Physical Therapy of Los Gatos

Therapeutic Exercise Demonstration Videos

Sometimes it's hard to remember exactly how to do the therapeutic exercises we prescribe. That's why we took these videos and posted them here and on YouTube.

We're grateful to endurance athlete Louise Kobin for demonstrating this set of exercises.

Side Situps Over Ball

Front Plank Exercise Sequence

Side Plank Sequence

Back Extension Over Gym Ball

Partial Situps Over Ball

Bridge On Ball Sequence

Run Sim with Partial Step Down

Run Sim with Balance

These exercise videos are for patients of Physical Therapy of Los Gatos who have been prescribed one or more of these exercises as part of a current treatment program.

If you have any questions or concerns about he exercises we've prescribed, or any other aspect of your treatment, please call the clinic at (408) 358-6505.

Helping San Jose Fit Run Clear of Injuries

A runner's ability to avoid and manage injury will determine his or her fitness on race day. To help local runners reach their goals, Physical Therapists Rob Naber and Jenny Warner from Physical Therapy of Los Gatos, and Dr. John Kao from the SOAR Medical Clinic teamed up in May to deliver a running injury prevention and treatment seminar to 150 members of the San Jose Fit marathon training club.

Already several weeks into their training program, the San Jose Fit runners were engaged and attentive as Rob Naber presented information on avoiding and managing injuries. The runners received information on pronation and supination, walking and running biomechanics, and some corrective exercises that Physical Therapists prescribe to address specific problems.

Dr. Kao's presentation provided information about the causes of injuries, specific training errors to avoid, and detailed medical descriptions of several kinds of running injuries. He also explained the injury first-aid “PRICEMM” protocol, which calls for Protection, Rest, Ice, Compression, Elevation, Medications, and other treatment Modalities.

The presenters offered these key take-away messages to the San Jose Fit runners:

• Avoiding injury is the key to running success
• Most injuries result from overtraining
• Do not increase training mileage or duration by more that 10% per week
• Complement your running training with specific stretching and strengthening exercises
• If you have an injury, use cross-training activities to continue your fitness training
• Use a heart rate monitor to maximize the benefit from your cross training efforts

Dr. Kao recommended contacting a physician whenever any of these circumstances arise:

• Pain is localized to the bone or joint
• Joint motion is accompanied by catching, popping or locking
• Pain cannot be controlled by the recommended dose of over-the-counter anti-inflammatory medication such as ibuprofen
• The problem persists for more than two weeks
• You are worried or concerned about your symptoms

Dr. Kao noted that individuals can make the most of any medical visit by coming prepared with accurate information about their injuries and symptoms. Dr. Kao can be reached by contacting his assistant Wendy at (408) 247-4900 x1214.

The seminar presenters thank Sports Basement for the use of their Sunnyvale store conference facility for the San Jose Fit seminar.

Neeraj Baheti, PT, MS, OCS, CSCS

Neeraj has been a practicing Physical Therapist since 2004 and joined the clinical team at Physical Therapy of Los Gatos in 2008. Neeraj's intense focus on the study of human biomechanics has led to a specialized clinical interest in working with baseball, soccer, cycling and basketball athletes. Neeraj’s research on shoulder strengthening protocols for high school baseball pitchers was published in the Journal of Athletic Training.

Neeraj received his Bachelor of Science degree in Physical Therapy from Bombay University, India. He was then awarded a scholarship from Oregon State University to pursue a Masters of Science degree with emphasis in Sports Medicine. Neeraj has obtained additional training and certifications in Spinal Manual Therapy techniques, and he is a Certified Strength and Conditioning Specialist with the National Strength and Conditioning Association. Neeraj was recently awarded the Certified Orthopedic Physical Therapy Specialist  designation  by the American Physical Therapy Association.

ACL Injury Information and Screening

Education, screening and specialized training can turn back the rising incidence of ACL (anterior cruciate ligament) injuries in young female athletes. That's why Physical Therapy of Los Gatos is pleased to announce the new community information web site Los Gatos ACL. There, you'll find information on the ACL, ACL injury, prevention, rehabilitation, and our Sportsmetrics™ -certified screening program for identifying individual athletes at greatest risk of injury.

The screening program is a free service for the Los Gatos community provided by Physical Therapy of Los Gatos. Donations for participating in the program go directly toward athletic team fund-raising goals.

For more information, visit www.losgatosacl.com.

Train-the-Trainer Seminar for Pilates Professionals

On Saturday January 20, 2007, Pilates instructors from around the Bay Area met at Los Gatos Pilates to attend the Physical Therapy of Los Gatos Train-the-Trainer seminar: "Assessment for Pilates Instructors." The purpose of the seminar was to present key physical assessment tools that Pilates instructors can use to customize exercise programs to meet the specific  needs of individual clients.

The seminar was presented by Rob Naber PT, OCS, ATC, Ariel Lehaitre, MSPT, and Jennifer Warner, DPT, who organized the seminar. "Given the many similarities between Physical Therapy and Pilates, the move to more prescriptive exercise provides greater long term results for clients," said Rob Naber, founder of Physical Therapy of Los Gatos.  The seminar included an instructional lecture and hands-on practice to assess client's posture, spinal lumbopelvic range of motion and rhythm, flexibility and core strength.  At the conclusion, case studies were presented with "home work" for the attendees.  Answers to the assignment are provided at the end of the presentation.

Physical Therapy of Los Gatos thanks Nancy Chin and Marcie Ryken at Los Gatos Pilates for hosting the seminar.

Download "Physical Assessment for the Pilates Professional (7.5 MB pdf)

Insurance Claims and Billing

Don’t go it alone! Physical therapy doesn’t mean filling out a lot of forms and arguing with your insurance company. Our office Account Manager Lisa Pullen is here to bill your insurance for you and submit all your paperwork properly.

Daily experience with claim forms and insurance companies has made Lisa an expert at obtaining prompt and complete insurance company payments for physical therapy services. Lisa frequently corrects the insurance company’s mistakes, which maximizes your insurance benefits.  After your insurance pays, we will send you a monthly statements for the remaining balance, just like the one you get from the phone company!

Any questions? Call us at (408) 358-6505.

Pilates at Physical Therapy of Los Gatos

Therapeutic exercise is a hallmark of physical therapy. Among many benefits, therapeutic exercise can restore correct strength ratios between muscles, increase functional capacity, and improve coordination.

When prescribing therapeutic exercise, the physical therapist must consider the entire sequence of neuromuscular events that allows the patient to perform their daily activities and sports. This sequence can be thought of as a chain composed of three elements: proximal (closest to the spine) stability, distal (away from the spine) motion, and finally, the desired fine motor skill.

