Patient Question Friday. Knee Pain



I am going to start a regular patient question answer thing here on Fridays. I will take any questions if you have them, just post in the comments or email them in. Or I will take questions from people I see here in the clinic.

Jen from Edwards asked me ” I have knee pain when hiking, especially down hill, and riding my mountain bike uphill. What should I do?”

When I asked Jen a bit more about her pain, she described it as pain under her knee cap. In addition to hiking downhill and biking up hill, she notices it with squats and kneeling too.

This type of pain is often called anterior knee pain, or sometimes patellofemoral pain. There are different reasons we get it. But generally the surface of the patella or the femur where they contact each other becomes sensitized. All the things Jen describes her pain with increase load in this area.


To help the pain we need to figure out ways to decrease loads on this joint, at least for a while. Then we need to build up loads gradually to allow return to the activities that are an issue.

The first way is to look at activity management. Sometimes the issue is we ramp up activities to fast. We don’t do something much for a while then we jump in and do too much too fast. This gets things irritated and then we keep them irritated by trying to push our way through. Or we are sensitive enough that things like walking and stairs keep it going. The solution in these cases is to back down on the offending activities, as you feel better then gradually build them up. In Jen’s case we talked about hikes with less vertical descent and mountain bike rides with less steep climbs. As she is able to do this easily she can build up.

The second way to reduce load is to look at how your knee is loading biomechanically. The knee is caught between the hip and the ankle. Sometimes things happening above and below the knee can increase loads on the knee. By altering things you can make changes. A few examples are:

  • A stiff ankle may increase load on the knee. Improving ankle flexibility may help your knee.
  • Poor hip strength or endurance may cause increased rotation at the knee with downhill activities. Working on strength and endurance in our hips can alter these mechanics.
  • Poor balance can add stress at the knee every time we are in single leg stance. Improving dynamic balance can reduce these loads.

There are others also, but you can see there are different issues which load the knee. Changing these loads combined with progressive loading of the knee will work very well in reducing pain.

If you have tried dealing with your knee pain and are stuck, getting a physical therapist to look at your management plan and mechanics can be helpful getting you on the right track. If you have any questions about your knee or anything else, post it in the comments call me at 970-949-9966 or

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Being Healthy in the Quarantine


The world is a strange place isn’t it now? Many of us are on lockdown, not going out for other than essential things. Maybe work and food. This is challenging for everyone. In different ways for everyone. Disruption of routine, boredom, stress, worry about health, loss of valued recreational and social activities, anxiety about what is coming and will happen are difficult for all of us in different ways.  And messages are mixed what we should do. Hunker down and rest? Use the time to come out better and amazing on the other side? I have heard both from different people and things I have seen. I don’t pretend to know the answer. I am struggling with this myself.  But a few things that can help can be on either side of this equation. We are biopsychosocial creatures, and our overall health depends on keeping each area of ourselves as healthy as we can. So lets address those areas as best we can while in quarantine.

  • Keep connection with the people in your social circle as best you can. We are social beings, not being able to see and enjoy our family and friends in the usual ways is hard. Make an effort to call, or video chat, or stand at the fence and talk to your neighbor. We need each other now.
  • Stay physically active. Moderate exercise is helpful in so many ways. If you can do it outside even better. It is good for immunity, overall health, and our psychological well being. This has been disrupted for a lot of us. Gyms are closed, exercise classes are closed, parks and other areas are limited. There are many resources online for home body weight exercises, virtual fitness classes and other things. Maybe not the same, but something. If you can get outside do it daily. Take a walk, work in the garden, ride your bike. Just use common sense to keep distance with people and if recreation areas look crowded move along or come back at a different time.
  • Find ways to express your creativity and do things you enjoy. Even if its not “productive” these things are great for mental health. What you may enjoy is different than everyone else. Do what feels right to you. Cooking, writing, drawing, painting, cleaning out the garage, gardening, building. If that means learning a new skill, great. If that means being super productive, and having the time to pursue a new thing fantastic, if that means just aimlessly creating to limit boredom, thats also great.
  • And most of all be kind to yourself and those you live with. These are uncharted waters for all of us. There is grief and loss and stress and uncertainty we are all processing. We need time to deal with that and come to terms with it. Sometimes its ok to not be ok, for us and the ones nearest us.

