Conditions and Treatments
Please find links below on different types of conditions and treatments we can assist you with at one of our physiotherapy locations. Feel free to download information in PDF form.
Click on the box names to expand the lists. You will find detailed information in each form as well as treatment options.
We are continually adding to this over time so please check back often.
Our Physiotherapists are trained in the assessment of lower limb biomechanics, including lumbo-pelvic control and mobility, foot position, hip range of motion, and muscle control of the hip, knee and ankle. Proprioception and balance are also essential components of assessment and rehabilitation of lower limb dysfunction.
Indications for Lower Limb Biomechanical Examination
- Overuse conditions of the lower limb
- Childhood growth type injuries
- Some acute ligamentous lesions
- Recalcitrant conditions, which have progressed to the chronic stage
- Postural lower limb dysfunctions
Mechanisms of injury: Predisposing factors.
1.Training error: doing plyometrics too early, progressing too quickly, changing technique.
2.Equipment: inappropriate footwear (no support where they need it), new shoes (not run in – should have 2 pairs going simultaneously).
3.Environment: camber of the road (the leg running on the high side has increased pronation/internal rotation and vice versa), surface (grass vs turf vs concrete etc), the “give” of the surface, the smoothness of the surface (rate of shock absorption), the evenness of the surface (grass needs improved proprioception/coordination to run on it), adding in hills if usually runs on the flat, etc.
4.Biomechanical features: in the subjective, check the past history, for example as children did they have any lower limb problems with birth or development, any recurrent problems.
Management may involve a variety of interventions, including:
- Orthotic prescription
- Stretches for the muscles of the lower limb
- Mobilisation of the lumbo-pelvic region
- Core stability retraining (lumbo-pelvic region)
- Increase of hip ROM
- Balancing muscle lengths and strengths of the lower limb
- Correction of training technique
- Balance retraining, proprioceptive retraining
- Liasing with the coach
- Cervical Spine - Acute Wry Neck
Acute Wry Neck
Have you ever woken up and your neck is “stuck” and you cannot move it in certain directions without sharp pain? Then you have experienced an acute wry neck!
Classification of Acute Wry Necks
- Traumatic O-C1 Block, Atlanto-Axial Fixation
- Sudden Onset Facet joint, cervical disc
- Spontaneous Disc (DDx facet joint)
- Post Viral Children/Adolescents
- Muscular Post trauma – lateral flexion TOWARDS pain
- Acquired Related to childhood torticollis (subtle)
- Hysterical Exaggerated deformity, lack of response to treatment
- Spasmodic Torticollis Cervical Dystonia – tremor with movement
Mode of Onset
The most common history is one of the patient waking with a bit of neck stiffness in the morning, but then when they turn their head in the shower or reverse out of the driveway they experience a sudden onset of sharp pain and locking in the neck. They are then unable to move their neck fully without experiencing sharp pain. This is usually due to a “locked” facet joint. It is thought that inflamed tissues get pinched in the joint and the neck “locks” in spasm to prevent further movement.
The most common wry neck presentation is a “locked” facet joint occurring at the C2/3 or C3/4 level. The deformity, if present, will usually present as rotation and side flexion away from the side of pain. Therefore, the opposite movement (rotation and side flexion towards) will result in pain of moderate to severe intensity. Cervical wry necks due to disc derangements tend to occur at the C4/5 and C5/6 levels and the patient presents with a slightly flexed neck posture and pain in the neck radiating down into the upper trapezius or upper back region.
Physiotherapy involving joint mobilisations or manipulations and muscle relaxation, hot packs, dry needling as well as a tailored home exercise program, can greatly improve the comfort and range of motion of an “acute wry neck”. Generally, if the patient is seen within 12 hours of onset, almost total relief may be attained with only 2 or 3 sessions. Disc lesions can take several weeks to settle, therefore it is important to get an accurate diagnosis. A physiotherapist can determine the cause of the wry neck so appropriate treatment may be implemented immediately. An acute wry neck that is not treated but left to resolve over several weeks can often result in a stiffened segment predisposing the patient to recurrent episodes of the same condition.
- Cervical Spine - Cervicogenic Headaches
Physiotherapy has been shown to be highly effective in the management of cervicogenic headaches.