While this sequence of neuromuscular events accompanies all deliberate human motion, it is perhaps most readily illustrated by the action of throwing a dart. The motion requires a firm basis of proximal support and slight rotation around the spine, distal motion performed by muscles of the chest, shoulder, and upper and lower arm, and fine motor skill as the fingers take control of the dart’s release. The controlled, simultaneous engagement of all three elements is what enables the competitor to hit the target’s triple ring.

In Pilates-speak, the deep muscles of the trunk that provide proximal stability are called the "core," and the ability to move one's limbs and carry out skilled tasks while holding the trunk steady is called "dissociation." Strength and control over these deep muscles of your trunk provide the stable base required to perform tasks such as kicking a soccer ball or swinging a golf club.

Here at Physical Therapy of Los Gatos we draw from a wide a variety of exercises to help our patients coordinate, strengthen, and engage this three-part chain. Visitors to our clinic might recognize our use of movements from yoga, Swiss ball exercises, elastic band resistance exercises -- even pull ups and hands stands. They might also recognize mat-based and equipment-based Pilates exercises. As a form of exercise, Pilates expands the clinical repertoire of physical therapy with a diverse range of exercises, performed in multiple planes and positions.

Pilates for Neuromuscular Retraining
Full recovery from injury proceeds through overlapping stages. Therapy to bring about full recovery must be coordinated with these stages. Initially, a patient may need to unlearn inefficient movement patterns that allowed the injury to occur in the first place. The Pilates Reformer offers an effective exercise platform where this unlearning can occur, and old patterns of movement can be replaced by ones that properly engage the proximal to distal to fine motor skill sequence. The Reformer enforces correct exercise motion and helps the therapist and patient isolate and train the deep muscles of the trunk required for proximal stability.

On the Pilates Reformer, neuromuscular re-training exercises can be performed in kneeling, supine, prone, or side-lying positions. This allows the therapist to prescribe some unusual exercises, such as supine “jumping” and rowing while kneeling. Patients and therapists have found that neuromuscular retraining to correct injury-causing patterns of movement proceeds more rapidly in these unfamiliar exercise positions, where gravity pulls the body along different axes and the usual proprioceptive cues are absent. As training proceeds, the therapist can progress the patient to exercise postures needed for his or her sports and activities to fully restore endurance, power and agility.

Pilates for Correct and Calibrated Strengthening
At Physical Therapy of Los Gatos we design individualized treatment programs that coordinate the timing and intensity of therapeutic exercise with each patient’s condition and functional capabilities. Injured tissues such as bones and ligaments must be allowed to heal, but incremental loading (progressive resistance training to increase strength) along correct axes is required to bring about full maturation of healing tissue. If exercise is delayed or inadequate, the muscles around the injured site become weaker and atrophy, slowing down the recovery process. Pilates helps close the gap between bed rest and full recovery by providing a variety of exercises that can be performed over a wide range of functional abilities.

In the case of a basketball player recovering from knee arthroscopy, the mechanics of jumping can be practiced in a supine position on the horizontal carriage of the Pilates Reformer. In addition to providing the neuromuscular training benefits described above, the Reformer in this case allows the therapist to initiate incremental loading of the affected knee without subjecting injured tissues to the full forces of gravity. In this type of therapeutic exercise, the Reformer is unlike a traditional leg-press apparatus because the patient's position during the Reformer exercise simulates the relative head, torso, and leg alignment of regular upright jumping. With Pilates, the physical therapist can prescribe low-intensity jumping exercise in early treatment, and increase the intensity as recovery progresses. This enables the patient to recover upright jump capability and return to competition sooner.

Pilates for Full Recoveries
To us, "full recovery" does not simply mean returning the patient to his or her previous activities in order to be injured again. We are unique in our analytical approach into the causes of each patient’s susceptibility to injury. Our definition of full recovery includes identifying and strengthening weak muscles that allowed the injury to occur in the first place, and achieving neuromuscular control consistent with injury prevention. Ideas such as "dissociation" and “core” in Pilates helps isolate and train muscles responsible for preventing injury.

Rob Naber's Presentation at the West Valley College Sports Medicine Symposium

The Spring 2006 West Valley College Sports Medicine Symposium was held May 5th. The symposium was organized by John Kao MD for an audience consisting of physical therapists, athletic trainers, and physicians. The purpose of the Sports Medicine Symposia series is to continue improving the standard of orthopedic medicine here in the Bay Area by providing orthopedic professionals an opportunity to share their knowledge with one another and with other medical practitioners. This year's spring symposium focused on current challenges of treating the lower extremities.

The following local professionals gave presentations:

• John T. Kao, M.D.

• Grady L. Jeter, M.D.

• Robert S. Nishime, M.D.

• Thomas Elardo, D.P.M.

• Paul Christensen, DPT, OCS, ATC

• Rob Naber PT, OCS, ATC

• Ross Nakaji PT, OCS, ATC, CSCS

• Fabrice Rockich, DPT, OCS, CSCS

• Paul Starks, MA, ATC, PTA, CSCS

Physical Therapy of Los Gatos principal Rob Naber  spoke about the evaluation and treatment of problems affecting the knee. Rob began by noting the value of recent knee research and the bearing of research findings on the practitioner's approach to knee conditions and injuries:

"The knee is often the weakest link that defines and limits an athlete’s total competitive capacity. The knee is needed for speed, power and strength, but is also vulnerable to injury. A knee injury not only means missing practice or competition but may also lead to the loss of scholarship support and potential professional opportunities. Extensive research of the knee, and improved diagnostic, rehabilitation, and surgical methods have brought new hope to athletes and clinicians dealing with the challenges of the injured knee."

– from Current Issues in Sports Medicine: The Knee presented by Rob Naber PT, OCS, ATC

One of the key takeaway messages from Rob's presentation was the importance of quantifying the capability and condition of the knee while the joint is in motion. In the evaluation and treatment of anterior knee pain, for instance, measuring the concentric vs. eccentric torque capacities of the knee is critically important as a diagnostic aid and as a reliable indicator of treatment progress. In rehabilitation following surgical reconstruction of the anterior cruciate ligament, videographic analysis of lower extremity angles during landing and jumping provides data the therapist needs to design and carry out a course of treatment that brings about rapid restoration of function and corrects neuromuscular control deficiencies that would otherwise invite re-injury.

Using the links below, interested individuals can view visuals and handouts from Rob Naber's presentation to the Spring 2006 West Valley College Sports Medicine Symposium. For more information about Physical Therapy of Los Gatos' approach to the evaluation and treatment of knee problems, please call the clinic at (408) 358-6505.

