2014 ‘Injury of the year’

Yep I’m calling it… a little early maybe but it’s hard to imagine anything knocking this injury out of its top spot. Lachie  is one of those people that always manages to outdo himself when it comes to injury. It’s never simple or straight forward, and this one was no different. I wasn’t there to witness the actual injury but the photos speak for themselves…. it really is the most unbelievable injury I have EVER seen so much so that it even had high profile sports surgeons running for the hills. (if you don’t like gory stuff I suggest you don’t look at the photo).lachie

We see a whole range of acute knee injuries that require surgery. Usually people tear one, maybe 2 ligaments or injure the cartilage in the knee. Not this guy though, he actually managed to tear the big 4. Yep that’s all 4 major ligaments that are basically responsible for holding the knee together.  ACL… gone. PCL… rutured… MCL.. split… LCL…torn.

Take a moment to process that. I didn’t believe it until I had the MRI report in my hands and could read for myself.

How? well its kind of funny you asked. It was ‘rugby related’.. but not exactly on the footy field but rather in the ‘tram tracks’. Tram Tracks is a one-on-one tackling battle that continues until someone taps out. Its probably the dumbest game in the world but rugby boys seem to love it (especially after one or two beers). Must be something to do with testosterone and a little ‘healthy’ competition.

So amidst a Saturday session in the ‘tram tracks’ Lachie managed to dislocate his knee, not his kneecap his knee.

He required a full open knee reconstruction where the surgeon used two donor ligaments to pretty much design him a new knee. Usually a knee reconstruction uses a ligament created using a tendon graft from your own hamstring, however  in this case donor tissue was used because the surgeon wouldn’t have wanted to compromise the stabilitylachie 2 of the knee any further. Taking a graft weakens the hamstring tendon in the short term and potentially could slow the recovery & rehabilitation.

Lachie is now 10 weeks post surgery and I’ll admit I’m very surprised with how well he is recovering. He’s back in the gym doing a full legs program (with light weights). The focus is primarily on developing good hamstring & quadriceps control. His rehab also includes proprioceptive training and balance exercises on a wobble board.

This week he will progress to jumping and hopping to prepare him for a return to running program. His surgeon is very happy with his progress and expects him to make a good recovery.

The bit I still don’t get…. I asked Lachie the other day if he wanted to play rugby again next year, he did hesitate a little but not as much as I would have expected, before saying ‘yeah probably’. I guess it’s one of the things I love about my job, these guys go through so much just to get themselves back on the field. For many it’s a play at all costs attitude. Is that just a guy thing? Or is rugby really that good of a game? Maybe that’s why they say rugby is the game they play in heaven, because these boys literally can’t get enough.

Lachie works for Adwords Management Australia and is available for interviews upon request…. or he can just help you with website marketing & design stuff, he’s pretty good at that too!

Hope this has helped you through the Wednesday afternoon slump!

Have a great day

Em 🙂

Are you running into problems?

Iliotibial band (ITB) Friction syndrome is one of the most common causes of lateral (outside) knee pain that we see, especially in runners. It’s also probably one of the most frustrating problems both for myself and for the patient. It is largely an overuse injury due to the repetitive nature of activities such as running. It often starts out as a little ‘niggle’ however gradually worsens & worsens until it quite literally will stop you in your tracks.index

The ITB is a band of connective tissue that spans the length of the outer thigh. It originates up at the hip from another structure called the TFL (tensor fascia lata) and inserts onto the tibia just below the knee. It plays a crucial role in stabilizing the outside of the knee during activity. ITB friction occurs when the ITB gets tight & inflamed (as a result of overuse) and begins to rub over the lateral femoral condyle on the outside of the knee joint producing acute, often sharp pain in this area.

Many of my patients ask WHY? There are some factors such as pronated feel, tight calves, poor pelvic stability, anterior hip inflexibility and poor lower limb control that can increase the likelihood of developing this problem. Other extrinsic factors such as footwear & training loads also need to be addressed and considered when looking into the management of this issue.

