Overuse Knee Injuries

There are a number of common knee pain complaints that we see every day that are labelled as ‘overuse’ injuries. Overuse doesn’t necessarily mean that you as a person have overused that joint or body part (though it could well do!), rather than a soft tissue or connecting structure has been overloaded. In fact the cause may be from a change or increase in training, poor foot biomechanics, and often gluteal or hip weakness. The symptoms can be sharp, acute pain or a dull ache that lingers after activity – it varies depending on the condition.

Remember that pain is not equivocal to damage, rather it is a signal, and the more chronic the pain the more the signal may be interpreted abnormally by our brains!

This month’s blog article looks at the causes, symptoms and treatment for three overuse conditions that often cause knee pain:
– Patellofemoral Joint Pain Syndrome (PFPS or PFJ syndrome)
– Iliotibial Band Friction Syndrome (ITB syndrome)
– Patella Tendinopathy (Jumper’s knee)

Plus Knee osteoarthritis, which often underlies soft tissue changes in people over 40 years of age (yes, only 40!).

Patellofemoral pain syndrome (PFPS or PFJ syndrome):

PFPS is pain arising from the tissues within or surrounding the knee cap (patella) and the femur (thigh bone).

Pain is typically a vague, overall tenderness at the front aspect of the knee and can be hard to localize. It is usually aggravated by activities that involves a high amount of knee bend (eg. up/down stairs, running (especially downhill), squats, lunges, sitting in a car, plane or cinema for prolonged time).

There are a number of risk factors that may increase the stress placed on the patellofemoral joint including lower limb muscle weakness, abnormal patellofemoral joint alignment, increased foot pronation, increased Q angle at the hip, weak external rotator of the hip (gluteals), change in training load.

Patella tendinopathy (jumpers knee):

Patella tendinopathy is a diagnosis of pain and dysfunction in the patella tendon. This condition presents with well localized pain in the patella tendon, usually at the attachment to the patella. Typically people with this condition have aggravation with activities that increase loading on the patella tendon such as running and jumping.

Risk factors for this condition are similar to that of PFPS, however the most common trigger is an increase in training volume and frequency and reduced quadriceps muscle strength and length.

Iliotibial band syndrome (ITB Syndrome):

The ITB is a thick structure called fascia that runs from the outside of the hip to the outside of the knee. ITBS is an overuse condition where pain is felt on the outside aspect of the knee. It was previously thought that this was caused by increased friction of the ITB on the bone outside the knee, with excessive knee bending movements causing inflammation and pain. Recent literature suggests that there is a highly innervated layer of fat between the ITB and bone that is responsible for the pain felt.

Common causes of ITBS are once again rapid increases in training volume and intensity, thigh muscle weakness particularly gluteal and quadriceps, increased foot pronation, poor movement control and poor tissue flexibility of the ITB and glutes.

Treatment:

The treatment of these issues involves addressing lower limb biomechanics that may be contributing to increased pressure on the injured structure including lower limb muscle weakness, increased foot pronation and poor movement control.

Soft tissue techniques including dry needling and massage can be effective in order to reduce sensitivity of tight muscles contributing to the injury.

Taping can also be effective in the initial phase of rehabilitation in order to offload injured areas and enable easier return to activity.

Load management is also a key component that needs to be addressed, as rapid increases or decreases in activity often lead to these injuries developing.

Your physiotherapist will be able to guide you through a specific rehabilitation program and which of these methods of treatment will be suitable to you.

Knee osteoarthritis (OA):

Knee OA is another condition not to forget when considering overuse injuries around the knee. This condition typically arises when people have changes in activity level (either too much or too little). Common symptoms are pain with weight bearing, reduced range of joint motion, sensation of the knee giving way and joint line tenderness.  Our recent article discussing the latest evidence for knee OA and the GLA:D program will detail the appropriate treatment strategy in greater detail.

 

 

Christmas and Holiday Period Trading Hours

Xmas 2018 and new year Holiday trading hours for 2019

 

 

 

GLA:D® Program at Dandenong Ranges Physiotherapy, Olinda

In December 2018 we launch our participation in the worlds best first treatment for knee and hip arthritis – GLA:D®. And to celebrate we are offering our first 10 participants $50 off GLA:D® 12 or 18 session programs! Get in quick to reserve your discount.

Read all about GLA:D® here or contact us directly to join one of our free Knee and Hip Osteoarthritis information sessions.

GLA:D™ Australia is a program for all individuals who experience any hip and/or knee osteoarthritis symptoms, regardless of severity.

 

Do topical creams and gels help with pain relief?

Tim Hardiman, Musculoskeletal Physiotherapist, November 2018.