The University of Queensland completed the first multi-centre randomised controlled blind study of cervicogenic headache published in 2002. Physiotherapy treatment (joint mobilisations, specific muscle re-education exercises and spinal soft tissue mobilising techniques) was found to significantly improve symptoms in recognised cervicogenic headache sufferers, and was significantly more effective than medical management. It is suspected that over 30% of headaches are cervicogenic in origin, and physiotherapists are well placed to determine whether the cervical spine is playing any part in the production of headache symptoms.
The Cervicogenic International Headache Society Group (1998) published the following Diagnostic Criteria for diagnosing cervicogenic headache.
- Unilateral pain without sideshift (within that episode & typically between) NOTE: Can also be bilateral if bilateral trauma and/or degenerative changes.
- Begins in neck or occiput (maybe with shoulder/arm pain) (compare to migraine – begins in front especially behind the eye)
- Moderate intensity (not stabbing/lancinating, so can carry on activities but not very pleasant)
- Frequency/Duration highly variable – episodic ? continuous (some all the time, some very infrequent)
- Associated symptoms (mild & intermittent)
- Nausea (not very often); dizziness (@ times); photophobia (like hangover – no bright light/loud noise); ‘blurred vision’ (haziness/head feels a bit fuzzy or light)
- Precipitated by neck movement/posture (ranges from very easy to very hard to define) or
- Pain reproduced with external pressure to upper Cervical or occiput or
- Restricted neck mobility (very subtle)
- Positive anaesthetic block (in research and in practice!)
- The upper 3 (C1-3) cervical levels are most commonly involved cervicogenic headaches.
Physiotherapy Treatment Of Cervicogenic Headache
Physiotherapy treatment will include joint mobilizations and/or manipulations to the upper cervical spine, specific retraining of the deep neck flexors (upper cervical spine stabilising muscles), stretching tight muscles in the upper quadrant, postural correction exercises (thoracic spine extension range, lower trapezius muscle strength, head on neck position), neural mobilizations, and patient education. The physiotherapist may also use dry needling techniques and will give the patient home exercises to assist with management and decrease recurrence.
It is important to point out that many headache sufferers may suffer multi-source headaches. For example, a Migraine sufferer may simultaneously experience a Tension Type Headache and Neck Headache. Treatment varies depending in the symptoms and headache source.
- Cervical Spine - Non-Specific Neck Pain
Non-Specific Neck Pain
Physiotherapy treatment including joint mobilisations and manipulations, specific muscle re-education exercises and soft tissue mobilising techniques have all been found to be useful in the treatment of neck pain from acute through to chronic stages of the condition.
The Australian Physiotherapy Association has published the “Neck Pain Position Statement” (updated every 2 years), which reviews current research on efficacy of treatment for neck pain. Research published from the University of Queensland has proven that cervical spine mobilisation techniques directly improve pain and mobility levels in both acute and chronic neck pain syndromes.
This diagram, taken from: Aprill C., Dwyer A. & Bogduk N., (1990) Cervical Zygapophyseal Joint Pain Patterns II: A Clinical Evaluation. SPINE 15 (6), demonstrates the patterns of pain referral from the facet joints in the neck. 80% of cervical spine degeneration (discal and joint OA) occurs at the C5/6 level, so the area of pain across the top of the shoulder tends to be the most common patient presentation.
Degeneration of the Mid to Lower Cervical Segments
Degenerative changes at C4/5/6/7 can be accelerated by poor posture (slump sitting with chin poke). Manual physiotherapy treatment and postural correction exercises (strengthening of weak muscles, improving joint mobility of stiffened joints, patient education) are essential to slow down the degenerative process. You will note from the above diagram that upper thoracic spinal pain is often referred pain from the cervical spine rather than a local thoracic spine injury. Sustained poor postures can also lead to upper cervical spine stiffness and headache, and increased thoracic kyphosis with associated stiffening of the thoracic spine.
The patient may present with aching within the area of referral for the affected facet joint(s), restricted neck mobility (particularly with rotation, such as difficulty reversing in the car), and sharp pain with end range movement.
Joint mobilisations and manipulations, muscle stretches, muscle re-education (strengthening) exercises, postural exercises, thoracic mobility, neural mobilising techniques, and patient education are all important components of physiotherapy treatment for non-specific neck pain. Joints that look degenerative on x-ray do not necessarily have to cause pain. If the joints are mobile and the muscles are strong and flexible, then the patient can expect to have excellent pain free movement and function. It is important to “move it or lose it”.
