Should I fire my physiotherapist?

[loft33]

I first want to say that I wish I could see the physios in this forum. Some of you have been insanely kind to answer my posts in the past and you all seem very knowledgable. So thanks for that.

But now I have a pretty important decision: I wanted to get some feedback on whether I should fire my physiotherapist.

I have been seeing him for two weeks now for SIJ dysfunction. Right now it's in anterior tilt and my right leg (painful side) appears 3/4ths and inch shorter than my left -- X-ray showed this is not anatomical, no true leg length inequality. In the two weeks since I started seeing him I've been to him six times - every Monday, Wednesday, and Friday.

All he has me doing is 1 exercise and 3 stretches: glute med exercises, hamstring stretches, psaos stretches, and IT band stretches.

Now, I have progressed from clams to lateral leg raises to lateral leg raises with a resistance band, but other than that he won't give me ANY other exercises (like glute max or ab exercises -- which I understand are essential to fixing SIJ) until he sees "more improvement in my hamstrings."

Every single time I see him all he does is put heat on my back and does some light myofacial release on my glutes (I do my glute med exercises at home). Then he tests my hamstrings, frowns, and says "Okay, see you in a few days."

When I started seeing him he said my right and left hamstring were both at 80°. He wants them both at 50°. In the two weeks since I first saw him - stretching every two hours - I've gotten the left one down (up?) to 55°, but the right one only has improved to 70°. The right side is where I have my problem and I feel that maybe - just maybe - the right hamstring won't get any looser until I start strengthening my glute max so the SIJ can be held in the correct position.

When I confront him about this, his reasoning is that until the right hamstring is as loose as he wants it any glute or ab exercises would be pointless because I would be training my muscles with my SIJ out of position and that won't get it any better.

Is that true? Can that be true? Ideally, totally loose hamstrings would be great, I admit, but wouldn't training the glutes and abs maybe help take some pressure off my psoas and hamstrings - which might make my hamstrings easier to lengthen, not to mention giving my SIJ some support when I walk and sit?
I just don't see how getting that right hamstring a little looser is going to magically move my SIJ into position where it's safe to do glute and ab exercises.

I keep telling him that all I have is 20 PT appointments a year - and I've already used 6 on him. If I use another 6 and he doesn't like my hamstring length, I'll be wasting a lot of my visits. I also want to point out that he does not want me doing any walking, bike riding, or any other exercises besides the glute meds and the three stretches. I actually feel like because I've been so sedentary for the last two weeks (besides the stretches and glute med exercises) that I've lost MORE function in my glute max and abs.

I fully admit that my physio knows more about rehab than I do, but I'm just really frustrated and any advice would be very appreciated. I also want to make sure I'm not being milked by him to stretch my therapy out so he can make more off the insurance.

(BTW - I'm in the US right now, so I have private insurance - which is why I have limited PT appointments. -- US health care is....lacking....)

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[loft33]

So I saw the PT again today.

My right hamstring STILL has no improvement. That's even after I did more than my stretching ever two hours yesterday. I stretched it every hour and also sat on a kitchen counter and attacked it with a tennis ball.

Today more than ever my right glute just feels like it won't fire and it feel like my hamstring is so tight because it's trying to prop that side of my body up on its own.

And again, today the PT said he can't have me doing anything else until that right hamstring is where he wants it. He checked my stretching form and said its fine and that I need to keep stretching because "it will get there." But until it gets there - you guessed it - no ab or glute max stabilization exercises.

If anyone could reply I would really appreciate it. I'm at a loss if I should move on to another PT.

Can you begin glute max and ab exercises with a tight hamstring? Because this current PT says no way.

[loft33]

Saw the PT again today. Had me lay in some futuristic water bed that massaged me for 15 minutes, then used ultrasound on my hams, measured them, frowned, and said "schedule 3 appointments next week."

I got so fed up and confronted him and the physiatrist who share the same office (and told me to see him) and asked that if they're just going to keep testing my hamstrings and doing heat and massage, maybe I should only come once next week to give me more time to work on my hamstring flexibility at home.

They both freaked out and said no, I must come in 3 days next week.

Again, this seems shadier and shadier. I'm getting worse because I'm not allowed to do any pelvic stabilization of glute max activation until my hamstrings are apparently perfectly loose (even though I can touch my toes and lay on my back and bend my hamstrings 90° without pain).

Really fed up. Can anyone please give me some advice? Is this line of treatment normal?

[bikelet]

Hi there,

Sorry to hear of your frustrations. I'm not really sure what 'normal' treatment is- it does vary a lot depending on level of PT experience and even country to country. But I will answer your questions from my point of view as a physio and give as much justification for this as I can.

So I think you are right in wanting to try glut max activation exercises. Basically there are two hip extensors- the glut max and hamstring muscle group. If one of them is defective, the other will work like crazy and be over active. So no amount of hamstring stretching will change the fact that it is overactive. If you learn to engage your gluts, it could actually give the hamstrings a break and a fighting chance to relax.

Muscle tightness is almost always a secondary problem- secondary to excess load, poor postures, pain, uneven muscle patterns etc and so generally speaking stretching shouldn't be the only line of treatment. Often muscles tighten in a protective pattern (which implicates neurological structures and involvement) to protect an injured joint or ligament and so needs to be a addressed at this level. Stretching a muscle while not addressing why it was protecting tensing is not likely to be helpful and may cause more problems.

There has been a lot of work done by Peter O'Sullivan and colleagues in research about best practice for SIJ dysfunction issues. Look for his papers if you can. Basically, with chronic SIJ problems, it is likely that there is abnormal muscle use around the pelvis which is a strong driver of the condition- this includes the abdominals (transversus, internal/external obliques, rectus abdominus), pelvic floor muscles, diaphragm, adductors, glut max, glut med, multifidus and lumbar erector spinae. So a good physio should assess these structures and give activation and postural control exercises around the pelvis. It is really important to consider how you are using all of these muscles and in what pattern you use them in day to day activities and sport. Stretching alone is unlikely to be helpful although it may be used as part of a solution for correcting tight strong muscles versus weak, long muscles.

Hope this makes sense.

[loft33]

Thanks so much, bikelet. I have sinced fired my PT and found a new one, who actually to quite angry when I told him my other one said I could do no other exercises until my hamstrings were perfectly stretched.