Physiotherapists are often asked about the potential benefits of the various creams that are purported to help people with pain or movement problems. Because of the expanding knowledge of adverse side effects of many medicines, people wonder about the benefits of the creams we see advertised and whether they may be safer than tablets.

Anti-inflammatory medicines and creams are an interesting example. Non-steroidal anti-inflammatories (NSAIDS) have a long list of serious side effects including stomach ulcers and bleeding as well as heart attack and stroke risks.

All NSAIDS work to interrupt the production of inflammatory hormones called prostaglandins. Since their introduction in the late 1800’s these drugs are among the most commonly used worldwide.

Unfortunately, a direct consequence of the action of these drugs on prostaglandins results in weakening of the lining of the gut, and consequently ulcers. Routine consumption of NSAIDS has been shown to cause around 3 events per 1000 patients per year of heart attack or stroke (x4 above usual levels). 20-40 per 1000 per year may experience a stomach bleed. When treating short-term conditions for people without cardiovascular disease, the risks of these events associated with taking NSAIDS are probably very low.

New research suggests that substantial pain relief can occur with the use of topical anti-inflammatory creams. The suggestion is that because the active ingredients are able to penetrate to the affected tissue (superficial joints or tissues such as the ankle, knee, wrist and elbow, rather than deeper joints such as the shoulder, hip, spine) there is less exposure of the active ingredient to the whole person (including their gut).

Studies comparing the benefit of these creams to placebo (the same cream, without the active medicine in it) suggest that about 10% more people will report a significant reduction in their pain than those using the placebo cream. Of note in a study of one of these creams was that there is moderate quality evidence suggesting that 6 in 10 people using an anti-inflammatory cream reported improvements in arthritis symptoms after 6-12 weeks use. The group using the placebo cream had 5 in 10 reporting similar results!

Another way of expressing this is that for every 6 people using the cream, one person has a benefit greater than placebo, and that the placebo response is strong when it comes to these creams.

There is little to no evidence suggesting that anti-inflammatory creams work for certain types of pain such as low back pain, headache or neuropathic pain. Creams likely present a safer risk profile for people needing pain relief for superficial structures than oral NSAIDS.

It is much more difficult to assess the myriad of alternative creams and gels, since they do not need to pass the rigours of validated trials that pharmaceutical products do. They are often marketed aggressively despite weak or non-existent evidence and quality controls during the manufacturing process are lax compared to medicines.  

You can walk into many chemist shops and see posters about the miraculous magnesium oil sprays that penetrate the skin, bypassing the gut and targeting your sore muscles directly (assuming you are low in magnesium obviously). Most products quote the same weak evidence from quite a few years ago that blood serum magnesium levels slightly increased after bathing in magnesium chloride, said to mimic the therapeutic benefits bathing in the Dead Sea. What they don’t tell you is that urine levels didn’t change, a raft of other blood markers also rose, levels only rose in ‘non-athletes’, the sample size was tiny and over a two-week period levels returned to normal. Also, a comprehensive literature review in 2017 found that there is no evidence to suggest magnesium oil can be absorbed topically & concluded that any benefit from using magnesium oil is likely due to a placebo effect.  

Pain relief for musculoskeletal conditions can occur with appropriate exercise too. Which is why physiotherapists will often prescribe safe and specifically targeted exercise to speed recovery, prevent recurrence and improve functional outcomes for people with pain or movement problems. So whilst there is room for topical NSAID’s for specific and superficial pain in the short term, developing good behaviours, awareness and routine with respect to exercise and movement is likely the best way forward. 

To book a session with one of physiotherapists, please , myotherapists or Exercise Physiologist, please call us on 9751 0400 or book online.

 

Achilles Tendinopathy – About, Causes & Treatment

Check out physiotherapist Liam Gellie demonstrating some isometric calf raises on this video

 

The Achilles tendon is one of the strongest structures in our bodies. It connects the calf muscles to our heels, and enormous forces pass through it in order for us to push off for walking, running or jumping. Whilst rupture is an occasional issue, tendon degradation is the most common complaint. Formerly known as tendinitis, we now call this process Achilles tendinopathy and it troubles a lot of walkers, runners, and, as it happens, commonly keen gardeners in the Dandenong Ranges. 

What is Achilles Tendinopathy?

Just as in our previous month’s article where fasciitis is now fasciosis, there is no inflammation in Achilles tendinopathy, hence no ‘itis’ suffix. Due to the natural paucity of blood supply in tendons, once they are injured they are unlikely to self repair easily or quickly. The good news is that there are many things we, as patients and physiotherapists, can do to assist the speed and quality of the recovery process.

An Achilles tendinopathy is a failed healing response inside the tendon where the damage caused to the tendon exceeds the repair that takes place by the body. This typically occurs to rapid increases in loads placed through the Achilles. For the athlete this is typically from an increase in distance, reduced rest days, or a change in training type or surfaces such as hills or softer ground.