SYMPTOMS

  • Pain felt on the outside of the knee
  • Tenderness over the outside of the knee
  • Pain generally worsens with activities such as running, particularly downhills and downstairs
  • In more severe cases there may be swelling and or crepitus (creaking) over the side of the knee
  • Pain can extend up into the thigh along the length of the ITB

Often people suffering from ITB friction may be able to run a few hundred metres before the pain will kick in. It is not advisable to try and run through this pain, you will aggravate the tendon which can then take several days to settle down.

DIAGNOSIS: A skilled physiotherapist will be able to diagnose ITB friction from your clinical history and a thorough examination. There is usually no need for further investigation unless you do not improve with appropriate management.

TREATMENT & MANAGEMENT

Physiotherapy is a vital tool to manage ITB friction syndrome. In the initial stages rest from aggravating activities will be required to allow inflammation and pain to settle.

Physiotherapy treatment should involve a variety of the following:

  • Soft tissue releases to tight structures such as the ITB, TFL, gluteus medius, lateral quadriceps and lateral hamstring. This should then be complemented with use of a foam roller at home on a daily basis
  • Addressing bio-mechanical factors such as poor pelvic stability and anterior hip inflexibility
  • Advice regarding exercise modification, footwear & training loads. Some elements within training sessions should also be looked at such as the direction of running if using a track, if you are repeatedly running the same bend you will be overloading one side more than the other which can result in overuse injuries such as this.
  • Dry needling is an awesome way of releasing tight bands of muscle. Often with this problem I find these all around the outside of the hip and down the length of the thigh.
  • Electrophysical therapy such as TENS to help with pain & inflammation.
  • Icing & use of anti-inflammatory medication

With the correct treatment most people with ITB friction syndrome will make a full recovery, however rehabilitation can be a lengthy process in those patients who have had the condition for a while. In saying that it is so important that this problem is caught early. If you get on top of ITB issues in the first 48-72 hours you will drastically reduce the amount of time off running.

Can it be prevented? There are some exercises that I would advise runners do on a regular basis in an attempt to prevent excessive tightness of structures such as the ITB. Use of a foam roller is a great form of self massage, it’s a bit of a love / hate relationship but it is extremely effective. Hip flexor stretches, general pelvic stability exercises and bilateral calf strengthening are essential in the long term management plan. Chat to your physio if you want someone to go over such exercises more thoroughly.

Have a great week!

Ems

Dealing with stubborn tendon problems

Treating and managing ‘tendon’ problems one of the most frustrating group of injuries I encounter, mainly because their recovery often has no time frame, it’s never linear, instead they tend to be a 2 steps forward one step back kind of problem. If it’s frustrating for me, I can only imagine how my patients must feel.

Why?

The answer isn’t black & white (it never is in medicine). There are however a few anatomical and physiological factors that can help explain why tendon problems can be stubborn as all hell.

I’ll quickly given you a little anatomical insight as to what a tendon actually is, and no a tendon is not a ligament (I do kind of understand why people get this concept confused). Tendons are thin fibrous bands which connect a muscle to a bone. Their function is to transmit forces, essentially providing stability with no real ‘active’ work. Not all tendons function the same. Some are positional purely assisting with controlling the position of the joint (fingers) while some can actually store energy & work as springs to assist with basic movements of the body such as walking.

Tendon dysfunction is usually a result of overuse due to repetitive stress being placed through one particular area of the body. Common sites include the Achilles, the patella tendon, the rotator cuff, tennis elbow & the hamstring tendon. Problems can be categorized as either

TENDONITIS: inflammation of the tendon OR

TENDINOSIS: inflammation with additional micro tearing and wear & tear of the tendon fibres.

Many clinicians also now use the umbrella term ‘tendinopathy’ which encompasses aspects of both.

Anyone can suffer from tendinopathy if there is great enough forces transmitted through a tendon that may not be conditioned to deal with it. Take me for example when I was 22, no history of knee problems, started doing a lot of stair running & plyometric training (jumping lunges, squats etc) combined with running. Ended up with acute patella tendonitis.