- Cervical Spine - Whiplash
Physiotherapy can greatly assist patients who have whiplash injury following a motor vehicle accident.
The NSW Motor Accidents Authority published the “Guidelines for the Management of Whiplash-Associated Disorders” in 2001. In this publication the recommended treatment includes “Manual and physical therapies – exercise” and details that range of movement exercises, muscle re-education and low load isometric exercises should be implemented immediately. Joint mobilisations are also recommended and should be commenced within the first 7 days following the injury. Recommendations for immediate physiotherapy treatment were included due to a growing research base in the area of cervical whiplash injuries.
What is whiplash?
The rapid motion of the neck during a crash can result in a number of injuries. Many of these injuries are impossible to see on x-rays or MRI. Even though there may be minimal damage to your car or cycle, you can still sustain whiplash. In fact, even at low speeds, occupants can experience severe whiplash.
Signs and Symptoms
- Neck pain and stiffness
- Upper back and/or arm pain
- Associated stress and anxiety
- Jaw tightness or pain
Most soft tissue injuries take 6 to 8 weeks to settle down. It is important to implement early treatment and encourage return to normal function as soon as possible. Research has shown that the prognosis of whiplash depends on many factors, including the availability of early physiotherapy intervention which aims to prevent the injured joints from “seizing up”, retrain stabilising muscle function, encourage movement and reassure the patient. The speed or direction of the accident may not be as important a factor as your stress and anxiety related to the accident. It is important that you continue to move as freely as you can and take advice from your physiotherapist and doctor.
Treatment will include mobilisations, postural correction exercises, stabilising muscle exercises, stretching and more general exercises for the upper body. Education is an important part of treatment. Your physiotherapist may also use other techniques
- Children - Growing Pains
“Growing pains” are used to describe specific aches and pains that occur in children as they experience growth spurts. These pains occur at the insertion of tendons onto bone.
As children grow, the long bones of the body grow faster than the associated muscles. As a result, these extra forces cause an irritation at the insertion of the relatively shortened muscles onto the bones.
The most common sites for these injuries are the tibial tubercle where the patella tendon inserts into the tibia (Osgood Slatters), and the calcaneum where the Achilles Tendon inserts into the calcaneum (Severs). However, these stress reactions can occur at other sites around the body wherever tendons join onto bones and growth occurs at a rapid or inconsistent rate. A less common site is the anterior superior iliac spine (ASIS) where the quadratus femoris attaches (iliac apophisitis).
During the inflammatory phase, the ideal treatment is relative rest (from sport or any other aggravating activities), ice, and stretches to lengthen the appropriate muscle groups. It is important not to directly stretch the affected musculo-tendinous unit while the inflammation is still acute, hot and swollen, as this can make the condition worse. The patient might need to be on crutches for a week or so if the pain is very bad, but they should not be completely non weight bearing. As the condition settles, stretches can become more aggressive and include direct stretching of the affected musculo-tendinous unit. Eccentric strengthening of the appropriate muscle groups can also commence. Further rehabilitation should be designed to improve muscle balance around the lumbar spine, pelvis and lower limbs (both strength and length), but also to improve muscle timing and co-ordination specific to their sport or daily activities. Specific taping techniques can also assist greatly during the acute, sub-acute and return-to-sport phases by decreasing pain and improving muscle co-ordination and function. Physiotherapy is essential in the acute, chronic and rehabilitation phases to ensure appropriate progression.
These injuries settle very well with appropriate physiotherapy treatment and exercise prescription. However, the injury can re-occur during further rapid growth spurts and the child should be encouraged to maintain muscle flexibility to decrease the potential for future problems until they have finished growing. The condition is self limiting and will settle permanently once the child has finished growing and the growth plates have fully fused.
- Children - Injuries in Children
Injuries in Children
Children have developing and growing bodies and abnormal forces applied to their tissues often result in different injuries than those seen when similar forces are applied to the adult body. Below are some examples of how injuries to children can differ from those seen in the adult population.
Children often present with a greenstick fracture rather than a complete bone disruption, where the bone bends and cracks like a green stick pulled from a tree. In this instance the bone does not fracture all the way through, but splinters or splits on one side of the bone. The bone can still be deformed but often the child can move the limb better than one would expect with a fracture present and may even be full weight bearing on a green stick fracture of the lower limb.