Other Contributing Factors

Biomechanical factors contribute strongly to the cause. These include poor foot biomechanics or reduced calf and hip strength which can cause excess loading on the calf and Achilles, poor running or walking technique & incorrect or worn out footwear. Another contributing factor is when the Achilles or calf is shortened over time due to chronic muscle tightness, other injury or a history of wearing high heels.

Early Treatment

Whilst a small heel lift (4-8mm) may be used in the early stages to aid relief, it should not be used beyond a 2-4 week period for most people as it can lead to chronic shortening, and worsen the problem in the mid-long term. Reviewing foot biomechanics and footwear, and the use of orthotics, is generally extremely helpful before returning to full activity and often in early stages.

Relatively new evidence new evidence that isometric exercise can reduce pain and maintain muscle strength in the early phase of rehab.  Isometric exercise is where a muscle works against resistance without movement in a joint or muscle (static hold of position). Ideally the static holds should be aimed to be sustained for a period of 45 seconds and repeated 5 times with an adequate rest period in between sets (eg. 1-2 min).

Complete rest from activity is something that may have previously been prescribed for tendinopathy but has actually been shown to be detrimental. In the early stage when trying to settle the tendinopathy down reducing provocative activities, without cutting them out completely can be useful. The use of alternative training methods including cross training, (such as cycling, rowing machine, swimming, hydrotherapy, Yoga and Pilates) can also be utilised to avoid complete rest.  

Dry needling is more effective than massage though both are helpful. Frictions (pressure technique used by physios) on the tendon itself is helpful to stimulate blood flow.

Stretching is something to steer clear of as this likely to place the tendon in a position that can aggravate. Instead try using a foam roller or massage ball to improve flexibility without stirring up the tendon.

Late Stage Rehab and Return to Activity

Load management is a key component of middle to late stages of tendinopathy rehab. Tendons can adapt to load given adequate rest time. In order to allow the tendon to adapt to load, changes to training needs to be done gradually while monitoring symptoms during and after exercise, usually 10% increase in training volume per week is a safe level to increase.

Concentric (against gravity) and eccentric (with gravity) calf raises can be excellent within pain free ranges, and progressed for speed, weight and range of movement but must be carefully implemented at the right stage of recovery in order to avoid flare-ups and regression of the injury.

What About Eccentric Strengthening?

Eccentric calf raise exercises, whereby the load is only maintained during the with-gravity stage (not against gravity), have been shown to be extra effective in battling degenerative Achilles tendinopathy. These are the more chronic cases or recurrent cases. Eccentric contraction allows for increased loading of the tendon with weight but cafe must be taken with gradual progression of the program, without flare-ups, to get back to full activity.

Further Intervention

There are a host of more invasive interventions out there, all of which have some anecdoctal evidence but no strong peer reviewed evidence of efficacy. From our experience, they are hit and miss, with the injections often causing flare-ups. The creams are worth a try though. These include:

  • Plasma rich protein injections (PRP) – blood is taken & spun for higher plasma content then re-injected into the tendon, attempting to stimulate an acute inflammatory healing effect and the healing response that should come with it
  • Autologous injections – as for PRP except just the patients blood from elsewhere, not spun, injected straight into the tendon
  • Glyceryl Trinitrate patches or cream (GTN) – similar to angina patches to stimulate blood flow into the tendon. Gives bad headaches to some people.
  • Hirudoid cream – often used for bruises, haemorrhoids. Recently trialed with tendinopathies and some encouraging signs for early evidence.

 

Before starting your own rehab please get some advice from a physiotherapist first. A ruptured Achilles is an unlikely but real complication of a poor or overly eager rehab program! And there are likely to be inherent causes that need attention prior to any rehab or strengthening program for it to be effective. Don’t let your stubbornness or pride be your real Achilles heel!

 

Plantar Fasciitis or Fasciosis – About, Causes, Treatment and Prevention

Plantar Fasciitis, or fasciosisis a common and painful foot condition affecting the soft tissues in the arch of the foot. Recently there has been some exciting research on how exercises to strengthen the calf and foot muscles may assist in alleviating symptoms, alongside traditional conservative treatment methods such as footwear modification, orthotics and weight loss. Corticosteroid injections may have a role in pain relief for those that do not respond to conservative methods, but the evidence suggests that it will not provide relief beyond conservative means in most cases and is linked to increased risk of tear or rupture.

When one of our physios, Liam, brought this new evidence to us recently, my initial reaction was that it was only a short term study. However, as many of us who have suffered or are suffering from this condition know, it is the short term pain and loss of function that can be debilitating and anything to treat this conservatively should be embraced. Plus it appears that strengthening and biomechanical changes will have positive long term effects to prevent recurrence.