Such cases in ‘younger’ athletes are easier to manage. Tendonitis is acute & generally we are dealing with inflammation which with rest from aggravating activities & appropriate rehab will clear up in a matter of weeks.knee

Tendinosis is a little different & this is where the frustration sets it. Athletes in the 35-40+ category who do a lot of activity are those we worry about here. At this age (which is by no means old) most tendons will be starting to show signs of wear and tear. Small degenerative fraying of the collagen fibres at a microscopic level which is usually asymptomatic. When you start to place a lot of load through that ‘weakened’ area problems begin to arise. It starts as a dull ache, which gradually gets worse. Often stiffest in the morning upon rising. The area may also be tender & swollen if inflammation is also present. In very acute cases there can be ‘crepitus’ or creaking in the tendon itself.

The longer you push through some of these seemingly minor symptoms the harder it will be to manage.

Why are they stubborn?

Well for one tendons don’t get a great blood supply in comparison to our muscles & organs which are constantly bathed in fresh blood filled with oxygen & other lovely nutrients. This contributes to a slightly slower healing process.

Microscopically tendinosis is due to the disruption of the collagen fibres of the tendon. Normal healthy tendon fibres line up side by side while inflamed injured fibres will bunch together & get a little ‘tangled’. It can take up to 100 days for our body to reestablish strong collagen fibres.

Is there any good news?

Yes. Kind of.

In the acute stages you will need to rest from aggravating activities whether it be running, weights, tennis, surfing. However some activity will actually be favourable to your rehabilitation by promoting remodeling of the tendon fibres, however this will normally need to be cross training of some sort so as to reduce the overall load through the tendon.

There will also be certain exercises depending on the tendon in question that will be required to strengthen the tendon for long term management. Such exercises are usually eccentric & focused on the negative phase of movement, this simply means loading the tendon as its lengthening. This has been show to encourage rebuilding of collagen.

The treatment course is always individualized & you and your physiotherapist should work together to develop a rehabilitation program that controls your symptoms whilst also incorporating appropriate strengthening.

There are also alternatives… such as injections, patches to promote blood flow & more recently the PRP (platelet rich plasma) which involves an injection of a concentrated solution made from your own blood to promote healing. (more to come on this in an upcoming blog). Such options can be discussed with your physio or doctor.

Have a great day!

Em

Your City 2 Surf ‘preparation guide’

Isn’t it so EXCITING that City 2 Surf is only 5 days away!?! It’s easily the best day on Sydney’s fitness calendar & my favourite day of the year to run a muck (literally) in Bondi. For me this day marks the beginning of the end of winter… It’s usually always sunny, people rock bright clothing & some of the most incredible costumes, there is music, people dancing, face paint & people lining the sidewalk cheering the runners on. It’s almost as if for a day everyone in Sydney is one big happy fun fit family!

So many of you have been training for this day, getting up early & braving the cold for early morning running sessions and heartbreak hill sprints. This weekend you get to see all of your hard work pay off & then there is the celebratory breakfast (or brunch) with a few celebratory beverages of course! Nothing says congratulations like a jug of fresh Pimms punch!

When it comes to being prepared, what you do over the next 5 days is almost as important as what you have done for the last 6 weeks. Don’t fall off the wagon in the home straight, just follow these couple of basic tips so you are super super prepared come Sunday.

  1. TAPER: Yes you are allowed to finally back off the training and have a light week. I would suggest 2 runs (max 3 if you really really cityneed too). Early on in the week aim for a steady 8km sitting just under race pace. Later in the week push out a 6-7km flat effort just to wind the legs over.
  2. DAY OF REST: Saturday is your day off. Have a massage, do a yoga stretch session if you feel like you need it, but give the legs a day of rest.
  3. RACE DAY PACK: don’t forget you need to collect your race day kit with your bib and timing chip. Available for collection Thursday – Saturday at Moore Park (check your registration details for times etc). You cannot collect these on the day!
  4. NUTRITION: I am not a huge believer in altering your diet in any significant way in the lead up to an event. I have been eating my usual diet throughout my training regime so the last thing I want to do is load up on a whole heap of foods my body isn’t used to the day before.
    • Friday & Saturday eat a few more good ‘complex carbs’ like sweet potato, lentils, quinoa and nuts in your meals.
    • Don’t stuff your face the night before, keep dinner relatively small make sure you have some good sources of carbohydrates on your plate. Think sweet potato, starchy vegetables (carrots, pumpkin, green peas, beetroot, parsnip) or lentils as opposed to white bread & pasta.
    • Do you eat before you run? This comes down to personal preference. Some people can’t stomach the thought of food before a 14km run, others like to have something small such as a banana or small bowl of oatmeal with fresh berries. Do what you are familiar with!
  5. HYDRATION: Your body needs water more than anything else. Make sure you are getting your 8 glasses every single day this week. I like to add a little sea salt (NOT TABLE SALT) to my water bottle, it helps you’re body stay hydrated!