Current Issues in Sports Medicine: The Knee (view presentation visuals)
Current Issues In Sports Medicine: The Knee (download text)

Jump Strength Training Program (download program description)

 Jump Strength Training Glossary (download glossary)

Ligament Sprains

You know the feeling. You've put in the miles, the hills, the interval training. Now it's race day and you're having a good one. You feel balanced, light, and fast. You press the pace one more click and leave another pack of runners behind.

Then it happens. Your foot comes down on a rock and rolls painfully inward. You hear a sickening "pop," you go down, and the runners you just passed thunder past you. Nauseating pain overwhelms your interest in the torn skin on your hands and stays with you throughout the long limp back to town.

Here in Los Gatos we're fortunate to have miles of unpaved recreational trails and utility roads, such as the Los Gatos Creek Trail, the Flume Trail, the Jones Trail, and the Limekiln Trail, offering a variety of terrain through our open space preserves. The race described above could well be our own late-summer annual event, the Dammit Run. If you suffer an ankle sprain while running in competition or in training, here's what you need to know to get back on the trail and back up to speed. 

A Few Definitions
A ligament is a band of fibrous tissue in a joint connecting bone to bone. Each joint has several ligaments. Ligaments are distinct from tendons, which connect muscle to bone. Ligaments support and strengthen joints and make joints stable by limiting joint motion from movements in unwanted directions.

A sprain occurs when a ligament is stretched beyond its normal limits. Sprains are classified according to degrees of severity. A Grade I sprain involves damaging a ligament but not compromising its function of restraining unwanted motion. In a Grade II sprain, the ligament is partially torn and allows some unwanted motion. In a Grade III sprain, the ligament is completely torn and cannot stop unwanted motion, and joint stability and function are lost. Grade III sprains cause diffuse swelling and bruising around the affected joint.

A sprain is more than a simple mechanical injury. Sprains affect proprioception, the neural feedback mechanism that enables us to know the angles of our joints, and the positions of our limbs and extremities, without looking. Good proprioception is what enables us to run in the dark without thinking about where to put our feet, or land a jump shot when focusing on the hoop.

First Aid for Sprains
First Aid for sprains can be remembered by the acronym  "RICE," (Rest, Ice, Compression, Elevation). For Grade I sprains, First Aid treatment alone is often adequate. Grade II and III sprains require rapid administration of First Aid, plus medical evaluation and treatment including some external support, such as a McDavid ankle brace , to protect the ligament while healing. Complete recovery from a Grade II or Grade III sprain is unlikely to occur without medical attention.

Recovery from Sprain
Recovery from a sprain involves promoting the healing of the ligament, elimination of swelling and bruising, increasing strength, and restoring proprioception. At Physical Therapy of Los Gatos the goal of treatment is returning the individual to their pre-injury level of activities and sports, without elevated risk of re-injury. If our runner returns to training on the Los Gatos Creek Trail without fully restored proprioception, he or she will find intense concentration is needed on the exact placement of each foot-fall to prevent the injured ankle from rolling inward again. Longer term, residual changes in joint forces and mechanics, due to incomplete recovery, can accelerate degenerative changes and conditions, such as arthritis.

Restoring Proprioception
Proprioception is based on neural feedback loops that carry and compare information from the eyes and middle ear, and from the stretch receptors of muscles and connective tissues. Following a sprain injury, proprioception is restored by thoroughly rehabilitating neuromuscular control over the affected joint with facilitory techniques such as compression, vibration, and biofeedback. This must be accomplished in a way that promotes, rather than impairs, healing of the injured ligament, and trains the surrounding muscles to assist the injured ligament in supporting the joint while it heals.

Elements of Therapy for Sprain
Therapy begins with a thorough evaluation of the sprain injury. If a Grade III sprain is suspected, the injury should be evaluated by an orthopedic specialist, who will order and evaluate X-ray or MRI images to detect any damage to the underlying bone structure of the affected joint and to obtain a clear picture of soft tissue injuries. Evaluation of a sprain performed by a physical therapist or a physician will also include stress tests to measure the extent of abnormal joint motion caused by the injury, and the progressive tightening of the joint as the injured ligament heals, as compared to the stress-bearing characteristics of the opposite joint and normative values.

In addition to specific, individualized strengthening exercises aimed at re-establishing neuromuscular control and joint strength, physical therapy for sprain should also include evaluation and training of muscles affecting the entire limb of the injured joint. For instance, when ankle pain, weakness, or injury compromise proprioceptive cues, the hips and low back muscles will compensate by altering the injured individuals' walking and running patterns. Because the goal of therapy is complete recovery, including normal or improved function, specific, progressive exercises are prescribed over the course of rehabilitation to restore motion, strength, and control throughout the entire limb.

If you suspect you have a joint injury involving ligament sprain, please contact us for expert advice by calling (408) 358-6505. For additional information about ankle sprain, see the related article "Foot and Ankle Injuries of Ballet Dancers."

Foot and Ankle Injuries of Ballet Dancers

Injuries arising from inadequate or incorrect neuromuscular control during practice or performance, or poor management of an existing orthopedic injury, can sideline a ballet dancer for a season or for an entire career. In a recent workshop on the diagnosis, treatment, and prevention of foot and ankle injuries, Physical Therapy of Los Gatos physical therapist Ariel Lehaitre showed members of a local studio how to avoid and manage specific problems for which ballet dancers are at increased risk due to the physical challenges of their art.

With years of experience as a student of ballet, and specialized training in body mechanics and motions, Ariel brings a unique and valuable body of essential health information to the Bay Area ballet dance community. Though the workshop is incomplete without Ariel's comments, explanations, and demonstrations, the presentation visuals available below provide useful information on specific dance injury types, causes, and degrees of severity. Additional visuals cover elements of effective treatment designs that enable dancers to return to practice without pain or elevated risk of re-injury.

The clinical staff at Physical Therapy of Los Gatos has the specialized training and direct experience required to understand the unique orthopedic challenges of ballet and provide care that produces complete recoveries from dance injuries. To discuss an individual concern, please contact us by calling (408) 358-6505.

Presentation visuals from workshop presentation "Foot and Ankle Injuries of Ballet Dancers" by Ariel Lehaitre (12 MB .pdf download)

Western Occupational Health Conference: Lumbar Spine Stability

At the September 2005 Western Occupational Health Conference, Physical Therapy of Los Gatos principal Rob Naber delivered presentations on anterior knee pain and lumbar active range of motion. At the same conference, Rob also gave a somewhat more technical presentation for physicians on the topic of lumbar spine stability. This web site article was adapted from his presentation notes and materials.