Let’s get some background anatomy in first, and then look at how the evidence suggests it is best managed.

What is the Plantar Fascia?

The Plantar fascia itself is a thick band of connective tissue that runs the length of the sole of the foot, from the inside border of the heel (medial tubercle of calcaneus) to the underside of the base of the toes (proximal phalanges).It lies superficial to the deep intrinsic muscles of the foot.

 

 

What does the Plantar Fascia do?

The plantar fascia has two main roles:

    1. Assisting in the propulsion of walking, known as the windlass  echanism. When you go to push-off in walking or running, the joints at the ball of the foot (metatarsal-phalangeal or MTP joints) extend back which creates a bow-stringing stretch effect on the plantar fascia. This locks up the midfoot, giving the foot a rigid lever to push-off with. Without this, we would be trying to step off a floppy foot – not a greatly efficient way to move.
    2. Assisting in shock absorption of the foot in walking and running.

 

 

What is Plantar Fasciitis or Fasciosis?

It is an overload soft tissue disorder, with little or no inflammation, resembling the degenerative effects of chronic tendon damage (tendinosis) when looking under a microscope. Hence the term fasciosis is more widely and correctly used these days, as the ‘itis’ suffix denotes an inflammatory effect. 

The pain is almost always at the origin site where the fascia inserts into the heel, though tender spots will be present through the fascia band in the arch. Concurrent Achilles, ankle and midfoot problems are not uncommon as all can be part of a greater biomechanical picture.

A typical presentation includes a sensation similar to walking on broken glass on the first steps in the morning or after a prolonged period of sitting – ouch!

How is it diagnosed?

Plantar fasciosis can easily be diagnosed in clinic. Ultrasound and MRI are useful to exclude other more sinister pathology if required. Heel spurs can be evident on X-Ray in those who have chronic symptoms, but it is the actual plantar fascia tightening over time that causes the heel spur not the other way around, and the pain emanates from the insertion of the plantar fascia onto the heel not the spur itself. In fact, the heel spur is often a red herring and usually clinically insignificant apart from telling us that the problem is chronic in nature (<12 months).

What are the Causes of Plantar Fasciosis?

Technically, non-optimal motor recruitment strategies in weightbearing. In lay terms, this means that the biomechanics of the foot, lower limb, hip and even lower back may be contributing to overloading the soft tissue under the foot. Examples of this include poor posture with a forward pelvic tilt bringing your body weight further onto the forefoot in standing, excessively rolling in (pronating) feet, reduced ankle mobility, weak or tight calves, increased angles at the hip or knee due to structural and/or weakness issues and uneven weight distribution through the lower limb (compensatory from previous injury, leg length discrepancies, scoliosis of lower spine etc).

Sub-optimal footwear and increased training or weightbearing loads will often trigger the condition. Common examples that we see of this are wearing thongs or flat shoes for a period of time on holidays, increased weight gain (a big factor), football/soccer boots on hard grounds early in the season & increase in walking or running training.

What is the treatment for Plantar Fasciosis?

There are two main components to the treatment: alleviation of symptoms, and addressing causative factors. Often we will need to address the causes in order to alleviate the symptoms, but sometimes the pain needs to be settled to a degree before corrective action and exercises can be introduced.

Alleviation of symptoms. Initial conservative approach includes:

  1. Strengthening: Relatively new evidence coming out showing that a plantar fascia specific program can have better treatment effects than a plantar specific stretching program at 3 months. There is no long term benefits to this form of treatment however it can improve foot pain and function in the short term. This research also outlines that more value should be placed on strengthening of the lower limbs in order to prevent future recurrences – be it calf strength or hip/pelvic strength. Expect this to be a feature of how physiotherapists and doctors treat plantar fasciosis going forward.
  2. Foot taping (Low dye): Effective for short-term relief of pain. Usually indicates that orthotics will be beneficial. Should be implemented early in the early phase of rehab.
  3. Stretching: Utilise a stretching program involving calf and plantar specific stretching. Shown to provide short term relief.
  4. Strasbourg sock: Has shown to be effective in chronic cases where first line treatment strategies have not produced desired results. We have these in clinic and they can be extremely useful for certain people.
  5. Orthotics: Can be used to help offload the fascia and have shown improvement in short and long term outcomes. No difference between the use of off the shelf orthotics and custom orthotics in early stages. If there is a biomechanical factor as to why the plantar fascia has occurred than a custom orthotic to address this issue will be important once the acute symptoms have settled.
  6. Footwear education: Footwear can be an aggravating factor for this condition. Some arch support in the shoe should be considered without being too rigid so as to irritate the plantar fascia. A well cushioned shoe is also important. Shoe selection can be a tricky balancing act for this condition so some help may be required.
  7. Rest from or modifying weightbearing activities, aim to reduce time on feet significantly
  8. Non-weightbearing exercise: go crazy in the pool, Pilates reformer, on the bike, rowing machine or even a cross-training machine.
  9. Cortisone injections: Limited evidence to support use and should be used as a last resort. May provide short term pain relief but has been associated with a greater risk of plantar fascia tears, particularly in more chronic cases.
  10. Surgery: Poor results and associated with poor short and long term outcomes.