Most importantly, don’t forget to HAVE FUN!

GOOD LUCK RUNNERS!!

EMS xox

 

Can high heels damage our feet?

Very excited to have a little guest blog from our friends down at PodMed in Double Bay.  We treat alot of women with foot & lower limb problems…. when discussing aspects of their rehabilitation the wearing of high heels is often a question that comes up… So we asked the podiatrists…. they are at the end of the day experts when it comes to feet!

I am asked this questioned nearly every day by women who present with all kinds of different foot pain. There is a common misconception out there that high heels are the primary cause of most foot pain and deformity in women. Yes, I can guarantee you that if your foot is squeezed into a high-heeled shoe eight hours a day, at some stage foot pain and deformity will be the end result. High heeled shoes can do a lot of irreparable damage to the feet and ankles. However when used in moderation some of the pitfalls can be avoided. Many of my patients wear high heels on the odd occasion and as long as it’s only for a couple of hours at a time at a party or out to dinner; it’s generally not a problem. Of great concern to us is the number of young teenage girls presenting in our clinic showing early onset deformities as a result of high heel wearing. Parents need to discourage their teenage daughters from wearing high heels at any time. The developing and immature foot structure does not cope at all well with the excessive forces placed on the foot by the high heeled shoes. High heels put the anatomical structures inside your foot into an unnatural position. With each step the toes are squashed inside the shoe. The pointier the shoe and the higher the heel the more pressure placed on the toes. It’s important not to under estimate the damage this can do to the foot in the long term. Habitual long-term high heel wearers routinely present with problems like clawed toes, bunion formation, metatarsalgia and nerve damage. Foot structure will have some bearing on how resilient the foot structure is to the adverse effects of high heels but as I like to say, footwear is designed to protect your feet, not to hurt you. If your high heels are hurting you, take them off because they have already been on too long. ‘If the pain persists…..see your Podiatrist’. High heeled shoes shift an unnaturally large amount of force onto the forefoot with every step. The natural heel to toe transition is altered and the force moves too quickly from heel to the forefoot where the high loading remains for the duration of the steps. It is the increase in time that the foot is overloaded with every step that does as much damage as the pressure itself.

The postural position high heels places the body has historically and is still considered aesthetically appealing to the human eye. In the leg, the calf muscles protrude more in high heels giving the impression the legs are strong and slender. At the knee, it is bent when the heel is lifted up. Usually with a 3 inch heel, the pelvis is tilted forward 10-15 degrees which leads to a “sexy” curvature in the spine. This makes the buttocks protrude 25% and also lifts the bust (see picture below). That is how a sexy and wavy body posture is obtained and explains why 3-inches high heel is apparently more popular and loved by most women. However, it is also due to these minor postural adjustments that can have negative effects on the body after a long period of time.

imagesUZ8FBV1EWhat steps can you take to minimise the effects of high heels?

Heel height: Wearing a shoe with a lower heel can certainly help. By lowering the heel you can take some of the pressure of the foot structure but you can also help reduce the negative postural effects on knees, hips and low back. Lowering the heel can also reduce the stiffness in Achilles tendon’s and calf muscles that habitual high heel wearers suffer. If the Achilles and calf muscles shorten too much then wearing flat shoes or walking barefoot becomes almost impossible.
Insoles: Insoles or customised orthotics can prove to be a wonderful way to manage foot pain on a daily basis. However, it is best to discuss what type of insoles or orthotic might be right for you with your local Podiatrist.
Wearing well-fitted shoes: When a shoe fits very well it will generally be comfortable for eight hours or one hour. It is important to select the right type of shoes for right occasion. You wouldn’t wear your high-heeled shoes for exercising i.e. a long walk, a run or to the gym. Nor would you choose to wear your exercising footwear or comfortable casual shoesout to dinner or to a cocktail party (unless you had to). Alternating between flats and heels can sometimes prove difficult (see ‘wearing a lower heel’). However, providing that the difference in the heel height between the flats in the heels it’s not too extreme, alternating between the two is a fantastic way to go. Try to make sure that the flats still have some small amount of heel raise in them. Most foot types appreciate a small amount of heel raise in their flats and this makes the transition from high-heeled shoes into to flattish shoes much easier.