Children’s growing bones are softer than fully formed adult bones. As a result, instead of a joint sprain resulting in ligament rupture as is the case with an adult, the ligament may avulse from the bone itself, leaving the ligament intact, or the bone itself will fracture. Examples most commonly seen are avulsions of the superior attachment of the ACL in a child rather than complete ACL rupture, or fracture of the distal tibial growth plate with a severe lateral ankle sprain.
Acute Wry Necks
The uncovertebral joints in the cervical spine do not form until around 8 years of age. This means that young children have a more unstable neck, as well as a larger head compared to body size, than adults. Trauma to the neck which results in an acute wry neck (such as a fall onto the head) can be a sign that quite severe damage has occurred to the upper cervical spinal joints. An x-ray is highly recommended in this situation. Cervical manipulation is contra-indicated in children under about 12 years of age for this very reason.
Slipped Upper Femoral Epiphysis
The child often presents with either severe acute knee pain or severe acute groin pain, and is unable to weight bear on the leg. Immediate x-ray is essential and if positive, hospitalisation is required. If the x-ray is clear, the diagnosis is the less severe Irritable Hip Syndrome, which responds to a couple of days rest followed by physiotherapy treatment for mobility and strengthening.
- Tennis Elbow
Research has demonstrated that Physiotherapy treatment can be highly effective in the treatment of acute and chronic “tennis elbow”. Tennis elbow, or “lateral epicondylalgia” as it has more recently been named, often involves more than localised pathology around the elbow.
Tennis elbow, or lateral epicondylalgia, is a common affliction not often related to actually playing tennis. Research has demonstrated that if tennis elbow pain has been present for about 8 weeks, or if the condition has been active previously, then there will also be a neck component maintaining the pain and dysfunction rather than just a local elbow problem.
What is Tennis Elbow?
Tennis elbow can certainly be caused by racquet sports, but it is common in any sport or occupation that involves gripping or throwing eg weightlifting or canoeing, or carpentry and brick laying. You will feel pain with gripping and lifting.
Where Is Tennis Elbow Pain Felt?
You’ll feel pain over the outside bump of the elbow. This bump is known as your lateral epicondyle. The medical term for tennis elbow is “lateral epicondyalgia” meaning a painful lateral epicondyle. Typically you’ll suffer sharp localised pain over the bony bump. As the condition deteriorates, the forearm muscles become tender and remain in a spasm-like contraction.
What’s the Cause of Tennis Elbow?
Like most overuse injuries, it is most commonly caused by repeated microtrauma. You may not have allowed the injury to ever fully heal and ultimately it becomes increasingly painful. It may also be caused if you do an activity that you are not used to, and your muscles are not strong enough to keep doing the activity (such as pruning in the garden).
How is Tennis Elbow Diagnosed?
Your physiotherapist or doctor regularly diagnoses these injuries. X-rays are often normal so not useful. An ultrasound scan may show tears within the tendon. Research has shown that the neck joints of C5 and C6 are common referrers of pain down to the elbow. Always ask your physiotherapist or doctor to examine your neck for tenderness. Your symptoms may be cured by treating your neck and your elbow! Unfortunately, delaying treatment is not good. The longer you experience pain the more likely it is that you’ll develop compensatory problems in your neck, shoulder or forearm.
What’s the Best Treatment for Tennis Elbow?
During the acute phase, rest is vital. “No Pain … No Gain” is usually wrong. Apply ice 2 or 3 times daily to reduce inflammation and pain. Anti-inflammatory medication or gels can work very well. Recent research has shown that physiotherapy is better than cortisone injections in the medium to long-term. In addition to hastening the healing rate, your physio will ensure that the perfect musculoskeletal environment is present to avoid any recurrence. Sometimes cortisone injections are good to settle the pain to assist with physiotherapy management.
When Should You Use a Tennis Elbow Brace?
A tennis elbow brace can be very effective from the moment you put it on. In these instances, the brace will dissipate the stressful gripping forces away from your injured structures. However, tennis elbow braces do not work in 100% of cases. In our experience, we recommend that you seek physiotherapy assistance in these cases. In stubborn cases, you have a very high likelihood of referred symptoms from your C5/C6. Only a thorough examination of your neck, shoulder, elbow and upper limb nerve structures will confirm your diagnosis and direct which treatment options will assist you the quickest.