Addressing Causative Factors, once symptoms begin to improve:

It is often a long slow road if symptoms persist beyond the initial first few weeks, but a biomechanics assessment combined with a guided exercises program, and orthotics or footwear modification, from your physiotherapist is key to a full recovery and preventing recurrence. This will likely include:

  • Correcting walking and running technique: overstriding is a key and common factor
  • Retraining with simple cues: e.g. walk quietly, lift knees higher, walk on the front of your heel
  • Postural control: improve pelvic, lower back and hip strength in order to provide better standing and walking posture, particularly for those who are on their feet for many hours
  • Single leg stability and strength – can you squat on one leg without tilting hips or levis sideways, and without the knee angling inward?
  • Address weakness, tightness and stiffness issues in hips, knees and ankles – particularly ankle and Achilles tightness
  • Gradual return to sports and walking or running based on strength and biomechanical capabilities

For further advice please make an appointment to see one of our physiotherapists in Olinda you can now book online or call us on 9751 0400.

 

 

Dry Needling – what is it, how does it work and when is it used?

OK I realise needles aren’t for everyone. But even those needle-phobics must be at least curious. Even just a little? Firstly, let’s start with a quick rundown of the history of anatomy which will help to explain why dry needling is quite different to acupuncture. And then how it works (we think) and what it can help with.

Let’s go back to the start. 6000 years ago, or so the legend goes, in ancient China. The warrior inserted a sharpened stone into his first web space (that fleshy bit between your thumb and first finger) and just like that his chronic headaches suddenly improved. From here, Eastern medicine developed theories of meridians, or systems of energy flow within the body. Within these systems, organs and other deep tissue line up with superficial points on the body, and therefore can be influenced by stimulating these superficial points. And to this day, meridians continue to dominate eastern medicine.

Fast forward to the 15th century. Da Vinci’s drawings of the human body thrust western medicine toward our modern understanding of anatomy, and in turn the teaching of anatomy evolved throughout this period to routinely include dissection of cadavers.

Here we have the major divergence of eastern and western medicine – eastern theories of medicine are largely theoretical, with little or no dissection for hard evidence of these theories. In contrast, western medicine relies almost solely, and some may say too much, on evidence and proof of theory.

The term “dry needling” was coined by the American physician Janet Travell, who also pioneered studies into myofascial pain and trigger points (and was personal physician to JFK). From as early as the 1940’s Travell began interested in the idea of injecting these trigger points, or tight bands within muscles, with all different kinds of solutions – from lignocaine to saline to steroids – in order to treat muscular and chronic pain. Later on, she discovered that patients with myofascial and chronic pain improved with both wet (a solution) or dry (no solution) needling into these points.

It wasn’t until the 1990’s that an unknown genius started using thin gauge acupuncture needles instead of hypodermic needles. When practitioners realised that the effect was the same as using hypodermic needles, the practice took off. Firstly with sports medicine physios and physicians within elite sporting teams, and now to almost every physio, osteopath and myotherapist.

Travell and David Simons, another American physician, mapped out the entire human body of myofascial trigger points from their years of research into two thick volumes. And to this day Travell & SImons is still the bible for practitioners of dry needling for myofascial trigger points.

Yet this bible is also the ruin of many dry needling practitioners if they rely on hitting these plotted points, rather like acupuncture, instead of accurately assessing and diagnosing muscles that are causing pain and/or tightness, and targeting the tight bands within those muscles. The myofascial trigger points which cause pain and restriction are located within these tight bands of affected muscles. These tight bands can only be ‘felt’ with experience, and with a solid understanding of anatomy. Releasing these are the key to aid in restoring normal muscle function and reducing pain with dry needling.

The idea that dry needling is akin to acupuncture is false. Apart from using the same needles, the only similarities lie with the effects of inserting a needle into tissue – localised pain relief and systemic endorphin-like response. Acupuncture needling relies on targeting very specific points within meridians in order to influence other points in that meridian, which could like on a completely different part of the body or be internal or even habitual.

Dry needling is purely dumb western medicine at its best – see tight muscle, hit tight muscle.