Also it is best to buy high heels in the afternoon when your feet are at their largest. Therefore when your legs and feet expand, the shoe size is correct and the toes aren’t cramped.

Stretching: Most of us have been wearing shoes with some form of heel raise in them from a very young age and this somewhat shortens the Achilles tendon’s and calf muscles. For this reason, stretching is very important. Stretching is even more important for long-term high heel wearers because their Achilles tendon’s and calf muscles can become extremely short and tight. To walk normally and without having to make unnecessary compensations is not only important to have a good range of motion in your calf muscles but also in the other important muscles of the leg, thigh and hip. High-heeled wearers typically have very tight planter flexers in the bottom of the foot, short calf muscles, tight hamstrings, quadriceps, ITB’s, hip flexors, gluteals and over time the body over compensates and muscle imbalances and postural issues often arise.
Thanks to Sarah Bongioletti from Pod Med Podiatry Centre for her words of wisdom.

Check out their website HERE

 

 

Sometimes it’s not ‘just a cork’

Throughout winter my Saturdays are spent on the sidelines of a rugby field. I have been working with Easts for 7 years now and I still haven’t quite figured out how the boys do it…. They actually just go out there are smash themselves around for 80 minutes; its no wonder half of them can hardly walk come Sunday… Then they front up to training on Monday ready to do it all again.

We see alot of different injuries & they range hugely in severity; from dislocated shoulders to sprained ankles, concussion & head cuts to hamstring strains. Given that we are dealing with rugby as a sport here one very common injury we see is a ‘cork’ or more technically a ‘haematoma’ This is caused by a direct blow or impact to a muscle, causing bleeding within the muscle. The force of the blow will be reflected by the amount of bleeding and swelling within the muscle; you will suffer a loss of range of movement & pain as a result of this acute response.

Now this all sounds relatively innocent compared to some of the other traumatic injuries we see & hear about BUT unfortunately its ‘not just a cork’. This injury, if not managed properly can actually be a cause present an athlete with some significant frustration down the track.thigh-contusion180

Mild contusions can usually recover fully in 1-2 weeks often the player may not even miss a game.

Moderate to severe contusions can take 4-6 weeks to recover with a few weeks spent on the sidelines.

In some cases, often due to poor management or return to sport too soon players can develop a condition called myositis ossificans. This is a rare but exceptionally painful problem where bone growth or calcification begins within the traumatized muscle. Bony growth continues for 6 weeks before your body will begin to reabsorb the calcified material, making it a rather length rehabilitation period. The risk of developing this is higher in those players that return to playing early and receive another direct blow to the same spot causing the muscle to re-bleed.

The initial phase of management is immensely important. This first 72 hours should consist of:

  • Compression
  • Ice – best done in as much stretch as tolerated. For example when a player suffers a cork to their quadricep on a Saturday we apply the ice immediately with the knee in as much flexion as possible (bent). This puts the muscle in a lengthened position & if done straight away you can help to prevent significant loss of range of movement. This process should be continued the following day by the player
  • DO NOT TAKE ANTI INFLAMMATORY MEDICATION this will increase the amount of bleeding within the muscle
  • Avoid alcohol, heat & massage to the affected area. All of these will increase blood flow to the area which will contribute to excessive swelling.

Following the acute phase management focuses on restoring full pain free range of motion of the injured muscle and also strength. This is done via gentle active stretches, soft tissue massage & basic strengthening exercises.

For example: If we are dealing with a moderate quad contusion. On Monday / Tuesday the player should start basic range of movement exercises in the form of heel slides along a bed to get the muscle moving through its available range. Inner range quadriceps strengthening with body weight and also seated leg extension with body weight can also be commenced. As soon as there is enough range to ride an exercise bike this can be introduced. Start with the seat as high as possible and as the muscle loosens you can lower the seat as tolerated which results in greater flexion of the knee thus greater stretch through the injured muscle.