Lumbar spine stability is an important concept in orthopedic medicine because its absence is often identified as the cause of lower back pain. When the lumbar spine is insufficiently stable, the motion between the joints of the lower back is exaggerated and abnormal. A patient with lumbar spine instability will experience lower back pain when the joints of the lumbar spine "wobble" in use rather than transferring forces with the smooth, synchronous movements of a healthy spine.

If lumbar spine instability is identified as the cause in a case of lower back pain, lumbar spine stabilization must be the cure. Too often this simplistic view of the relationship between lumbar spine stability and lower back pain is used as the basis for handing out "core strengthening" exercise instructions as a treatment for lower back pain. Few cases of lower back pain caused by lumbar spine instability are relieved by pre-printed handouts of abdominal and paraspinal, or "core," strengthening exercises.

While we encourage our patients toward any healthy form of exercise, including those forms that address core strength, we are critical of physical therapists and other health care providers who prescribe pre-printed, generic strengthening exercises to patients suffering from lower back pain. In most cases, these exercises will fail to provide any relief. And unfortunately, the most motivated patients receiving these instructions will succeed in strengthening their abdominal and paraspinal muscles. Greater strength will cause untreated lumbar spine joint wobbling to occur with greater force and velocity, and the patient will feel much worse.

In the maintenance of healthy lumbar spine stability, muscle endurance is more important than muscle strength. Furthermore, muscle endurance, the condition of ligaments, and motor control of the structures supporting the spine must be in balance if lumbar spine stability is to be achieved. Generic muscle strengthening regimes that disregard initial measures of paraspinal and abdominal wall muscle endurance, and do not aim to restore correct, specific, balanced, and sustainable force vector ratios around the lumbar spine will fail to produce measurable improvements and will likely increase the patient's pain and disability.

At Physical Therapy of Los Gatos, our physical therapists are trained to evaluate lumbar spine instability using effective methods and clinical precision. Measurements taken during the evaluation phase of therapy and at key intervals over the course of treatment include timed isometric holding exercises in right and left "side plank" positions, a sixty degree sit-up position, and the Biering-Sorensen position (pictured). The results of these tests are compared with normative time values determined in research studies and are used to design individualized treatment protocols to restore correct force vector ratios around the lumbar spine. These individualized treatment protocols produce complete and rapid recoveries from lower back pain caused by lumbar instability.

 Lumbar Spine Stability presentation by Rob Naber to the 2005 Western Occupational Health Conference (16.1 MB .pdf download)

Conference program abstract of Lumbar Spine Stabilization presentation (76 KB .pdf download)

Western Occupational Health Conference: Lumbar Active Range of Motion (AROM)

This entry is adapted from a talk presented by Physical Therapy of Los Gatos principal  Rob Naber at the Western Occupational Health Conference 2005, held September, 2005 in Monterey, California:

Active Range of Motion (AROM) refers to the range of motion for a specific movement that a patient can achieve without assistance, such as a measurement of how far the back moves when a patient bends forward to touch his or her toes. The distance or angle between the starting and finishing position is the AROM. A reduction in AROM can impair routine, vocational, and athletic movements and overall functional capability. Restoring AROM following injury, surgery, or the effects of an illness on the musculoskeletal system is often the goal of physical therapy and the principal reason that many patients are referred to physical therapy.

In the past, physical therapists used goniometers to quantify lumbar AROM. Though practical for AROM measurements around knees and shoulders, the goniometer was of of very limited clinical utility as a means of measuring motions of the spine and surrounding joints. Other tools and methods, such as flexible rulers and measuring tapes, suffered from a lack of precision and reference values, and were also of little diagnostic value.

In 1984, Mayer, et al. proposed a method using specific inclinometer measurements to enable quantification of lumbar forward bending AROM and discrimination between the contributions of the hip and spine to the overall motion. In 1986, Keeley, et al. published a follow-up article that validated the reliability of the inclinometer-based technique and presented the reference values needed to make measurements made in the clinic meaningful.

While necessary as components of a complete evaluation, individual inclinometer measurements of lumbar AROM offer little information of clinical value and should not be used to report degrees of impairment. Multiple inclinometer measurements are necessary to determine the effects of the patient’s starting posture and the relative contributions of hip, pelvis, and lumbar joints to forward and backward bending. A patient can present with a normal lumbar AROM but still suffer from a “weak back” and recurring back pain and disability.

Physical therapy to restore a diminished lumbar AROM is not simply a matter of achieving a specific AROM value. A more nuanced therapeutic goal of restoring ideal ratios between the contributions of involved joints to composite lumbar motions will lead to more rapid and sustained reductions in impairment and more complete and satisfying recoveries.

Lumbar Spine Active Range of Motion: Significance and Relevance in Rehabilitation presentation by Rob Naber to the Western Occupational Health Conference 2005
Western Occupational Health Conference 2005: New Horizons in Occupational Medicine

Tennis Elbow (“But I Don’t Play Tennis!”)

Tennis elbow, also known as “lateral epicondylitis,” often affects active adults between the ages of 30 and 60 years, and causes pain on the outside of the elbow joint where the forearm meets the elbow. Internally, tennis elbow pain is localized where the muscles of the forearm merge into tendons and attach to end of the upper arm bone. A patient with tennis elbow will typically feel pain upon extending (unbending) the wrist (think of the wrist motion required to rev a motorcycle). As an aid to evaluation, a therapist can reproduce the pain by resisting the patient’s wrist motion. Sometimes tennis elbow can be so painful that the patient cannot raise his or her hand, even when no resistance is applied.

Although the condition is known by two names, neither is very accurate. You don't have to play tennis to get tennis elbow! In addition to the high tensile stresses of the backhand tennis stroke, any other activity involving a firm grip, such as using a hammer or screwdriver, or heavy lifting, such as lifting suitcases away from the body with the palm facing the ground, can cause tennis elbow. And the "-itis" suffix of the name "lateral epicondylitis" signifies that the condition is characterized by inflammation, which is not the case. Factors normally associated with inflammation, such as certain white blood cells, cytokines, and chemokines, are not found at the site of the lateral epicondyle of the elbow. What surgeons do find, however, upon opening and examining an affected elbow, is disorganized connective tissue in the form of a characteristic yellow-brown scar. By contrast, healthy tendon tissue is glistening white and is composed of cells organized in neat rows along the axis of tension between the muscles of the forearm and the lateral epicondyle of the elbow.

Palliative measures for tennis elbow include rest and anti-inflammatory medication. Tennis elbow patients are also sometimes instructed to use a tight band around the upper forearm to help rest the painful area and protect it from damaging tensile loads. Although these measures are effective at reducing pain while they are used, they rarely result in full recovery, because they do not restore proper connective tissue alignment.

