of the body (posterior chain) may exacerbate other conditions (e.g. stenosis, spondylolisthesis).

Take home message:

Pilates is too broad a term to use when making suggestions regarding a patient’s rehabilitation.

Pilates should never replace work with a qualified rehabilitation specialist trained to treat injury.  Nor should someone with an injury attempt to use self-guided Pilates exercises to treat or manage their injury.  A successful treatment strategy often includes work with both a physical therapist and a Pilates instructor open to collaborating in order to best help their client.

If your physician has recommended Pilates, or you need a specialized program, find a physical therapist with training in Pilates.  You will receive a thorough examination that will help the therapist develop a treatment plan and determine if you are appropriate to begin work with a Pilates instructor, or if you should start with Pilates-based physical therapy.  

It’s Beginning to Look a lot Like…already??

Maiden LaneReady or not, the holiday season is upon us!  The days are shorter, the air is crisp and, believe it or not, decorative snowflakes already adorn San Francisco city streetlights. As our calendars fill with holiday dinners, work celebrations and parties with friends, it can be hard to maintain our normal eating and exercise routines.  Yet, all it takes is a little bit of planning to make it through the season and still fit into your favorite pants come January.

1. Schedule your workouts: Just as you would with any meeting, add your daily workout to your calendar and treat it as you would any other commitment.  Everyone has a preferred time of day for a workout, but when the days get busy, it’s great to have your workout done first thing.  Another benefit of exercising early was shown in a 2011 study at Appalachian State University when researchers discovered that morning workouts are best to help provide a good night’s sleep.  Early morning exercisers slept longer and spent more time in the reparative or deep sleep cycle at nigh

2. Make exercise easy:  If you’re heading out for some shopping, park farther away to get a little extra walk in.  Take a breather from close quarters with family to take a run or walk through the neighborhood.  Almost 13 years ago I started my Birthday Run tradition.  I was born on Christmas and have the good fortune to spend most of my day surrounded by loved ones.  As a way to start to my new year and have some time on my own at the beginning of the day, I take a run the length of my new age wherever I am.  This may be a problem when I hit my 70s, but for now I enjoy the time by myself.  I tried to skip it once on a rainy Christmas Day a few years ago.  Fortunately, my cousin Jordan shamed me into going and, thanks to him, I haven’t missed a Birthday Run in 13 years.  If you can’t head out by yourself, make it a family affair and enjoy some fresh air and exercise with them.

3. Have someone to keep you accountable:  Just like Jordan was my conscience, sometimes it is helpful to enlist a friend to meet for a workout.  If you need a bigger push, schedule time with one of the therapists at TherapydiaSF who can design a program and help you stick with it.  Trained in movement and experts in musculoskeletal anatomy, physical therapists work with both injured and healthy clients.  At TherapydiaSF more than a quarter of our clients take part in our Wellness Programs including group classes, Pilates, TRX, or RunRx.

4. Everything in moderation:  Can’t pass up mom’s mashed potatoes at Thanksgiving or your friend’s toffee at her holiday party?  Feel free to sample, but watch your portions.  My friend and I had a rule around the holidays when we worked together at another PT clinic.  If we were going to indulge in a treat, it “had to be worth it”.  This generally included various homemade and gourmet treats.  Sometimes we disagreed on whether it was worth it, but just asking the question made us stop to think.  Some believe that the Law of Diminishing Returns applies to eating–the more you eat of something, the less enjoyment it provides. At parties, know what you’re eating by making one trip to the food table to fill a small plate versus sampling from passed hors d’oeuvres or revisiting the buffet over and over…and make sure it’s worth it!

A Collaborative Effort: Acupuncture for Athletes

Guest post by Vita Yee, L.Ac.

Vita Yee, L.Ac.

Vita Yee, L.Ac.

Acupuncture Helps Athletes Like You!