I hope you find these ideas helpful. I will be focusing some posts on the exercise part of all this in upcoming days as this is what my area of expertise is. If you have any specific exercise questions drop them here or to

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Pain Around The World


Here’s an article about the prevalence of pain in New Zealand.

New Zealand Article

I posted it for 2 reasons. One is my friend Bronnie Thompson an OT from New Zealand is quoted. Two is it explains how big and widespread this problem is. The numbers are 1 in 5 people in New Zealand live with pain. This is similar to many other developed countries including the US. So if you are dealing with pain you aren’t alone. It also shows how complex the problem is. People want answers and fixes, but they aren’t always easy.

If you are dealing with pain you will have a challenge. Talk to someone who will listen. Try to see through the easy answer and quick fixes.

Let me know if you have concerns or questions about your pain. Give is a call at 970-949-9966 or


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Concepts of Pain Part 5

conceptsof pain

This is the 4th point of my ongoing series about basic concepts of pain many people don’t know or understand. Acute pain serves a useful function to help warn or protect us from danger and injury.

Acute pain basically means new pain. It is a necessary thing for your survival. It lets us know when something is happening in our body that might endanger us. Injury, disease, infection. You have nerve endings throughout your body that can sense tissue damage, extreme temperatures and inflammation. When these are stimulated enough they send signals to the spinal cord and brain. These are processed and action is taken. Pain could be felt. You might tense up. You might run. You might feel tight. Nothing may happen. This all depends on a variety of things including the amount of input from the nerve endings, but also context. What is happening besides that. What has happened before. Memories. Fears. Emotions.Neuromatrix-Simplified

Pain sucks. But it is needed. You need to know if you cut yourself, or broke a bone, or put your hand on the burner. And acute pain tends to be driven by these inputs of stress on the body. But there are always influences at play that make it more or less.

Next time I will talk about what happens when pain becomes more chronic.

If you have comments or questions about pain, post them below, give us a call at 970-949-9966, or visit

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Make a Wish




photography of disneyland

Photo by Makenzie Kublin on


I talk a lot about the other factors for pain and health besides the obvious physical things that we normally associate with pain and health. One model of health is the biopsychosocial model. This model basically says that biology, psychology, and sociology can all interact with each other and affect each other and affect pain and our health in ways that we wouldn’t think possible. It may look something like this.


We never know exactly how or how much each is contributing. And, these things can change over time even day to day. But, knowing that not everything is caused only by physical issues, especially structural issues, can allow us to see how complex pain can be and offer insight when things aren’t getting better when we think they should.

Today, while driving in the car I heard an interesting story on NPR which highlighted the complexity of pain and health. Researchers wondered if programs like Make A Wish were helpful beyond just making kids feel better for a bit. These programs raise money to grant wishes to kids with serious illnesses or diseases.  They and their families might go to Disney World or meet a celebrity that they admire. Whatever they choose.

Researchers looked at over 1000 kids with these serious illnesses. Half had gotten a wish, the other half didn’t. The results were mind boggling. After the wish they followed both groups. The group with wishes granted had much fewer rehospitalizations, fewer doctors visits, and spent a lot less money for healthcare on average than the other group. They actually in many cases saved enough money from reduced healthcare to pay for the wish and then some.

Here is a link to the story.

Make A Wish

The lead researcher did not know exactly why this happened. But, understanding the power of psychology and sociology to health may give us some insight. People with hope. With something to look forward to. With fun and joy and wonder in their life. People living a bit better can have powerful effects. So many people living with pain or major health issues have lost this. They spend all of their time going to doctors. Recovering from surgery. Looking for answers. Many people I work with say “When this is over with I will or I want to……” They have life put on hold. Maybe giving a kid a wish gets them unstuck for a while and it helps.

I think we can learn from this. Saying pain or health are biopsychosocial in nature doesn’t mean there is nothing wrong or damaged or broken. It does mean that other things can happen that make the damaged or broken thing have more or less of an affect on you and your body. Not all of us can get granted a wish. But, we can figure out ways to get more into our lives when we have pain or other health issues. Do things we enjoy. Get together with people we love. Find wonder and joy, even when things aren’t working like we planned. Our medical system doesn’t talk about much past the injury or illness. Sometimes we just need to try to be human and live our lives more like we want.