There is no clear consensus on whether deep or superficial dry needling works best. Deep involves hitting trigger points and invoking a muscle twitch response and is what we find works best for the majority of people with muscle pain and tightness. The twitch response sends a signal to your spinal cord to tell it that the muscle has worked maximally, and in response a reflexive signal is sent back to relax the muscle in order not to do any damage to it. The result is a tired, worn out muscle, which may have some soreness akin to post-exercise soreness, yet with maximal relaxation. The soreness can last from 5 minutes to 2 days, with most people having little or no soreness the day after. The relaxation component lasts from between two to seven days for chronic complaints, and can be instantaneous relief for acute muscular tightness. The difference is that chronic complaints are often part of muscle patterns that are habitual, and so the muscle tightness can begin to return after a few days or a week once incorrect muscle patterns are used again. For this reason, dry needling is best done for chronic complaints in conjunction with an exercise program to help retrain these muscle patterns over at least a 6-8 week period.

Superficial dry needling is also practised for pain relieving effects, and with less post-treatment soreness. Whilst we do not find it as effective for releasing tight muscle bands, it is preferable for people who are needle-phobic or who experience significant post-treatment soreness. Many people with chronic pain syndromes tend to fall into this basket, and for these we will often begin initial dry needling sessions with gentler techniques to see how they respond before being too aggressive with deep dry needling.

Post treatment, localise heat (heat packs), stretching and gentle exercise is best. If any bleeding or bruising occurs, which is usually minimal and superficial if it does, then ice must be applied instead of heat. Some people can play football after needling, and some need to lie down! It’s best to have your first session on a day when you either have not much on, or later int he day where you can relax.

For more information or to try dry needling from the experts, feel free to make an appointment with one of our physiotherapists. Make sure you let our receptionists know that you are interested in dry needling so that we can guide you to the right physio or myotherapist to start with.

 

Will My Disc Ever Heal?

Physiotherapists are often asked this question. If you’ve ever had, or currently have, a disc injury to your lower back, you will understand why.

There are two main mechanisms by which discs can create pain.

1. Annular Tear

In the 1950’s, it was discovered that discs actually have a nerve supply. Prior to that time, the tiny nerves that supply the outer fibres of the disc (annulus) had never been seen, thus the disc itself was thought to be insensitive to pain. Others since have elaborated that there is an overlap of these nerve up to 3 spinal levels above and below the affected disc. Following these discoveries, we know that the disc can itself be a source of pain, that this pain can be poorly localised due to this overlap, and that the disc may be unique in human musculoskeletal tissue in that the pain may mimic visceral pain more so than standard orthopaedic pain.

Annular disc injuries are typically degenerative in nature, though can also be the result of trauma. They will generally respond favourably to physiotherapy and guided exercises although patience and persistence is required.

2. Disc extrusion or Protrusion

The second mechanism is when an extruded or protruded disc comes into contact with the descending spinal nerves. This can cause unrelenting and severe pain into the legs, as well as sensory changes and muscle weakness in the lower limbs.

There is a common misconception that if there is material from a disc pressing against nerve tissue that it never heals, which is simply false. Discs can heal if the conditions for this are created.

The natural process of the human body to clean up the extruded material from the disc is called resorption and the pace of which this occurs can vary between individuals. This can be affected by genetics, systemic health, smoking & whether your activities or postures (especially repetitive bending and prolonged sitting) continue to provoke the disc.

Interesting to also note that MRI findings will lag behind improvement of leg symptoms  (Ito, 1996) and that the larger the disc injury, the more likely it is to resorb (Maigne 1992, Bush 1992, Jensen 1996).

The most hopeful part about this information is that surgery to remove the disc material from being in contact with the nerve root is no longer indicated as an early treatment measure in most cases, as we know that the material will resorb over time.

Surgery should be urgently considered for a disc extrusion or protrusion if there is a change in bowel or bladder function (incontinence or retention) or numbness in the saddle area near the genitals or anus.

Otherwise, surgery is considered elective and is indicated only if:

  • Progressive weakness of leg muscles is occurring & numbness is evident in the skin of the leg, and/or
  • The pain is not manageable with conservative care

Conservative care for any disc injury includes physiotherapy, low weight-bearing exercise, rest from aggravating activities & postures as guided by your physiotherapist, and short-term pain relieving medication or injections into the affected area if required. Examples of low weight-bearing exercise are hydrotherapy and equipment Clinical Pilates guided by a physiotherapist to be performed across gravity.

It is extremely important to have these injuries assessed on a case by case basis as not all will respond to the same set of exercises. The simplest way to explain why is because disc injuries can occur in a 360 degree plane, and movements to a particular direction for one person will not automatically suit another. This is one reason why Clinical Pilates programs need to be tailored to the individual.