Whether you’re a weekend warrior or an Olympic athlete, whether you dance for the SF Ballet or for fun, as long as you move, you’re going to put your body to work under stressful and challenging conditions.  We all juggle extremely full lives, and want to perform at our very best in all situations.  Acupuncture can be a powerful tool to help keep us tuned for optimal health so we can continue to do what makes us happy!

Acupuncture is part of a comprehensive natural health care system that has been used for thousands of years to preserve health as well as diagnose, treat and prevent illness.  According to Chinese medicine theory, optimal physiological function and health depend on the proper circulation of nutrients, substances and energy through a network of “channels” or “meridians” in the body.  Like a very complex and extensive roadmap, this network connects every organ and part of the body, providing balance, regulation and coordination of anatomy and physiological processes.  By inserting very fine needles into specific acupuncture points along these channels of circulation, we can influence the physiological functioning of the body.  Acupuncture activates the natural, self-healing abilities of the body through the stimulation of  “acupoints.”

In my clinic, I use acupuncture for a variety of conditions, including traumatic injuries, post-surgery rehab, and musculoskeletal and constitutional imbalances.  It is often effective for relieving pain and muscle spasm and improving circulation to tense or injured tissues.  I find acupuncture especially effective for acute injuries (like sprains and strains) as well as chronic injuries which have responded poorly to other types of treatment.

Here are some good reasons to try acupuncture!

1. Acupuncture relieves pain:  According to Chinese medicine, energy is constantly moving through the body. When it is circulating properly, we feel balanced and strong. When energy is blocked or stagnated, we experience it as pain, dysfunction and disease. Western Medicine studies have shown that acupuncture leads to the release of endorphins1, natural painkillers that help reduce pain2 and promote an increased sense of wellbeing.

2. Acupuncture reduces inflammation: Acupuncture sends signals through the peripheral and central nervous systems to stimulate a healing response.3 Reducing inflammation and improving the circulation of oxygen and nutrient-rich blood flow into the injured tissue allows for increases in range of motion, helping us move better!

3.  Acupuncture restores homeostasis: Athletes train hard and for extended periods of time, which can lead to muscular and physiological imbalances.  Treating specific acupoints of injured or imbalanced muscles resets the communication between the muscles and the brain, reducing pain and restoring proper muscle function.4 Restoring balance to complimentary muscle groups releases pressure on joints and nerves, which allows the body to move more freely and efficiently and, ultimately, prevents extreme wear and tear on the body.

4.  Acupuncture enhances sports performance:  The Journal of Strength and Conditioning Research reports that the use of acupuncture in resistance and endurance sports activities increases muscular strength and power.  The study also suggests acupuncture improves the hemodynamic parameters of endurance athletes.5

5. Acupuncture improves blood flow:  Blood flow decreases as we age and can be impacted by trauma, injuries, and disease.  A study from UCLA Medical Center concludes that one reason acupuncture is effective is due to its ability to increase the release of nitric oxide throughout the body.6 Nitric oxide is a vasodilator, which opens up the arteries and allows for more blood flow to your heart and other internal organs.  This is significant because everything the body needs to heal is in the blood, including oxygen, nutrients that promote good tissue health, immunity support, hormones, natural analgesics, and anti-inflammatories. Restoring proper blood flow is vital to promoting and maintaining health.

6. Better quality of life:  Perhaps the most important systemic effect of acupuncture is its ability to reduce stress. Research from Georgetown University Medical Center suggests that acupuncture significantly reduces levels of a protein linked to chronic stress, which may help explain the sense of well-being that many people receive from acupuncture.7 A preliminary report in 2004 found that acupuncture increased nighttime melatonin production and total sleep time.8 The patients who received acupuncture fell asleep easier, were less restless at night, and were less stressed.  The body repairs itself at rest, so sleeping well is vital for improved athletic performance!

Chinese medicine requires us to look at health with a different perspective. It operates under the premise that our bodies are constantly seeking balance and strength naturally.  In this context, health is a dynamic result of nurturing, supporting and cultivating the inherent intelligence of the body to do its own job.  Whether you are experiencing a chronic problem, a recent injury or want to achieve optimal health, restoring balance is the key to your well-being.

