Physiotherapy and Performance


Ballou PT Blog

It is not so simple

There is not always 1 specific reason we have pain, especially back pain. Pain is a multidimensional issue that includes factors inside and outside of the body. Many things can make pain better but there is no 'quick fix' and not usually one biomechanical process like your hips being out of alignment that is the cause.

Good post by Dr. Stefanie Cohen, DPT on Instagram for @trustmephyiotherapist:

We need to shift away from providing simplistic, structural and strictly biomechanical diagnosis, begin acknowledging all the factors that play a role in the management of back pain and ensure that our current practice is nondiscordant with contemporary evidence, specifically the interpretation of MRI and other diagnostic tools, its implications in the management or rehabilitation of the individual as well as the dialogue between clinician/fitness professional and patient/client.

---Dr. Stefanie Cohen, DPT

Daniel Ballou
Language Matters

The words we use matter.

A lot.

If you tell a patient how their x-ray looks, what their squat form is like, or the prognosis for a condition you can say it in multiple ways.

Great short write up on instagram from @the_movement_dr:

Unfortunately, there are still many many people of power using poor language to explain diagnoses, findings, symptoms, and conditions with dangerous wording.

Hearing that you have the back of a 60 year old makes you think of a frail old person barely making it down the hall!
— Dr. CJ DePalma DPT, CSCS
Daniel Ballou
New Years Deal with On The Mark Meals!

Make 2019 the year you fix your body and your diet.

Get a 20% discount at Ballou Physiotherapy if you order On The Mark Meals in January!

The new year is a great time to refocus your energy on improving your health. There is no better way than enhancing your diet with On The Mark Meals and improving your body with Ballou PT. Every week you order 2 meals from On The Mark Meals, you receive a 20% discount on a physical therapy appointment at Ballou PT. Each discount can be applied once for any appointment at Ballou PT through February!

Strengthen your body and your diet with Ballou PT and On The Mark Meals this New Year!

Call (804) 495-1161 to schedule your appointment with Ballou PT.

Daniel Ballou
A Better Hamstring Stretch

I have one of my favorite techniques for helping you touch your toes. It is perfect as a warm up because it is dynamic and not static.

Do you ever feel like you keep stretching your hamstrings and you don’t get any closer to touching your toes? I use this technique to get some shockingly quick results.

Use this technique as a warm up for anything where you have to pull from the floor like deadlifts, cleans, snatches.

Disclaimer: if you are having some sore of sciatic pain or are injured seek help from your physical therapist or chiropractor that understands your needs to see what can work for you.

Step by step instructions:

Pre test: can you touch your toes? Note how far you get on your shins, shoes or floor.

  1. Put the front of your feet up on some small object, like a slant board, half foam roll, or 2x4 or anything of a similar height.
  2. Bend forward and bend your knees as much as you need to touch the floor.
  3. Now, try and start locking your knees out until they can’t go any further.
  4. Once you can’t go any further you can start raising you hands up and continue to lock out your knees.
  5. Once your legs are straight return back to the starting position with knees bent and hands touching the floor.
  6. Do about 10-15 reps.

Post test: Now bend forward again and try and touch your toes. I’m willing to bet you can go a lot further.

Daniel Ballou
What is Dry Needling?

Ballou Physiotherapy and Performance now offers Trigger Point Dry Needling!

This technique has become more popular in the last few years and can change the game for pain, tightness, and muscle dysfunction.

What is it? A trained physical therapist puts a very small needle into a muscle that is tight or dysfunctional in some way. It causes the muscle to release or relax which will reduce pain, improve mobility, improve muscle function and contraction and help you get back to normal.

Is it acupuncture?

No (the acupuncture lobby makes us say this.) Dry Needling works through very different mechanisms than acupuncture.

How it works

Dry Needling likely works through a combination of the theories below.

  1. Trigger Point Theory: If you have tight bands of muscle fibers in your muscle it can be painful and dysfunctional. Dry needling that ‘knot’ will cause it to contract or ’twitch’ and relax and reset the muscle.

  2. Spinal/Neural Theory: If the muscles along the spine are tight, dysfunctional, not firing, or uneven it can put pressure on a nerve and affect things downstream in the arms and legs. Dry needling the muscle along the spine can reset this system and reset the nerves themselves.

The actual reality is a result of many different unique factors for each person and area. Your dysfunction in one area can sometimes be caused by dysfunction much further away in your body. Your ankle could be causing your shoulder pain.