Fortunately, there are more effective measures. Twenty years ago, exercise physiologists discovered that eccentric exercise is a necessary component of rehabilitation from tendinitis. Eccentric exercise occurs when a muscle generates tension as it is lengthening. For instance, when you place a coffee cup down on a table, you are performing eccentric exercise: your biceps muscles must lengthen in a controlled manner to lower your forearm and place the cup down gently. You may think of eccentric exercise as the braking force needed to slow down the motion. The opposite of eccentric exercise is concentric exercise, which involves active muscle shortening.

Although the exact way in which eccentric exercise improves tendinitis is not known, researchers have discovered that muscle elasticity is a key feature of eccentric muscle contraction, and that eccentric exercise increases muscle elasticity. The leading hypothesis is that muscle tissues that have been made elastic by eccentric exercise effectively distribute and absorb forces that would otherwise lead to fraying of the tendon, formation of disorganized scar tissue, and tennis elbow pain.

At Physical Therapy of Los Gatos, treatment for tennis elbow begins with a thorough evaluation of the problem and a discussion of the patient's rehabilitation goals. Movements associated with the activities that cause tennis elbow pain must be identified and analyzed. If the patient began having tennis elbow pain after playing tennis on rainy days, perhaps he or she needs only a short course of treatment and to stop hitting wet, heavy tennis balls. In other cases, we may find that improper use or involvement of the neck, shoulder, or wrist during sports or other activities has caused excessive loading of the elbow. In these cases, therapy includes instruction and retraining to balance the physical forces required for the chosen activity correctly.

However, regardless of the other required elements of effective treatment, rehabilitation of tennis elbow will include progressive, eccentric muscle training. Eccentric muscle rehabilitation involves using wrist motion to lower a weight over the edge of a table while the forearm is supported. The patient uses his or her forearm muscles to raise the weight and then lower the weight in a controlled manner. The greatest eccentric muscle force occurs when the patient changes the weight’s direction of motion from downward to upward. Therefore, the amount of weight and the speed at which the weight is moved downward and upward can be varied to increase or decrease the intensity of training. As training progresses, the amount of weight and the speed of weighted movements are both increased. Effective eccentric muscle rehabilitation can also be accomplished using elastic resistance bands.

When going over the instructions for eccentric muscle training, patients might be surprised to hear that their tennis elbow pain should increase towards the end of each exercise session. This is a case where “no pain, no gain” applies. Insufficient loading of the tendon (inadequate intensity) or loading along the wrong axis, will delay recovery.

Progressive, eccentric muscle training is the only type of exercise known to increase muscle elasticity and tendon strength and is the process by which disorganized connective tissues associated with tennis elbow pain are remodeled to become functional once again. In the treatment of tennis elbow, progressive eccentric muscle training as prescribed by a qualified physical therapist is a reliable and effective means of achieving specific recovery goals. The precise method, intensity, frequency, and duration of eccentric muscle training must match the recovery goals of each patient, allowing the tennis player to return to playing tennis and getting the carpenter back to work swinging a hammer without pain.

WE'VE MOVED

To meet increasing demand from referrals for our unique, recovery-oriented, one-on-one method of physical therapy, we have carefully increased the size of our expert clinical staff, and have now completed our move to a convenient new office space with more exam rooms and a larger treatment area. We'll see you at our new location on your next visit!

Physical Therapy of Los Gatos
15047 Los Gatos Boulevard, Suite 180
Los Gatos, CA 95032

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Western Occupational Health Conference: Anterior Knee Pain

Physical Therapy of Los Gatos principal Rob Naber spoke by invitation at the Western Occupational Health Conference 2005, held September 15 - 17 in Monterey, California. The annual conference is sponsored by the Western Occupational and Environmental Medicine Association, an educational and advisory organization that helps bring about and preserve legislation aimed at improving worker injury care. The organization is part of the influential American College of Occupational and Environmental Medicine.

As the only physical therapist invited to speak at the conference, Rob chose to present information on the diagnosis and treatment of knee and back maladies, which can result from on-the-job injuries and overuse.

Information on anterior knee pain has been previously published on this web site. Rob's presentation on anterior knee pain to conference attendees contained additional clinical information of value to health care professionals involved in setting treatment guidelines for rehabilitation of work-related injuries.

Anterior Knee Pain: The Use of Eccentric Strength Exercise

presentation to the Western Occupational Health Conference 2005

Western Occupational Health Conference 2005: New Horizons in Occupational Medicine
Western Occupational and Environmental Medicine Association
American College of Occupational and Environmental Medicine

Jennifer Warner, DPT

Jennifer has refined her clinical skills through participating in medical teams at San Jose Medical Center, Lucile Packard Children's Hospital at Stanford, and an outpatient orthopedic clinic in Sunnyvale, California. She is specialized in the physical requirements of athletes and performing artists. Jennifer is trained in advanced spine therapies, Pilates, and advanced treatment methods for orthopedics and sports rehabilitation.

Jennifer received her Doctor of Physical Therapy degree from USC and graduated from Loyola Marymount University with a BS in Natural Sciences. Jennifer held leadership positions in physical therapy organizations at both campuses. Her continuing education includes current enrollment in a year-long post-graduate course in orthopedic manual therapy.

Anterior Knee Pain

Anterior Knee Pain, also known as "runner's knee," is the second most common reason for joint pain related physical therapy office visits. Patients with anterior knee pain complain of a dull ache at the front of the knee that feels like it's coming from behind the patella (kneecap). Patients feel pain most strongly after sitting for a long time with their knees bent, as in a long meeting or at the movies, and when walking downstairs or bending down into a crouching or squatting position. In almost all cases, anterior knee pain can be relieved temporarily by simply straightening the leg. Untreated anterior knee pain is often severe enough to limit knee function, requiring sufferers to discontinue sports activities, avoid stairs, and seek out seating that allows frequent full leg extension.

The exact cause of anterior knee pain is not known, and the condition is considered difficult to treat. Most interventions for anterior knee pain are based on one or the other of two popular theories: "chondromalacia" of the cartilage behind the patella, and "malalignment" between the patella and femur.

Chondromalacia in the context of anterior knee pain refers to softening and degradation of cartilage behind the patella. Chondromalacia is so commonly considered the cause of anterior knee pain that the word is often used incorrectly as a synonym for anterior knee pain.