- Foot and Ankle - Ankle Sprains
Acute Ankle Sprains
Treatment administered in the first 24 hours is the most important determinant of long-term recovery from an acute ankle sprain. Chronic or recurrent ankle sprains also need physiotherapy rehabilitation to achieve stability and should be treated immediately by a physiotherapist to improve stability and decrease pain.
The most common type of ankle sprain is due to excessive inversion and plantarflexion, called an “inversion sprain”, and stretches or tears the lateral and anterior ankle ligaments, can damage the retinaculum and often impinges the medial ankle structures. Egg-shaped swelling appears on the outside of the ankle. A grade one injury is caused by mild over-stretching with less than 10% of ligament fibres torn. A grade two injury involves considerable tearing of the ligament fibres and a grade three injury is a complete rupture or avulsion of a ligament.
Treatment within the first 24-72 hours should be aimed at preventing further damage and reducing swelling by immobilising the ankle in an everted and dorsiflexed position. This can be effectively achieved by rigid strapping with compression that can be loosened by the patient if the ankle continues to swell. Keeping the ankle elevated above the level of the heart and applying icepacks to the ankle for 20-30 minutes every 2 hours is effective at reducing pain and swelling also. If the injury is a grade 2 or 3 sprain, the patient should use crutches for the first 48-72 hours and partial weight bearing should commence after this time to assist with removal of oedema. Early but gentle active and passive mobilisations to the subtalar and talo-crural joints have been shown to recover range of movement safely and effectively. Treatment in the sub-acute phase consists primarily of exercises and manual therapy to regain proprioception, strength and range of movement.
Chronic or Recurrent Ankle Sprains
Recurrent ankle injuries are unfortunately far too common and the two main factors leading to recurrent or chronic injuries are poor proprioception and stiffness of the talocrural joint, where most of the ankle’s eversion and inversion movement occurs. Proprioceptive retraining, or balance retraining, should commence as soon as practical following an acute ankle injury and exercises should be continued for at least 8 weeks post-injury. If proprioception is not retrained, the patient will be at high risk of recurrence and can eventually develop chronic ankle weakness and instability. It can take up to 9 months for the ankle to regain full strength and balance following a moderate injury.
Avulsion or Talar Dome Fractures
Severe swelling and bruising following acute injury can indicate either an avulsion fracture or a talar dome fracture. An X-ray will determine the presence of a ligamentous avulsion fracture, but the talar dome fracture (cartilaginous) will not show up on plain X-ray. If the ankle does not respond to conservative management as expected, or if the ankle remains unstable with weight bearing, a talar dome fracture should be suspected and a bone scan or CT scan arranged. Large talar dome fractures usually require surgery, with MACI (chondral grafting) now showing excellent results for these cartilaginous lesions.
Fracture of 5th Metatarsal
A fracture of the head of the 5th metatarsal is also possible with an inversion ankle injury. These injuries can be easily missed, as the patient can be fully weight bearing with only moderate discomfort. More pronounced swelling and bruising extending into the lateral foot is usually observed in these cases.
Contact us at one of our Movewell Clinic Locations if we can assist.
- Foot and Ankle - Ortotics
Physiotherapists are qualified to assess and fit orthotics to individuals requiring orthotic support for compromised foot and lower limb biomechanics. Move Forward Physiotherapists may prescribe GaitScan orthotics which are individually assessed and formatted for each patient.
Why heat moulded orthotics?
Heat moulded orthotics are a cost effective solution for many patients requiring orthotic control on a temporary basis. Heat moulded orthotics last for approximately one year in an active individual (longer for a sedentary person) and can be purchased in a variety of shapes and sizes, but must be correctly fitted by the physiotherapist. These orthotics are ideal for children who have growing feet and may require a new pair every 12 to 18 months, or for adults requiring short term orthotic control for mild or short term conditions, such as acute planter fasciitis or post surgical, or for minor foot discomfort due to arthritic changes. The orthotics come in full length or ¾ length, soft (for diabetic elderly patients) to firm (sporting population), flexible or rigid control (the physiotherapist will determine the degree of control required), and even in models suitable for wearing with high healed shoes.
What is the GaitScan Orthotic System?