If you’ve got more questions, you can find me at v.acupuncture@gmail.com!

BONUS: Acupuncture + Physical Therapy:  A study published in the American Journal of Chinese Medicine showed that the integration of acupuncture and physical therapy to treat frozen shoulder led to a better outcome than using only one method.9

1 http://www.ncbi.nlm.nih.gov/pubmed/22965186

2 http://www.ncbi.nlm.nih.gov/pubmed/15135942

3 http://www.ncbi.nlm.nih.gov/pubmed/20512135

4 Callison, M.  “The Effect of Motor Point Needling on Painful Shoulder Conditions: Range of Motion and Manual Muscle Testing.” [Unpublished] 1997.

5 http://www.ncbi.nlm.nih.gov/pubmed/20386479

6 http://www.ncbi.nlm.nih.gov/pubmed/19468961

7 http://www.ncbi.nlm.nih.gov/pubmed/22156045

8 http://www.ncbi.nlm.nih.gov/pubmed/14990755

9 http://www.ncbi.nlm.nih.gov/pubmed/17080543

Healthy Hydration

ImageGuest post by San Francisco-based Nutritionist, Bethany Pianca:

We have all heard that staying hydrated is important.  It is also widely known that the body is mostly made up of water (approximately 60% in adults).  So what’s the big deal?  Many of the reactions that take place in our cells require water.  That can be hard for us to visualize, but it results in things we can see and feel.  When dehydrated, our skin can be dry, as opposed to plump and healthy looking.  Our brain doesn’t work as well when we are dehydrated, and slower thinking and headaches can result. It even makes a difference in the world of sports.  Dehydration can affect our muscle strength and endurance, and even our aerobic performance.  An additional undesirable effect of dehydration – it can make you think you’re hungry, when really you’re thirsty, resulting in often-unwanted weight gain.  Even with this knowledge, some people still have a hard time staying hydrated throughout the day. So how much water should you have each day?  The Adequate Intake set by the United States Department of Agriculture is 3.7 liters per day for adult males (15-16 cups) and 2.7 liters per day for adult females (11-12 cups).  Keep in mind that it is possible to drink too much water, so it is important never to force yourself to drink too much.  Here are some tips for staying optimally hydrated.

  • Weigh yourself before and after you exercise.  For every pound you lost while exercising, drink 16oz of fluid to replace it.
  • Keep a water bottle with you throughout the day and take small sips so you don’t feel like you have to drink a lot at a time.
  • Keep caffeine and alcohol to a minimum as these both act as diuretics, which can dehydrate you further.
  •  If you don’t like plain water, try putting a little lemon in it, or drinking an herbal tea (Note: make sure to fully research an herbal tea before consumption, some can have dangerous side effects).
  • For exercise lasting longer than 60 minutes, you may need to replace electrolytes in addition to water.  This can be accomplished by having a snack (such as a banana) along with your water, or by consuming a sports drink (careful though, sports drinks can be tough on teeth!).

Bethany Pianca is a Nutritionist with a B.S. in Dietetics from San Francisco State University.  She is currently an intern at San Francisco State University working towards becoming a Registered Dietitian.  With experience counseling those looking to lose weight, boost energy, or just improve their diet, Bethany focuses on making changes that fit the client’s lifestyle.

What is Wellness?

Seems like everyone I know is a Wellness Coach these days.  Sounds great, but what exactly does it mean?  As much a buzzword in the health, fitness, and nutrition industry as local, organic, and artisanal are to the food and beverage industry, the term wellness may need a little more explanation.