If this is happens to be a situation you find yourself in, you should:

  • Seek guidance from a physiotherapist,
  • Complete your rehabilitation,
  • Incorporate healthy physical activity into your life
  • Avoid provocative actions such as prolonged sitting, repeated bending or lifting with a flexed lower back

Then you:

  • Can be confident that your body will be working to help find the solution.
  • Will reduce the rate of recurrent episodes
  • Will give your disc the best chance of a full recovery.

And worth noting:

Around 50% of adults of all ages without back pain have disc abnormalities on MRI, with up to 30% having protrusions and 1-2% having the more severe extrusion. This likelihood increases with age. If you have lower back pain but no leg symptoms, the occurrence of disc abnormality on MRI may be coincidental and not necessarily linked to your pain (Jensen et al, 1994). If this is you, then physiotherapy and appropriate exercise is also your frontline treatment option.

To see one of our physiotherapists, please call us on 97510400 to make an appointment. They will guide you as to whether manual therapy, exercises, Clinical Pilates or a combination of either is appropriate.

 

Apophysitis – Adolescent ankle, knee and hip pains explained

One of the most common categories of pain in sporty or active children is what is collectively known as apophysitis. Not a very catchy word, but you may know these better by their regional names: Sever’s Disease at the rear of the heel or ankle, Osgood-Schlatter Disease below the knee, Sinding-Larsen-Johansson Syndrome (SLJ) at the base of the kneecap and the one they forgot to name – Ilium Apophysitis –  at the front of the hip. Add to this Osteitis Pubis in the groin for a slightly older, but still youthful, population.

What is Apophysitis

Apophysitis refers to inflammation – itis – of the apophysis – the junction of the growth plate to the musculo-tendinous unit in growing skeletons. It is caused by repetitive stress on the apophysis from the musculo-tendinous unit, and therefore is more likely to affect very active children. I often like to explain to my patients that where kids will get apophysitis, adults will get tendinitis or tendon injury. This is because the growth plate hasn’t fused in children and the apophysis becomes the weak point for any stress or overload. Once it is fused, the attachment on the bone itself (think plantar fasciitis) or the tendon (think rotator cuff, Achilles or patella tendinopathy) becomes the weak point.

Apophysitis presents at first as a dull pain on or after activity at or around the bony site, with the absence of any obvious one-off cause or injury event. Sever’s will feel like ankle pain to most kids. As the severity progresses, pain will be more severe, the onset of pain will be quicker during activity, and the pain will last for longer after activity & often worse after rest (e.g. the next morning). 

There will be precipitating extrinsic factors – change of training surfaces, conditions or type; change of footwear, especially to lower heeled shoes like thongs or football/soccer boots – and intrinsic factors – growth spurts, tight calves or quadriceps, pronating feet, poor running biomechanics and poor core or other muscle strength.

The reported ages of occurrence for all apophysitis conditions vary slightly, but correspond to the ‘growing skeleton’ definition:

  • Sever’s: 8-14 years old
  • OSD & SLJ: 8-15 years old (females 8-13, males 12-15)
  • Ilium: 11-15 years old
  • Osteitis Pubis: 15-25 years old

What is the Treatment

All of these apophysitis conditions are relatively straightforward for a physiotherapist to diagnose and treat without imaging being required. A thorough history and physical examination will point to causative factors that should be addressed prior to or whilst returning to activity in order to reduce the high risk of recurrence.

The factor of repetitive stress cannot be understated. In the past, rest and occasional ice was the only treatment. The pain will often settle with 2-4 weeks rest and icing, however without addressing the underlying factors the pain will return until the growth plates fuse, often once training is ramped up again and coincides with the next growth spurt. And problems will persist for the patient in the musculo-tendinous or bony region as an adult once the growth plate is fused.

More recent knowledge has physios tackling the contributing factors, which is particularly helpful during the initial rest period, or the early stages if the condition has not progressed to the severity to require rest:

    • Foot posture – excessive rolling in or out during gait, rotated heel or forefoot in standing; treated with footwear advice, taping and orthotics
    • Reduced joint range of movement – particularly ankles, hips and lower back; treated with hands on treatment and home exercises
    • Increased muscle tension – calves for Sever’s, quadriceps, adductors, hamstrings, glutes; treated with massage and stretching, dry needling an option > 14 years old depending on the child
    • Muscle weakness – particularly core and hips for OSD, SLJ and Osteitis Pubis; treated with tailored core, pelvis and lower limb strengthening program, Pilates for the serious adolescent athlete >12 years
    • Education  – perhaps the most important, so that children and parents know the signs and how to manage the condition in the future before it gets bad enough to warrant resting from sport
    • Running Biomechanics – evaluating what is happening with each joint and major muscle groups during gait and running, and tailoring stretching, strengthening and running exercises to the individual

 

Each of our physiotherapists at Dandenong Ranges Physio are to assist with assessment, treatment and advice for Sever’s Disease, Osgood-Schlatter’s, SLJ, Ilium Apophysitis or Osteitis Pubis. To make an appointment please call us on 9751 0400.