Gradually strengthening & rehabilitation exercises can be progressed and a return to running program introduced.

Players really shouldn’t go back to playing until they have full pan free range of motion & strength in that muscle.

Sometimes I don’t think I give these boys enough credit when it comes to what injuries they are willing to carry into a game. BUT in the case of a cork there really is nothing we can do as physios to prevent them from getting another blow to that area; it’s the nature of the sport. We can pad it & they can do the most thorough warm up in history, it’s not going to help the response of your muscle when a 120kg bag rower’s knee makes contact with your quad. The risks of developing complications with returning too early are minimal BUT they do exist. Be careful, sometimes its not ‘just a cork’.

Have you injured your meniscus?

The knee is of the most commonly injured areas in the body. Generally we see a pretty even spread between acute knee injuries sustained from a traumatic event such as during sport or from a trip or fall; on the other hand we have the overuse knee problems…. the runners that pump out a huge amount of km per week resulting to overload or inflammation of some of the structures in and around the knee.

The meniscus or menisci (we have two in each knee) and one of the internal cartilages within the knee joint that can be prone to injury both acutely and as a result of overuse.

The menisci are moon shaped cartilages that are located in the knee. They are the ‘shock absorbers’ which permit us to undertake such high intensity and high impact activities. We have one located on the inside and one on the outside of the knee.index

The signs & symptoms of a meniscal injury will vary significantly depending on the severity of the damage:

  • An inflamed or irritated meniscus will present with joint line tenderness, discomfort at end of range extension (straightening the knee) and a reproduction of pain at end of range flexion (bending). There may be a small amount of swelling present.
  • A meniscus that is torn will have swelling, joint line tenderness and potentially an inability to move the knee through full range of motion due to pain. In cases where the tear is large you may experience locking of the knee in certain positions.
  • A Baker’s cyst which is a pocket of swelling directly behind the knee may be present & can be an indication of a tear in the meniscus

A diagnosis can be made by a skilled physiotherapist based on your history & from a proper examination. There are special tests that assess the integrity of the meniscus. Further investigation, usually an MRI, may be warranted to confirm the diagnosis & make decisions regarding future management of your injury.

Management

Treatment of a meniscal injury will again depend on the severity. Being cartilage in nature these structures don’t receive a very good blood supply, making the healing process slightly slower.

An inflamed meniscus can take up to 6 weeks to settle down. A torn meniscus can be managed conservatively in some cases, however in others surgical intervention may be required. This will depend on the size & position of the tear and the degree to which it is affecting your function.

Physiotherapy treatment can include the following:

  • Soft tissue massage to tight, overactive muscles
  • Electrophysical therapy to assist with management of swelling & pain
  • Dry needling – targeted towards overactive tight muscles or to assist with management of swelling, pain & inflammation
  • Exercise prescription: stretching & strengthening exercises to target tight & weak muscles around the knee
  • Advice regarding activity modification

If surgical intervention is required your physiotherapist will prepare you for surgery and also be able to assist you with the post surgery rehabilitation.

Probably the most common question we get from clients is if and when can they go back to sport, whether it be running, soccer, netball. The time frame unfortunately isn’t that clear cut as it comes down to the severity of the injury. Generally speaking its at least 6 weeks before people get back into higher intensity exercise BUT that is very ball park. Those that end up in surgery take a little longer as many surgeons are in no rush to have you placing heavy loads through the knee.

I recently was working with a professional snowboarder who injured his knee. He ended up in surgery & its been about 9 weeks now and he is just beginning to become confident with jumping, running & high intensity exercise that puts alot of load through his knee. The good news this is just in time for him to hit the slopes for the Australian Ski Season…. that is if we actually get any snow this year!

If knee pain is holding you back from exercise or its just there irritating you throughout your day to day life I would suggest getting it checked out by your physiotherapist.