Cartilage behind the patella is thought to allow the patella and the end of the femur to slide smoothly relative to each other when the knee joint is in motion. Chondromalacia theory says that anterior knee pain occurs when the cartilage is softened or degraded. Chondromalacia is treated by surgery aimed at encouraging new cartilage to grow inside the knee joint or by separating intact cartilage from its original location and moving it to sites where the surgeon believes it will be more useful.

Surgery to correct chondromalacia has not been shown in rigorously designed, statistically valid studies to provide long-term relief from anterior knee pain. This lack of effect is consistent with what we know about joint cartilage: joint cartilage does not have nerve endings and can therefore not be a source of pain. The absence of pain receptors in knee cartilage was confirmed in an unusual experiment carried out on orthopedic surgeon Scott Dye, MD, who reported no sensation during direct probing, without anesthesia, of the cartilage behind his patella.

The presence or absence of chondromalacia does not predict whether someone does or does not have anterior knee pain. Many individuals with advanced chondromalacia do not have anterior knee pain, and many individuals with anterior knee pain do not have chondromalacia.

Malalignment theory proposes that the patella is somehow crooked or is located too far to one side or the other of the knee, causing excessive friction and pain. A number of therapies aimed at correcting malalignment have been developed, including:

• using tape applied to the skin to try to hold the patella in a "medial glide" position
• specific muscle training exercises aimed at changing the position of the patella
• "lateral release" surgery to change the position of the patella

None of the non-surgical treatments for patellar malalignment have been shown to change the position of the patella for any clinically meaningful duration of time. Therefore, it has been difficult to detect a statistical correlation between malalignment and anterior knee pain. In addition, none of the non-surgical or surgical treatments based on correcting malalignment have been shown statistically to provide long-term relief of anterior knee pain.

Like chondromalacia, patella alignment or malalignment does not predict whether an individual will experience anterior knee pain. Chondromalacia theory and malalignment theory are also similar in that they are both based on observations made when the knee is not moving.

At Physical Therapy of Los Gatos, we view the knee as a dynamic process, and we believe that anterior knee pain must be evaluated while the knee is in motion.

Our approach to understanding and treating anterior knee pain is influenced by the work of Bennet and Stauber, who in 1986 noticed that, in individuals with anterior knee pain, the amount of torque produced around the knee joint by the quadriceps muscles during dynamic, eccentric exercise (when the quadriceps muscles are lengthening to allow the knee to bend) was not normal in its distribution around the axis of rotation of knees affected by anterior knee pain. Contrary to the differences normally observed between eccentric and concentric muscle strength, torque measured around affected knees was less than torque measured around the same knees during concentric exercise. Bennet and Stauber also found that specific exercises could restore eccentric torque and torque distribution to normal, and when that was accomplished, anterior knee pain went away.

Analyzing the relative torque-producing capabilities of the quadriceps muscles during eccentric and concentric exercise is a critical aspect of our approach to evaluating patients with anterior knee pain. In our experience, re-defining the eccentric and concentric torque profiles of the quadriceps can be readily accomplished by a motivated patient using specific exercises that emphasize eccentric muscle strength. This approach provides long-term relief from anterior knee pain and allows our patients to return to sports and other activities requiring normal knee function.

Oswestry Low Back Pain Disability Questionnaire

Low back pain is a vexing medical and personal problem. Almost everyone has to deal with it sooner or later. Low back pain can interfere with almost every aspect of daily living and causes more days lost from work than any other malady except the common cold. Low back pain can make finding a comfortable sleeping or sitting position impossible, and due to the central position of the lower back and its key mechanical role in supporting and enabling movement, resting the painful spine during waking hours is very difficult.

A clear physical evaluation and focused goals are imperative when solving enigmatic health problems such as low back pain. At Physical Therapy of Los Gatos, evaluation for low back pain includes objective measurement of the patient’s function, mobility of the spine, neurological assessment, dynamic strength, flexibility, and gait analysis. In our experience, the outcome of physical therapy that begins with a comprehensive evaluation is more likely to be successful than one that passes over the opportunity to use up-to-date diagnostic instrumentation and methods for precise patient evaluation.

One of many tools and methods we use to evaluate low back pain is the Oswestry Low Back Pain Disability Questionnaire. Originally published in 1980, the Oswestry questionnaire measures how one’s low back pain affects a variety of daily activities. Patients usually complete the questionnaire in less than five minutes. The answers patients select from the multiple-choice questionnaire provide useful information about the behavior, mechanical cause, and severity of the patient’s low back pain. This information, combined with other responses and measures used in our evaluation, help us to design a personalized, effective course of treatment, and prognosticate the duration of treatment.

If you’d like to take the Oswestry Low Back Pain Disability Questionnaire, you can pick up a copy at Physical Therapy of Los Gatos, or call to have us fax or mail it to you, or download the questionnaire. You can find our location and contact information near the top right-hand corner of this web page. Afterwards, we’ll be happy to discuss the results with you and, depending on your score, discuss our recommendations for more precise evaluation of your low back pain.

Does Running Cause Arthritis?

Osteoarthritis is a degenerative joint disease marked by joint inflammation and deterioration. Osteoarthritis is common: according to the Arthritis Foundation, nearly 21 million Americans, or 7% of the US population, are affected by osteoarthritis. The incidence of osteoarthritis goes up sharply with age.

Considering its prevalence, you probably already know someone who has been diagnosed with osteoarthritis. If that person is a competitive or recreational runner, one might expect to hear others say, “All that running. It’s no wonder he’s got arthritis.”

The fact is, there are plenty of non-runners with osteoarthritis, too, and there is a lack of evidence to support the notion that running causes arthritis.

In his excellent book, “Lore of Running,” Dr. Timothy Noakes cites a variety of research studies designed to examine the relationship between running and arthritis. Studies published in 1994 and 1997 determined that recreational joggers are not at any increased risk of developing osteoarthritis. A study published in 1985 found that the incidence of osteoarthritis in a group of runners who competed between 1930 and 1960 was lower than a matched group of swimmers who competed at the same time. A Danish study published in 1990 found that a group of athletes that ran 20 to 40 km per week for 30 years had an incidence of osteoarthritis that was no different from that of a comparison group. And a 1986 study found that runners with an average age of 60 who had run an average of three hours per week for 12 years did not have a greater prevalence of osteoarthritis than a comparison group.

Though at no greater risk of developing osteoarthritis than others, runners can and do experience pain from soft tissue injuries, such as hip bursitis, iliotibial band (ITB) friction, and tendonitis. Pain resulting from these other causes can be serious enough to interrupt training and recreational running. The runner with poor mechanics may never train long enough to develop osteoarthritis from running. And clearly an athlete who has jogged for 30 years has the correct biomechanics to run without breaking down.