On January 1, 2005 new legislation was passed to allow physical therapists in California to practice “wellness”.  What exactly did that permit us to do?  We could now see clients for “the promotion and maintenance of physical fitness to enhance the bodily movement related to health and wellness of individuals through the use of physical therapy interventions.” It is perplexing that physical therapists, healthcare professionals with extensive training in anatomy, physiology and pathology, had been previously relegated to treating only the injured.  There is no legislation to limit access to personal trainers and massage therapists.  Funny that it took a Senate Bill to allow CA PT’s to work preventatively with healthy adults.

I have always enjoyed my role as Wellness Provider (see definition above).   I believe that physical therapists are best poised to fill this role beyond formal rehabilitation.  Physical therapists have the training and formal education to help you before an injury occurs. You see your doctor and dentist on a regular basis.  Why not schedule an annual exam with an expert in neuromuscular health?

In addition to the Wellness Screen that many clients schedule annually, we offer a range of Wellness Services at TherapydiaSF.  Many clients have continued working with me following rehabilitation for a specific injury because of my training as physical therapist.  For those who wish to schedule Wellness sessions, we offer customized single and partner Pilates or TRX sessions as well as small group classes that are limited in size to provide attention to form. Injured or healthy runners benefit from RunRx, our program to evaluate run form and provide a custom, progressive training plan for improved performance and prevention of injury.


The label “Wellness Provider” is not exclusive to physical therapists.  Other professions use this term though it’s meaning may be different from industry to industry.   If you are interested in working with someone who calls him or herself a Health or Wellness Coach, ask them what it means.  Do they have specialized training in a particular skill beyond their primary occupation?  How are they unique compared to another massage therapist, personal trainer, nutritionist or life coach?

Don’t be fooled by labels.

Pain IS the perfect excuse…

…to call your physical therapist.  I get it.  I’m the one who cleans the apartment BEFORE the housekeeper comes. But waiting to schedule because you’re in too much pain is like telling your dentist, “my teeth are too dirty”, your personal trainer, “I need to lose weight before I start ” or your therapist, “I’m too down in the dumps to see you today.”  I can understand the fear that a PT may make you move, but being in pain is exactly why you should see a PT who will assess your movement and choose a treatment to alleviate your symptoms.  

Suspension Training 101

ImageYou’ve probably seen the black and yellow “straps” hanging in your gym or, if you live in San Francisco, you’re just as likely to have seen them anchored to a stop sign at a busy intersection.  Developed by former Navy Seal and Stanford graduate Randy Hetrick, TRX is a San Francisco-based company that is sweeping the nation with a new form of fitness training.  Used in the military and found worldwide in professional sports team training facilities, TRX Suspension Training is a tool that allows individuals to use their own body weight to develop strength, stability and flexibility.

TRX can be used to make exercises more challenging by adding instability to a movement, make exercises more manageable by assisting the movement, and allows participants to work multiple areas of the body in all planes of movement.   By simply adjusting your body position, you can change the resistance of an exercise, and control how challenging the workout is. But before you start thinking TRX is only for the elite athlete, read on…

I have been working as part of the TRX team for over two years, originally as a client.  I knew of the product and even had one in the clinic where I worked, but it wasn’t until a patient told me that his goal for physical therapy was to get back to using his TRX that I started to wonder how it might be beneficial for my clients.  A case of perfect timing, TRX was just releasing their Sports Medicine Suspension Training Course for healthcare practitioners and I was asked to become an instructor.   Over the past two years I have presented the one day course around the country and have had the opportunity to meet and engage with some of the best and brightest in the rehabilitation and fitness industries.

While TRX is not the only tool I use in my treatments, I can’t think of any client for whom it would be inappropriate. So why exactly do I use TRX in my practice?  TRX is a tool that allows me to:

  • Teach proper movement
  • Assist movement that a client might otherwise have difficulty performing
  • Unload healing bones, joints, ligaments, tendons, and muscles during the rehab process
  • Combine balance, stability and strength work into challenging full body exercises.
  • Provide a workout to the entire body during the rehab process
  • Save space and improve compliance due to easy set up and portability

If you would like to learn more about how TRX might be useful in your rehabilitation or are looking for a new form of exercise contact us today!