What training is required?

Not every physical therapist can do dry needling. They have to meet a few different requirements, which vary by state. Virginia has the following rules:

  1. 54 hours of direct training about dry needling (this is a lot).
  2. A Physician referral for dry needling is required.
  3. A consent form must state that dry needling is not acupuncture.

This is all in addition to the 3 years every physical therapist must spend in a doctoral program that focuses extensively on anatomy, including a cadaver dissection portion.

What should you expect?

  • Soreness?
    • You may have some soreness after dry needling. We do our best to needle in such a way to minimize soreness. If you do get some soreness it will feel more like exercise soreness, as if you were able to do a full workout for just that muscle, and it should go away in 12-24 hours.
  • Pain?
    • There will not be much pain. Needles for Dry Needling are very small, and do not have a cutting edge like a needle for drawing blood or giving a flu shot. You may feel a small pinch initially and the twitch contraction can be uncomfortable, like a mild cramp.
  • Improvement
    • Immediately after needling you should notice that the muscle feels a little looser, you should have more mobility, and some reduction in your pain. The exact improvement will vary by situation, person, and muscle.

Common Questions

  • Can I receive dry needling multiple times in a week?
    • Yes, depending on how you feel. In general, you can dry needle the same muscle after a few days, especially if you are no longer sore. If you want a different muscle needled then waiting is not necessary.
  • How many times do you stick a needle in during a session?
    • It depends. The more you do it the greater likelihood of soreness. As soon as the muscle releases you can stop and likely not have much soreness at all. Typically, you can do the same muscle between 1-3 times. You can do a lot of muscles in one area, but a good physical therapist will pick the most likely muscles to help first.
  • Can I be needled right before I go compete in my sport (or workout)
    • Yes, but I recommend that your first session be a few days before a competition. Once you know how you react to dry needling then you can definitely do it day of a competition.

And the biggest question of all: What if I am scared of needles?

Well, good news, I am too! I hate getting blood drawn or getting a flu shot. Dry needling is so much better than that. The needles are smaller, you feel them less, you feel much better afterwards, you can move more, and your pain has decreased. It is so much better than anything else you use a needle for.

How to Foam Roll

This post discussed the why and the broader ‘how’ of foam rolling. So let’s dig a little deeper with some specific techniques here.

Rolling lengthwise: You can roll up and down the entire muscle, not really stopping on any one point. This can feel good and be relaxing but don’t worry about doing this very long before moving on to another technique. 
Sustained pressure: If you find a particularly ‘nasty’ point in your muscle then you can hang out at that spot.  Try to relax into the spot, if you are fighting the pressure then it isn’t going to help at all and you are just causing yourself pain with no benefit. You can add overpressure with your other leg, a weight, or a friend that you truly trust.
Side to Side: On a spot, if the sustained pressure is ok but not doing the job then you can roll side to side over the foam roll or lacrosse ball to add extra pressure and roll the muscle, fascia and connective tissue. 

It shouldn’t be overly painful. It won’t be comfortable at all times, but it shouldn’t feel super nasty and gross. If you think it might be too much then it is. 

Only roll over a nice meaty area of muscle and tendons. Don’t roll right over the joints or right on the bony areas. That just doesn’t feel good.

Don’t spend forever on one spot. Max 2 minutes on a spot but really you can jump around along the whole muscle and between muscles after 30 seconds if you like. Hit a few tight areas an move on.

Don’t spend forever foam rolling, especially as a warm-up. A warm up is supposed to actually warm you up. Get blood flowing, raise your heart rate a little. Foam rolling can actually do the exact opposite. So only strategically use the foam roller for a few minutes, load that mobilized tissue, and then go do something else. Burpees anyone?

Remember to load the tissue after you have foam rolled. For example, if you roll out your calves then you might do some calf raises and some deep squats working on the ankle dorsiflexion.

Self CareDaniel Ballou
Should I Foam Roll to Warm Up?

You wake up early to get to the gym. Sleepily grab a foam roller and start to ‘warm up’. You roll on your upper back for a few minutes, get a few cracks and pops, then move to something that is tight, like your quads or calves. Those are a little painful so you grimace your way through and then you are done and ready to work out.

Does this sound familiar?

This is how many people foam roll, and maybe it is their entire warm up (I’ve definitely been guilty about this before) but it is not the best way and may actually be making you worse.