The GaitScan Orthotic System is a computer operated force plate that assesses the biomechanics of the foot during the gait cycle (functional) as well as in the standing position (non-functional). Together with the physical assessment already performed by the physiotherapist, the information recorded during the force plate assessment assists in the development of a pair of orthotics most suitable to correct the dysfunction for that individual. The physiotherapist determines what, if any, additions are required (such as a cut out for a plantarflexed first toe or a metatarsal dome) and the information is emailed to a laboratory interstate. The orthotics arrive approximately one week later and are then fitted by the physiotherapist who can arrange alterations if required. These orthotics also come in a variety of shapes, lengths and widths to allow comfortable fitting in a variety of shoes or for any circumstances. Patients will often order several pairs – one for work shoes, one for sporting shoes, and one for their high heals. The Orthotic Group website can be found at http://www.theorthoticgroup.com if you wish to learn more about this orthotic system.
Who can benefit from orthotics?
There are many foot dysfunctions that may benefit from orthotic control, the most common being over-pronators. Over pronation has been linked to a variety of lower limb dysfunctions, including plantar fasciitis, Achilles Tendonitis, Tibialis Posterior Tenditinitis, patello-femoral pain, talo-naviclaur joint inflammation, plantarflexion dysfunction of the first toe (arthritic changes), and even changes in the range of motion of the hip due to muscle imbalances. Belridge Move Forward Physiotherapists can determine if orthotics will benefit your patient in the short to long term.
- Foot and Ankle - Plantar Fascitis
Plantar Fasciitis is a painful condition affecting the sole of the foot, with pain usually localised around the front of the calcaneum and radiating along the middle of the sole of the foot towards the toes. There is usually point tenderness on the insertion of the plantar fascia onto the calcaneum.
What causes plantar fascia?
Plantar fascia can be an acute condition related to a sudden increase in walking or a change in shoe support, or even a direct impact on the sole of the foot, such as stepping onto a rock. Often, on X-ray, there will be a boney spur protruding from the calcaneum related to the insertion of the plantar fascia. Interestingly, a large percentage of the population have heal spurs present, but these are usually asymptomatic. The heal spur itself is not usually significant in this condition unless conservative measures fail. The most common pattern of plantar fasciitis is of gradual onset related to faulty foot or lower limb biomechanics. Factors that may predispose the patient to developing this condition include over pronation of the foot or weakness of the hip abductors leading to internal rotation of the hip during full weight bearing during the gait cycle.
What treatment can be beneficial?
Local physiotherapy treatment in the acute condition is usually able to settle the pain very quickly. This may include local releases, local electrotherapy to settle inflammation, and low-dye taping or functional fascial taping techniques designed to take pressure off the plantar fascia. The tibialis posterior muscle must also be assessed as the activity of this muscle supports the longitudinal arch of the foot assisting the plantar fascia in it’s supporting role. The hip abductors, similarly, are assessed and strengthened as required, as is the vastus medialis muscle of the knee, all of which are required to be operating effectively to maintain lower limb stability. In the more gradual onset situation, more long term orthotic foot control, rather than just taping techniques, may be required, and in this case, the physiotherapist will prescribe suitable orthotics.
What rehabilitation is required?
In the acute situation, often local therapy and taping is enough to settle the condition, as long as the cause of the onset is known. However, if the condition has occurred due to biomechanical faults, then rehabilitation will include muscle re-education for the intrinsic muscles of the foot, tibialis posterior, vastus medialis and the hip abductors, as well as orthotic control. Changes in the training environment, such as shoe choice or surface conditions, may also be implemented. If the condition does not settle as expected, a local cortisone injection may be required to settle the pain and give the physiotherapist a window of opportunity to strengthen and lengthen the required structures to take pressure off the structure and allow healing to take place. In extreme circumstances the spur may be removed but studies have shown that the rate of spur regrowth is high.
- Hip - Hip Pain
Pain from the hip joint is commonly experienced in the groin region, but can also refer to the lateral hip region, the medial knee, under the crease of the buttock and the lateral leg. The pain can occur spontaneously with no obvious cause, but on examination there is often quite restricted hip joint mobility and muscle weakness which suggests a gradual asymptomatic onset.
Superficial lateral hip pain which is tender on palpation is usually a result of bursitis of the trochanteric bursa. This usually responds favourably to conservative physiotherapy management of glut medius strengthening and stretching, ice, hip joint mobilisations, and correction of lumbo-pelvic stability and muscle lengths. Even if the bursa requires a local steroid injection, correction of the associated muscle weaknesses or loss of hip joint mobility is essential to prevent recurrence.