Choose physio for shoulder injuries before even considering surgery

Evidence supports at least 3 months of physio for shoulder injuries before considering surgery

Shoulder problems account for a large proportion of our caseload, second only to back pain. And of those, the two big ones we see are rotator cuff problems & shoulder impingement syndrome (SIS), and often both.

Surgical procedures have very limited windows of favourable outcomes compared with conservative management for these two problems, and other medical intervention such as cortisone injections even more limited.

Recent evidence shows that conservative management, or physiotherapy and exercises, should always be considered first for any rotator cuff  injury or SIS for a period of at least 3 months. .

These issues generally respond effectively to physiotherapy, with earlier intervention always bringing a more responsive treatment effect, sometimes even when there appears to be significant damage on ultrasound or MRI.

At the end of this article is a basic anatomy lesson, so please refer to that if you get lost in the text below!

How are these diagnosed?

Specific tests by an experienced physiotherapist or sports medicine practitioner in conjunction with radiology will yield a more accurate diagnosis than radiology alone. Often there is no need for radiology whatsoever.

For radiology, ultrasound can be effective in diagnosing very large rotator cuff tears only. MRI, whilst much more accurate, should be read with caution. One 1995 study (Sher et al) showed that in an asymptomatic, painless group of 97 patients across all age groups, 34% had rotator cuff tears, and 15% were full-thickness. Yet they had no symptoms!

Similar studies show bursitis (inflamed bursae) in up to 60% of men and 80% of women regardless of symptoms. We constantly have patients referred for bursitis when the problem is really SIS. 

Some basic anatomy!

The rotator cuff muscles sit around the scapula (shoulder blade) and send their attachments to the front, side and back of the top of the humerus (your upper arm bone). Injuries occur in the tendon or the musculo-tendinous junction near where they insert into the humerus. Around 90% of injuries are degenerative in nature, and as such, are often part of the normal wear and tear in our bodies. The job of the rotator cuff is to control the head of the humerus when we lift our arm, largely so that it doesn’t jam up into the bone above it.

Shoulder Impingement Syndrome (SIS) occurs when the supraspinatus tendon and overlying bursa (which acts as a cushion and to reduce friction on the tendon) get pinched in the sub-acromial space where they sit between the acromion (pointy edge of your shoulder) and the top of the humerus. When there is an injury to the rotator cuff, or if they aren’t working together well, then the humeral head moves upward into the subacromial space on lifting of the arm causing impingement of the supraspinatus tendon and bursa. Hence why we often get rotator cuff injury and SIS occurring together.

Other factors that influence the onset of both of these problems are:

  • Slouched posture, causing the scapula to sit forward or tilt down, reducing the sub-acromial space
  • Weak or poorly functioning scapula muscles and postural muscles of the back
  • History of occupational or sports using the arm above the head repetitively, or with heavy lifting
  • History of cortisone into the subacromial region increases risk of degenerative rotator cuff tendons
  • Presence of autoimmune disease (Ankylosing spondylitis, Rheumatoid Arthritis) or Diabetes

What is the treatment?

Physiotherapy involves addressing postural and biomechanical causative factors as well as providing symptomatic relief in the early stages with hands-on treatment (massage, dry needling, spinal mobilisation if required). The most important thing is to address the function of the scapula (shoulder blade) muscles and to correct the position of the scapula itself with postural exercises. Strengthening for the upper limb is progressed as pain reduces and graded toward returning to full activity over time.

The patient should also rest from aggravating activities in the early stages of rehabilitation, such as repetitive overhead movements, holding dead weights by the side (eg shopping bags) and slouching whilst working, relaxing or driving. Symptoms should start to improve within two weeks for most people. Full recovery can take between 6 – 26 weeks, and for rotator cuff tears there is often some ongoing rehab required.

Evidence suggests that surgery for SIS, where the pressure is relieved in the sub-acromial space by removing part of the acromion bone or the bursa itself, is no more effective than conservative treatment (Setola et al, 2015, & Saltychev et al, 2013). And cortisone injections are only effective for short term pain relief, and much more effective when combined with conservative physiotherapy management.

Surgical opinion for rotator cuff tears should only be considered for a healthy population under 50 years old that require high level use of the upper body for work or recreation, and only for tears greater than 3cm in length, and always after attempting at least 3 months of conservative management first.