If you are having issues with pain or injury and not sure what to do, drop a comment call us at 970-949-9966 or

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Patient Question Friday: What Do You Do For Achilles Tendon Pain?


This question is from Tom, who visits the Valley from New York. He began having Achilles tendon pain when he came here this fall. He was walking a lot, more with more hills than he does at home. He began with a bit of pain which he thought he bruised his heel walking down hill. He rested for a bit. Felt better. But, the pain returned as soon as he resumed his walks.

This is a common scenario. First he really had ramped up his walking quickly. From doing a couple miles to 6 or 7 and almost daily. When you don’t have an obvious trauma the first thing you should look at is change in activity. Whether its time, distance, intensity, or frequency. I have talked about grading and building load capacity. A lot. Because this is frequently one of the biggest contributors to pain and injury. Many people can get talked into believing that they are walking wrong, or need orthotics, or their muscles are out of balance or something along those lines. This means you need someone or something to fix you.

Keep it simple. Basic rehab is to calm down the area and then build it back up. Tom did the calm down part just right. But, when he returned to walking he went right back to his previous level that got him in trouble in the first place. He will be able to do this just fine. It will take a bit of time and building capacity.

When you have tendon pain, you frequently have what is known as tendinopathy. A part of the tendon has gotten unhealthy basically. We now know that this can cause pain, and even when it gets better and doesn’t hurt any more, it can still look unhealthy. We think that getting the tendon better around it and building its capacity can help. The program isn’t always easy. Many people with more severe or longer duration pain can have trouble returning. It can also be frustrating as frequently it means modifying an activity that you love like running or hiking. But it worked for Tom.

We did just as I said above. Calmed it down and built it back up. To calm it down we found out how much Tom could walk with little lingering pain. You don’t have to be pain free, but what we don’t want worsening pain during an activity or pain that lasts a long time after. Tom was able to walk some, but less than he had.  Some people will modify a little, some a lot, some will have to lay off totally for a bit. We also started loading his tendon to build capacity. For an achilles tendon, this was heel raises on both feet together, progressing to single heel raises, to raises off a step, to lunges, to weighted raises, to jumping and hopping. Any exercises that load the tendon will help. Heel raises are easy to do without a lot of equipment. The important thing is finding a dose that will challenge you without flaring your pain.


Again we are listening to his tendon trying to stress it without aggravating it. As he does these we are gradually upping his walking. In a few weeks he was walking 5 flat miles and after 6 weeks was back to normal. Everyone is different though in how their pain will respond.

If you have questions about Achilles pain drop a comment, give us a call at 970-949-9966  or


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Exercise Iceberg


Last week I posted a picture that I saw posted by Ben Cormack. It was a similar iceberg about diet and health.  Ben kindly made one about exercise that expresses the same thought process.

Many people get hung up on “the right” exercise. The best exercise to lose weight. 5 exercises to get rid of back pain. The best glut exercise and so on.

In many cases its not the specific exercise that’s important.  Its the fact they you are moving, you are building up to more, hopefully finding something you enjoy, and are working toward your goals.  All these things are helpful in reducing pain.

When you have pain or are training to get more fit or healthier, these concepts are important. Its important to find something you enjoy and gives meaning to you, something you can stick with, something that you understand and can build up yourself if needed, and gets you where you want to go. Not so much doing exactly the right thing.




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Concepts of Pain 4

conceptsof pain

I have been posting about some concepts of pain, that are widely understood, or at least not talked about when you have pain.  Today’s concept is #3 in this graphic. “Pain is influenced by multiple factors such as thoughts, activity, sleep, mood, and stress.”

You may understand some of this. It makes sense that stress and activity influence or pain. Many people understand or at least are aware of links between over doing it and stress to pain. Some of the other things, sometimes are not as well understood.

As I talked about in previous posts, pain is a protective response, and can be from a sensitive nervous system. That sensitivity can start from an injury. The injured tissue and the nerves around in can be sensitized to protect that part of the body. But, anything that’s can sensitize the nervous system then can influence what you feel. That can work to increase or decrease that pain.

Not sleeping can make things more painful, while a good sleep can help.

Thinking about your injury and understanding that the pain is normal and things can heal may reduce distress and some pain. Wondering what is wrong and getting many answers while nothing seems to work can sensitize out system and increase your pain.