Shoulder ‘impingement’ syndrome

It’s got many names…. rotator cuff tendinitis, swimmers shoulder, throwers shoulder, subacromial impingement or subacromial bursitis. These are all smart, intelligent sounding names for pain that occurs deep in the anterolateral shoulder (anterior meaning front & lateral meaning side… so to the front and side)

Lets do a little anatomy recap: The shoulder is a ball and socket joint; likened to a golf ball on a golf tee. The humerus or upper arm bone sits against a small socket called the glenoid. It’s an inherently unstable joint which is why we are able to perform all the weird & wacky movements with our arms.

The rotator cuff are a group of 4 muscles: supraspinatus, infraspinatus, subscapularis and teres minor. Their role? to depress the head of the humerus essentially assisting the joint capsule and shoulder ligaments to hold it snug in its socket.shoulder

The supraspinatus tendon is usually the one of interest when it comes to rotator cuff ‘impingement’. It passes between the acromion and head of the humerus in the ‘subacromial space’. This space is perfectly designed for the tendon with not a hell of a lot of ‘breathing space’. So when the tendon gets inflamed, irritated and swollen a pinching occurs as this space becomes a little too narrow!

This can be an overuse injury due to repetitive or prolonged strain on the rotator cuff tendons such as with overhead activities, pulling/pushing, lifting or repetitive reaching. It can also be the result of a direct blow or fall onto the point of the shoulder forcing the head of the humerus upwards into the subacromial space creating a pinching effect on the rotator cuff tendon.

Both outcomes result in a painful arc of movement of the arm that can begin to impact on simple activities of daily living such as reaching behind for your seat belt, doing up your bra (ladies) and overhead reaching tasks.

Patients will generally report feeling a deep ache deep inside their shoulder that they can’t quite pinpoint. The severity can vary enormously from a small niggle that is quite hard to replicate with testing to those that can barely lift their shoulder above shoulder height due to pain.

A few key symptoms that indicate ‘impingement’ syndrome include the inability to sleep to the affected shoulder; associated neck stiffness as a result of compensatory movement patterns and pain on repetitive overhead movements… often people will struggle with hanging out the clothes or unpacking the dishwasher.

How is it diagnosed?

A skilled physio need only listen to your history and do a few key clinical tests to know diagnose an impingement syndrome.

Further investigation such as ultrasound or MRI can be organised to confirm this diagnosis if required.

Is physio necessary?

The short answer is yes. Why?

In both presentations of impingement whether it is an overuse problem or as the result of acute trauma physiotherapy is a pretty important management tool.

Treatment can include:

Soft tissue massage: to tight overactive muscles particularly at the back of the shoulder. The upper trapezius found at the top of the shoulder is also tight.

Advice regarding activity modification in terms of training & exercise but also avoiding day to day tasks that may be aggravating their condition.

Dry needling & acupuncture: this is a really useful way to release tight muscles whilst also encouraging blood flow to the region. Fresh blood is packed full of oxygen and essential nutrients to assist with the healing process.

Rehabilitation: once the inflammation is under control most people need to undertake a rotator cuff strengthening program to restore correct shoulder biomechanics, improve posture and prevent ongoing pain and dysfunction. Some common exercises include internal and external rotation as well as lots & lots of upper back strengthening. Think seated row, high row, and prone row! Muscly backs are incredibly attractive boys….

What happens if ‘conservative’ management fails?

DON’T panic most cases don’t get to this stage but sometimes conservative management of impingement syndromes can fail. In these circumstances there are more aggressive forms of treatment that can be explored such as cortisone injections, platelet injections and in very severe non responsive cases surgical intervention maybe required.

Impingement syndrome can be a very very debilitating problem. When it’s chronic it’s a frustrating condition to suffer but also to treat. It’s stubborn and slow. If you’re noticing a niggle don’t ignore it, the sooner you get treatment & appropriate management strategies are employed the sooner you will be back in the surf, on the tennis court or in the pool.

Stubborn hip pain? Maybe its trochanteric bursitis.

What is it? Trochanteric bursitis is one of the common causes of pain on the lateral (outside) of the hip and is the result of inflammation of the superficial (& deep in severe cases) trochanteric bursa.

In some cases inflammation of these two bursae can be accompanied by local tendonitis or inflammation of the gluteal tendons & hip rotator muscles.