Acute anterior hip pain may be related to iliopsoas bursitis or tendinitis, and is often caused by an unusually difficult or prolonged walking session (bush walking or going on a walking holiday). This injury can be treated with stretching and strengthening of iliopsoas, ice, and strengthening of the stabilising muscle of the lumbo-pelvic region.
“Clicky” anterior hip pain is usually a long, weak iliopsoas muscle/tendon unit, and responds well to specific strengthening exercises and again, strengthening of the stabilising muscles of the lumbo-pelvic region. This condition is often seen in flexible females, such as dancers or gymnasts.
Low back Pain
The most common loss of ranges of movement of early stage osteoarthritis of the hip is extension and rotation. Often the patient will present with a mild hip flexion deformity resulting in an anteriorly rotated pelvis. This anteriorly rotated pelvic position leads to increased shear forces at the L5S1 segment of the lumbar spine, and can lead to associated degenerative changes at the L5S1 facet joints and the L5 disc. Patients with chronic or recurrent non-specific low back pain from the L5S1 region should have their range of hip movement assessed and treated as required, as well as having the lumbo-pelvic-hip musculature assessed for strength and length.
Physiotherapy treatment will depend on the diagnosis, but may include mobilisations, stretches, exercises, ice, electrotherapy, dry needling, and biomechanical correction. Physiotherapists are able to assess and effectively treat both early stage and later stage hip problems related to loss of mobility and loss of strength. The patient will also benefit from a home program to improve and maintain mobility and strength to prevent recurrence.
- Hip - Osteoarthritis of the Hip
OA of the Hip
Physiotherapy treatment can greatly improve hip range of movement, decrease pain and improve muscle strength around a hip joint affected by capsular restrictions and limited range of movement. Physiotherapy treatment can also significantly improve function and decrease hip pain associated with osteo-arthritic changes confirmed by X-ray.
Early stage OA of the hip can present as sudden onset acute hip pain, as the condition of the hip joint (usually initially just capsular tightening with no X-ray changes) can deteriorate slowly without associated signs or symptoms. The first three hip movements usually restricted by capsular tightening are medial rotation, abduction and extension of the hip joint.
Associated Low Back Pain
Hip joint extension range is essential for walking, so if there is a gradual loss of this range, the patient may experience onset of low back pain for some time before the hip joint itself becomes painful due to the increased shear forces on the L5S1 segment. It is essential therefore to assess the hip joint range of movement in patients with recurrent or chronic non-specific low back pain, and even in patients who have a specific lumbar lesion, but who continue to suffer recurrences, in case the hip is contributing to the problem.
Pain from the hip joint is often experienced deep in the groin region, but can also be referred into the lower buttock, the lateral thigh, lateral leg, and not uncommonly, the medial knee. The patient with OA of the hip may experience low back, buttock or thigh pain with lumbar range of movement testing, as these tests also place stresses upon the hip joint and good hip joint mobility is required for full pain free lumbar range of movement. In these cases, examination of the hip may be ignored as the presentation may suggest lumbar pathology.
Treatment for OA of the hip includes mobilisations of the hip joint (capsular stretches into the ranges that have been decreased, medial rotation in extension, for example), exercises for strengthening the glut max and medius muscles, exercises for lengthening and strengthening the iliopsoas muscle, hydrotherapy (strength, stretching, mobility and fitness), and land based stretches for any specific tight muscles in the lower limbs. The earlier the restricted hip is treated, the more likely the function of the hip can be restored and the pain diminished and the patient commenced on a home exercise program to maintain and even further improve strength, mobility and function.
- Knee - Osteoarthritis of the Knee
OA of Knee
OA of the knee can occur at the patello-femoral joint, the tibio-femoral joint, the superior tib-fib joint, or any combination of the above.
The Australian Physiotherapy Association’s Osteoarthritis of the Knee Position Statement (APA OA Knee Position Statement) has reviewed all current relevant literature on the treatment of this condition. Your Move Forward Physiotherapist can provide you with a copy of this position statement if you are interested.