Losing your relaxing or fun activities because of an injury can change your mood negatively which can increase pain. While, maintaining as much of normal life as possible can help.

None of these influences make pain less real. It still can be influenced by injury and damage of course.  None are saying just think positive or be happy and you will be better. These are simply influences that may change your pain one way or another. Understanding that these things can affect us, just gives us a bit more insight to what is happening, and may give us some tools to help.

If you have any questions about your pain or injury, give us a call at 970-949-9966 or drop a comment or


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Should I Get Rotator Cuff Surgery?


I get asked this question all the time. I have pain in my shoulder and my MRI shows some level of rotator cuff tear. Most people assume the only way to get rid of the pain is to surgically repair the tear. But, it really depends. Many people can improve with conservative treatment of their shoulder. These people then can function very well. The next question is, “But, won’t it eventually tear more and become more of a problem?” Its a reasonable question. If it might become worse just get it over with. The other question is “If I don’t get it fixed won’t I always have issues? Surgery is a no brainer”.

My answer usually is it depends. First, what are your symptoms and how is your function? Many people assume with a tear you have a fairly non functional arm. If this is true, then surgery is probably the right call. But, many people have some shoulder pain, but are still very functional. In this case conservative management may be very helpful.

Secondly, surgery is not so easy. Many cases of conservative management can help you reduce pain and improve function in a few weeks. Rotator cuff repair is a 6-12 month rehabilitation process after surgery. And. most people are better, but any are not perfect and still have some pain and some limitations after.

The answer to the question about it tearing more anyway has been given some light in a new study. The researchers followed people with rotator cuff tears. They tried conservative management for 3 month. The ones who did not respond had repairs. The group who did respond did not have repairs. They then followed both groups for 5 years after. The group without surgery had 75% success rate after 5 years. The quality of life index in both groups was similar.

This doesn’t mean you should or should not have surgery. Its a data point. Each case should be determined by your pain, symptoms and function. Just because your MRI says tear doesn’t mean you need surgery. You are not your MRI.

Here is the link to the study.

If you have shoulder pain and aren’t sure what to do, lets talk about your options. Give us call at 970-949-9966 or

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Concepts of Pain 3

conceptsof pain

The last couple of weeks I have been talking about pain and. This graphic above lists some things about pain that many people don’t know or understand. Knowledge of these concepts may help you make sense of your pain a bit more which can help in moving forward in your healing and life.

Today’s concept is pain does not equal the amount of tissue damage. You may assume that the more pain you experience the worse your injury is, or the worse the damage is.

Now sometimes this is true. Big injuries can cause a lot of pain for sure. But not always. The guy in the video below had a severe fractured leg. You can see that the other players and the fans watching had a much bigger reaction than he did. If you are squeamish maybe don’t watch.


You may have stubbed your toe and had severe pain and was sure it was broken, but a while later it was fine. Or think of a paper cut, how much it can hurt for a comparatively small injury.

These are a couple examples of how pain and tissue damage are related but not the same. This is important to know. As, when we are recovering from an injury and have pain, we tend to think if our pain is worse, we must be getting worse or have created new damage.   Many times our system is sensitized after an injury. When things that alter sensitivity occur like increased activity or physical load, poor sleep, stress, or worry, then our system may feel stuff more. Knowing this can allow us to better evaluate what is happening in our body or to our injury.

If you have any questions about your pain drop a comment, give us a call at 970-949-9966 or go to ascent-pt.

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Healthy Habits



Found this graphic thanks to Ben Cormack today.  Most healthy habits are behaviors are not one magic bullet, but persistent, sustainable changes. Taking small steps consistently in the right direction is what makes us healthier.

Unfortunately, the things that sell are the “best diet”, “the easy way to weight loss” or “the trick”. As humans, this is easy to understand. Sustainable change is difficult to make. It all goes great until it doesn’t, and its easy to slip back into old ways and habits.

This graphic is about diet and weight loss. It could also pertain to exercise, building a training program, recovering from surgery, or pain management. The quick fixes and magic bullets are what we focus on. The “right” exercise to get me better. The “best” exercise to get me going. Its probably more important that you find things that you can do and sustain. Things that you enjoy and bring meaning to your life. If you can do that you are more likely to be persistent and get things done.

If you have any questions give us a call at 970-949-9966 or

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