What is a bursa? Bursa are small sacs or ‘cushions’ of fluid found throughout the body. They sit between tendons & bones  to allow tendons to slide without friction over bony surfaces. When these sacs get inflamed or irritated they can cause pain

Why? Trochanteric bursitis can occur as an overuse injury due repetitive friction of the gluteal tendons as they pass over the greater trochanter during activities such as running and cycling. In these castroch_bursaes there is usually biomechanical deficiencies that need addressing. It can also be of acute onset from a direct blow or fall onto the lateral side of the hip

What are the signs & symptoms?

  • Pain & swelling on the side of the hip
  • Pain may travel down the outside of the thigh
  • Pain aggravated by lying on affected side
  • Pain made worse by activities such as climbing stairs, crossing & uncrossing legs, rising from a low seated position, running & cycling.
  • Tenderness directly over the greater trochanter.

How is it diagnosed?

A skilled physiotherapist will be able to diagnose trochanteric bursitis from your clinical history & examination. Diagnosis can be confirmed via ultrasound or MRI investigation should this be required.

What can be done?

Immediate diagnosis & correct management of this condition will assist with a speedy recovery. Physiotherapy treatment can involve:

  • Soft tissue massage to tight surrounding muscles
  •  Dry needling / acupuncture to assist with pain relief & relaxation of surrounding muscle spasm
  • Advice regarding activity modification, appropriate stretching & strengthening exercises.
  • Electrotherapy such as TENS to assist with pain relief & controlling inflammation
  • Correction of underlying biomechanical insufficiencies such as weak gluteals, pelvic stability & pronated feet
  • Use of ice to control inflammation
  • Medication such as non steroidal anti-inflammatories (discuss this with your pharmacist)

In cases where the patient does not respond to the conservative management discussed above a cortisone injection may be warranted. This is done under ultrasound guidance. Your physiotherapist will discuss these options with you should they feel it necessary.

If you are struggling with hip pain and think you would benefit from an assessment with Ross or Em feel free to give us a call on 9328 3822. You do not need a referral to see our physiotherapists!

Happy Monday! 🙂

Tibialis Posterior Tendonitis

Tibialis posterior dysfunction is one of the most common overuse injuries found in the foot & ankle.

The tibialis posterior muscle originates high in the shin from the back surfaces of the tibia and fibula. It tracks down along the inside border of the tibia, passes around the inside of the ankle and terminates via two attachments in the foot.  The main insertion (and that of interest to this particular injury) is into the tuberosittib posty of the navicular.

The tibialis posterior is an extremely important stabiliser of the foot & ankle. It functions to produce inversion at the ankle and also plays a major role in maintaining and supporting the medial arch.

Tibialis posterior tendonitis occurs when there is excessive strain put upon the tendon as it inserts into the navicular.

Why?

  • As an overuse injury through years of wear and tear associated with high impact activities such as running
  • Acutely as a result of sudden increase in training volume or intensity OR the use of inappropriate footwear

Athletes with poor foot biomechanics such as flat or pronated feet, tight calves and poor pelvic stability are at more risk of developing tibialis posterior dysfunction.

Signs & Symptoms:

  • Pain: felt along the inside of the foot
  • In acute cases there can be visible swelling on inside of the foot
  • Pain aggravated by high impact activities such as running & jumping
  • Crepitus may be felt along the length of the tendon.

A thorough physical examination by a physiotherapist will usually be sufficient to diagnose tibialis posterior tendonitis. In cases where diagnosis is in doubt an MRI may be required to rule out other potential pathologies.

Treatment:

Initial treatment must focus on unloading the tendon and allowing it to rest. In severe cases where simple weight bearing activities are painful a short period in a walking boot may be warranted. Icing and anti-inflammatory medications may also be suggested by your health care provider.

Physiotherapy management can involve:

  • Soft tissue massage to tight surrounding muscles, particularly the calf.
  • Electrophysical therapy to reduce inflammation & assist with pain relief.
  • Dry needling to reduce inflammation
  • Taping of the foot to unload the tendon
  • Advice regarding orthoses, shoe inserts & appropriate footwear
  • Activity modification
  • Exercise prescription of appropriate strengthening exercises

In chronic cases or those that have not responded to conservative therapy further intervention may be required. Options can include corticosteroid injections and surgery.

Have a wonderful week! 🙂