Excluding injuries resulting from falls, runners’ injuries are almost always due to progressing their training too quickly or overloading the muscle support around the affected joint. A runner’s muscular strength around his or her load-bearing joints must be considerably stronger than that of non-athletic individuals of the same age and sex. Furthermore, different types of running such as sprinting, long-distance, cross-country, and asphalt training have different muscle support requirements.

The running program at Physical Therapy of Los Gatos is a goal-directed training program designed to prevent running injuries, get runners who have been injured or recovering from orthopedic surgery back into training, and increase running speed. The evaluation for the running program includes a comprehensive interview process where we measure baseline parameters of running fitness, uncover specific deficiencies, analyze your running form, and help you clarify your goals. For additional information on preventing running injuries, rehabilitation of running injuries, and increasing running speed, please contact Physical Therapy of Los Gatos by calling (408) 358-6505.

New Evidence Revises Rehab of Young Female Athletes with ACL Injuries

An unintended consequence of the increase in sports participation by girls and young women over the past thirty years has been an extraordinary rise in the incidence of anterior cruciate ligament (ACL) injuries in young female athletes. At the college level, one in ten young female athletes participating in sports such as soccer, volleyball, and basketball will suffer an ACL tear injury. These girls are typically unable to practice or compete for one or more seasons and face potential loss of scholarship funding and significant psychological trauma. A widely cited 1985 study found that at the high school level, the knee injury rate among female athletes is one per 100 participants, and noted the need for preventative measures.

In 1983, sports medicine researchers determined that four-fifths of ACL injuries are non-contact injuries, that is, they are caused by the athlete’s own motions rather than collisions with other players. To the researchers, this finding meant that the high incidence of ACL tear injuries in young female athletes might be greatly reduced if those motions could be identified and avoided.

The ACL is one of four major ligaments that connect the upper and lower leg at the knee. The ACL provides joint stability and supports cutting and pivoting motions. Oftentimes, the ACL will tear with a “pop” that can be heard by spectators and other players. Pain and immediate swelling follow. ACL tears require surgical reconstruction using tendon grafts from other areas of the knee or from cadavers, followed by a long period of rehabilitation.

The frequency and seriousness of ACL tears in young female athletes has led to research studies aimed at understanding the problem. These studies are now yielding valuable data. Three major hypotheses to account for the higher number of ACL tears in female athletes versus male athletes have been examined: hormonal differences causing laxity of the female athlete’s ACL, a smaller and more narrow space within the knee for the female athlete’s ACL, and sex-based differences in lower extremity strength and coordination. The last of these three hypotheses is receiving the most scientific support from study data.

Certain aspects of lower extremity strength and coordination can be captured and measured by videotaping athletes while they perform athletic movements in the research lab. While video recordings do not capture complex three-dimensional movements and the rotational stresses that these movements place upon the knees, the recordings do enable researchers to make close measurements of joint and limb positions in a single plane. These measurements were found to have predictive value.

In one well-designed study of 205 young female athletes, researchers found that athletes with a specific way of posturing their lower extremities, known as “valgus” (or “knock-kneed”) alignment, during certain athletic movements were more likely to suffer ACL injury than athletes with more “neutral” or straighter lower extremity alignment. This valgus alignment can be seen by analyzing the angles formed between the ankles, knees, and hips when the athlete lands from a jump off a small box and when she jumps vertically from a crouched position. A separate study that included videographic analysis of 325 young female athletes showed that a six-week neuromuscular training program corrected the lower limb valgus alignment associated with injury during jump landing and takeoff.

It is already well-known to physical therapists that muscular strength stabilizes the knee by helping to maintain the correct relative positions of knee structures during sports movements and by allowing muscles in the legs to absorb forces that would otherwise subject the joint to potential injury. But physical therapists treating young female athletes must now consider the implications of the new studies. Physical therapists familiar with these studies infer that rehabilitation from ACL injury should, in addition to conventional strength training treatment methods, include specific neuromuscular training aimed at improving the athlete’s ability to avoid valgus alignment of the lower extremities during high-risk sports.

It is no longer acceptable to reconstruct the ACL but leave neuromuscular control deficient.

The jump strength training program at Physical Therapy of Los Gatos is an element of rehabilitation from surgical reconstruction of the ACL as well as a standalone performance improvement module. The program includes jump analysis, strength conditioning, and neuromuscular training designed to improve power and acceleration. The neuromuscular training methods employed include visual, auditory and proprioceptive cues to train athletes to use muscular strength to absorb jump impacts in a controlled fashion, and, if necessary, to correct jumping, landing, and pivoting techniques in order to avoid forces associated with injury. For additional information about prevention of ACL injury, rehabilitation from surgical ACL repair, and jump strength performance training for athletes, please call Physical Therapy of Los Gatos at (408) 358-6505.

What is an Inclinometer?

The role of a physical therapist is to help you regain your function and allow you to return to your life of work, recreation, and other daily activities. A key element of this role is determining whether you have the appropriate range of motion (ROM) available to accomplish your daily activities without pain. Until recently, physical therapists used a device known as a goniometer to measure this range of motion at a joint. Now, physical therapists measure ROM in a different way. This change was brought about by studies showing ROM measurements made using a new tool, known as an inclinometer, are more accurate, precise, and reproducible than measurements made using goniometers. According to the American Medical Association’s Guides to the Evaluation of Permanent Impairment (Third Edition), the inclinometer has been adopted to measure spinal ROM. Physical therapists have also found that inclinometers are easier to use, and provide new and more useful information.

Old School
A goniometer looks a bit like a protractor you may have used to measure angles in geometry class, but with arms, like the type of compass used for drawing circles. The arms of a goniometer intersect at a single axis or pin:

To measure the ROM at a joint with a goniometer, the patient moves his or her body part to the position directed by the therapist (i.e bend your knee). The therapist aligns the arms of the goniometer with the bones surrounding the joint and aligns the pin with the joint axis. Because the therapist cannot hold the goniometer directly against the bones, bone and joint axis positions must be estimated. The angle indicated by the goniometer is recorded. Goniometer measurements typically require the joint to be moved from the beginning of its range to the end of its range of motion. For example in the knee, a measurement is taken when the joint is fully bent and then again when it is fully straightened . Because the positions of the bones and axis points must be estimated, each reading made with a goniometer introduces error into the measurement. Normal joint mechanics introduce another source of error into goniometer measurements: unlike a door hinge rotating around a cylindrical pin, a joint rotates around the ends of the bones, which are not perfectly round. Therefore the joint axis itself moves, making the estimation of the axis position more difficult.