Soft tissue work like foam rolling, but also massages, joint mobilizations, manipulations (cracking backs), and dry needling probably don’t work the way we’ve been told over the last few years. It is very very very very difficult to make a true mechanical change to a tissue and the 5 minutes before your workout is definitely not going to accomplish that.

So what is actually going on? Most likely it is the novel neural stimulus that is telling the brain that the tissue needs to change. The act of pressing on a painful site and providing a brand new stimulus to the area can interrupt whatever cycle was going on and replace it or ‘trick’ the brain. This is probably why you can touch your toes after foam rolling when you were a foot away before. (Ok, you at least closer to touching your toes). Your hamstrings did not grow longer in 5 minutes, your brain just lets them relax more.

Once you have created some change to your ‘tight areas’ you are good right? Well if you don’t really do anything targeted to that area afterward then you probably will go back to the way you are before. Gaining some good range of motion and then doing a super intense workout probably won’t help. What will?


You have to load your brand new ranges of motion. If your body doesn’t think you need all of that sweet range you just created then it will gladly tighten up again.  The cliche ‘use it or lose it’ is a cliche because it is true. So if you foam roll your hamstring should do something to load that your hip in that new range, for example, a stiff leg deadlift with an empty bar or dumbbells. You have to tell your brain that you actually want to keep the range that you are working so hard to get. Otherwise, why bother?

You have to load your brand new ranges of motion.

Another thing about any sort of soft tissue work is that it can relax you. So it may be better to do your longer and more relaxing version of foam rolling at night right before you go to bed. It can help you sleep better which is never a bad thing. But a nice 20-minute long foam roll session right before you try and max out your squat and hit a PR Fran is probably not the right decision.

Self CareDaniel Ballou
Can Cash-Based Physical Therapy Save Me Money?

But, I have insurance to cover my medical costs. If I pay out-of-pocket I won't be reimbursed by my insurance company.

These are a few of the things I've heard when it comes to a cash-based physical therapy practice.

Isn't it more expensive? Well, not necessarily.

A lot depends on your insurance. You may have noticed that a lot of things when it comes to your healthcare depend on your insurance. What doctor or hospital you can go to, what medicines or tests can you get. The same things happen in physical therapy. 

You should know a few basic things about your insurance. These are the deductible, copays/coinsurance, coverage of physical therapy, differences between in-network and out-of-network coverage (you could have different copays or deductibles.)

When you look at your insurance you may notice a few things. You may have a deductible of a few thousand dollars (or more than a few), maybe a $50+ copay, or maybe little to no coverage for physical therapy. And, at a typical in-network physical therapy clinic, you may have to pay a bill of $200+ per session and you won't have been billed until weeks after your appointment has happened and you already went 5 more times.

Why so much? Well, insurance companies have been paying physical therapists less each year and so we have been billing insurance companies more for each visit though overall reimbursement keeps falling. If you still have your deductible to meet then you can be stuck with this whole bill!

Ready to try something other than the old insurance model? Cash-based physical therapy could be right for you. When you pay upfront for your care you know exactly what you are going to pay and can budget appropriately. No surprise bills 8 weeks from now. Because you know exactly what each session will cost you and your physical therapist can have an open and honest discussion of how many in clinic sessions you may need and how much you can do on our own to take care of yourself (hint: 90% of health is on each individual and not the health care provider).

I don't really want to see people 3x a week for 6-12 weeks. I would love to see you 1x a week or every other week for 5 sessions and then maybe see how you can do mostly on your own with some tune-up session now and again. (The exact plan of care and how many sessions you may need are very individual and can only be decided by you and your physical therapist.)

Can I be reimbursed for my out-of-pocket charge? This depends on your insurance, but most of the time the answer is YES! You can send a 'self-claim' with appropriate treatment codes and receipts which we can provide to you upon request.

How much will I be reimbursed? Again this depends entirely on your insurance. You will have to meet your out-of-network deductible first. Then it may be a percentage (e.g. 40%) or only up to a certain amount (e.g. $50).

I hope this clears up some of the confusing mess that is insurance and shows how a cash-based physical therapy practice can be a cost-effective and money saving option for your physical therapy care.

So if you have amazing insurance with no copay, a deductible of $250 and 100% PT coverage a cash-based PT practice may not be the most cost-effective option. But there are other factors at play that I will go over in future blog posts that could still make it worthwhile.