New School
No such estimates or alignments are necessary with an inclinometer. Inclinometers have dials or digital readouts that display the angle at which the inclinometer is situated relative to the line of gravity.



To use an inclinometer, the therapist holds the instrument on the patient, who begins in a standard starting position. The therapist zeroes-out the inclinometer and then instructs the patient to bend the joint through its ROM. The inclinometer’s final reading is the ROM measurement. The inclinometer never leaves contact with the patient and the axis does not need to be identified.

The accuracy of ROM measurements taken using inclinometers can be estimated by comparing their measurements with those taken from X-rays, which allow very direct joint angle measurements. Mayer et al. showed ROM measurements of the spine made using inclinometers are statistically similar to readings determined using X-rays. Keeley et al. showed repeated ROM measurements made using inclinometers yield very reliable values.

Unlike goniometers, inclinometers can be used in pairs to gain even more diagnostic information during patient evaluations. For instance, bending forward to touch the toes is a “composite” motion, that is, some of the motion comes from the hips and some comes from the lower back. When a patient has pain upon bending forward, the physical therapist can use two inclinometers at once to determine whether the lower back and hips are each contributing the proper amount of flexibility to support the movement. The inclinometer readings may indicate that the painful lower back is compensating for the inflexible hips. The therapist can then begin an effective course of physical therapy to relieve the lower back pain by restoring the patient’s hip function and flexibility.

To learn more about inclinometers or see how your spinal range of motion measures up, contact Physical Therapy of Los Gatos at (408) 358-6505.

Heat or Ice?

You may have just had a bad fall, a misstep while running, or a sports collision. Or perhaps you've simply overused a muscle, tendon or ligament. These types of injuries are often called sprains, strains, and tears. Should you apply heat or ice?

The short and definitive answer is: ice.

You’re certainly forgiven if you didn’t know that. After all, many people use heating pads, hot whirlpools, and hot gel packs for their injuries, and some even apply sprays, creams or liquids to their skin to make it feel hot. But in the aftermath of an injury, you don’t want to apply heat to the affected area. You want to cool it with ice or an ice substitute. Here’s why:

Any injury severe enough to damage muscles, tendons, or ligaments will also damage the small blood and lymph vessels around those tissues. When this happens, the normally well-regulated system of blood delivery and lymphatic drainage of tissues is disrupted, and blood and lymphatic fluids are released in an uncontrolled manner. This causes inflammation, swelling, and pain.

Applying ice to an injured area relieves pain by slowing the conduction of nerve impulses from the area. Ice therapy also takes advantage of the body’s natural, adaptive response to cold, which is to maintain normal body temperature by cutting back on the blood supply to the cold area. This has the effect of allowing fluids to drain away from the injury, taking away injured cells, cell fragments, and inflammation-causing molecules. The result is reduced swelling and pain, and faster repair of damaged tissues.

The application of heat has the opposite effect. The body’s response is to send extra blood through the heated area so that the heat can be carried off before the tissues get too warm. Extra blood delivery to the injured area increases swelling, inflammation, and pain.

The best type of ice or ice substitute to use is whatever type you have at hand! Chemical cold packs, which chill rapidly when you break a capsule inside the pack, are expensive but work well. Cold gel-packs right from the freezer will also do the job. A zip-loc plastic bag filled with crushed ice is inexpensive and very effective. You can even use a bag of frozen peas and carrots!

Place the ice pack on the injured area and leave it there for 20 minutes. Remove it for 20 minutes, then put it back on. The best ice-on, ice-off intervals and the number of times you should use ice each day depend on the type, severity, and site of your injury. Please call our office for advice.

Should heat ever be applied to injuries? Yes, but only under limited, specific circumstances. For instance, several days after an injury, your physical therapist may instruct you to contrast your injury treatment with heat between ice applications. This has the effect of restoring normal blood circulation to the cold area quickly and accelerates the removal of injured cells, cell fragments, and by-products of the healing process from the injured site. We do not advise the use of heat to warm up a recovering joint or muscle prior to exercise. A slow and progressive active exercise warm-up, such as walking prior to jogging, is much more effective.

If you have sustained a soft tissue injury, the correct application of ice or ice substitutes will help control swelling, reduce pain, and speed your recovery. If you are unable to return to your day-to-day routine after a week of treatment with ice, or if you are in training for athletic competition, please call our office for additional advice and assistance.

Lisa Pullen

Account Manager Lisa Pullen makes sure that the mountain of details behind any medical office visit do not intrude upon our ability to deliver, or your ability to receive, the complete attention of our clinical staff. Lisa ensures that critical communications between your physician and your therapist take place on time, and that all the letters, faxes, phone calls, forms, diagnostic codes, and claims you need for treatment authorization and reimbursement are handled swiftly and professionally. Lisa graduated from San Jose State University with a BS in Business Administration.

Ariel Lehaitre, MSPT

Ariel began her clinical career at the New England Baptist Hospital in 2001, and has held orthopedic and physical therapist positions at Stanford, Santa Clara Valley Medical Center, and other private practices in Los Gatos. Ariel’s education in body mechanics and motion includes ten years of ballet training at the San Francisco Ballet School, the Pacific Northwest Ballet, and New York’s School of American Ballet. Bringing specialized and personal understanding to the needs of injured dancers, skaters, and gymnasts, Ariel integrates Pilates training into her physical therapy treatment programs to help these athletes maintain flexibility and build strength during rehabilitation. Ariel received her Master of Science degree in Physical Therapy from the Sargent College of Boston University and graduated with honors from Boston University with a B.S. in Clinical Exercise Biology.

Rob Naber, PT, OCS, AT,C

Rob Naber has been practicing orthopedic physical therapy for over 20 years. With early and continuing emphasis on rehabilitation of sports injuries, Rob has gained extensive experience treating football, basketball, soccer, tennis, track, and other athletes in a variety of settings, including the Sports Medicine department of Stanford University and West Valley College, where he also served on the teaching faculty.

An advocate and adherent of evidence-based physical therapy, Rob founded Physical Therapy of Los Gatos in 1997 to offer specialized treatment of lower extremity and spine problems related to gait dysfunction, and has extended his technical approach to include accelerated rehabilitation of complex shoulder problems experienced by throwing and swimming athletes.

Rob received his Master of Arts in Physical Therapy from Stanford University, where he also received the Dean’s Award for his contributions to the university and its students. Rob received his BS degree from USC where he studied exercise physiology. He has earned additional certifications in Manual Therapy, Athletic Training, and Strength and Conditioning, and holds a specialization in Orthopedic Physical Therapy from the American Physical Therapy Association. Rob's continuing academic service includes instructing physical therapists at national post-graduate seminars.