APA OA Knee Position Statement
The literature review undertaken to produce the APA OA Knee Position statement demonstrates that a variety of studies undertaken conclude that Physiotherapy treatment can be highly effective in the treatment of OA of the knee, with supervised exercise programs being one of the most useful physiotherapy modalities. Joint mobilisations of the affected joints have also been demonstrated to be useful, and together with a structured hydrotherapy program, strengthening exercises, balance exercises, and stretches, the pain of OA of the knee and the function of the affected limb can be greatly improved.
Often the degree of OA of the knee demonstrated on X-ray does not correlate with the amount of pain or the limitation in function experienced by the patient. A patient with relatively minor OA changes on X-ray may be quite incapacitated by pain and stiffness, while a patient with hardly any joint space left on X-ray may be quite functional and not complaining of any pain.
The patient may have knee pain and stiffness, ranging from aching at rest to sharp pain with movement. They may have difficulty going up and down stairs and the knee might feel weak. They might feel clikcing or locking or collapsing and they might hear “crunching” as they bend the knee.
Conservative treatment such as physiotherapy, can improve and then maintain the patient’s knee function often for many years. Treatment can include mobilisations, exercises, stretches, hydrotherapy and balance exercises. This can delay the need for arthroscopic joint maintenance surgery and, even if this is eventually required, following a clean-out of the OA joint, physiotherapy rehabilitation can then delay, or even prevent, the need for joint replacement surgery.
- Knee - Patello-Femoral Joint Pain
Patello-femoral joint pain is thought to be a major component in over 80% of all knee pain.
Patello-femoral joint pain can occur in both children and adults and usually responds extremely well to physiotherapy treatment. Scientific research has confirmed that physiotherapy intervention is the most effective long-term solution for kneecap pain.
Approximately 90% of patello-femoral syndrome sufferers will be pain-free within six weeks of starting a physiotherapist guided rehabilitation program. For those who fails to respond, surgery may be required to repair any severely damaged joint surfaces.
The patient will usually present with medial knee pain of gradual onset. Patello-femoral pain can also refer to the lateral, inferior and posterior knee regions. There will be tenderness of the medial patella facet (underneath the patella), and they will complain of pain with squat, standing up after prolonged sitting, and pain particularly walking up and down stairs. Children may complain of knee pain during or after sport. Often in children there has been a change in activity levels or a growth spurt associated with the increase in knee pain.
Usually the vastus medialis oblique muscle (the VMO on the inside of the knee) will be small and weak on the side of the knee pain, and this muscle is responsible for maintaining some medial glide of the patella during functional activities. If the VMO is weak, the patella tracks laterally which can lead to pain, compression and even subluxation/dislocation. The VMO is also inhibited immediately with the onset of knee pain, so patello-femoral joint symptoms can occur some time after an acute knee injury that was initially unrelated to the patello-femoral joint.
Treatment of patello-femoral joint pain includes patella taping, appropriate stretches and strengthening exercises to correct lower limb muscle imbalances, orthotics if indicated, and localised patella mobilisations to stretch the tight lateral tissues (including the ITB). This treatment approach is often referred to as the McConnell’s treatment regime. Sometimes there is an associated hip weakness or hip tightness on the same side which allows the leg to internally rotate too much during activity which places stress on the knee and results in patello-femoral pain. Your physiotherapist will also check your hip biomechanics and mobilise the hip if required and give you appropriate strengthening exercises to improve your general biomechanics.
Contact us at one of our Movewell Clinic Locations if we can assist.
- Lumbar Spine - Ankylosing Spondylitis
Ankylosing Spondylitis is a systemic spondyloarthropathy, more common in males than in females. In the acute phase, the condition is characterised by widespread spinal joint inflammation, but severe cases can progress to eventual fusion of the spine.
The patient may present as a late teen or early twenties male complaining of shoulder and pelvic girdle pain with no specific history of trauma. Night pain is often significant and the symptoms display inflammatory type characteristics such as morning joint stiffness. The signs and symptoms tend to settle well with manual therapy but the improvements are only short term. Failure of the signs and symptoms to resolve with appropriate treatment will alert the physiotherapist to the possibility of an underlying systemic condition and the patient will be referred to their doctor for blood tests.
Physiotherapists at the Shenton Park Annex of Royal Perth Hospital many years ago implemented a rehabilitation program for patients suffering from severe Ankylosing Spondylitis. The first cohort had an excellent outcome and the program encouraged self management of mobility, fitness and general health. The program has been highly successful and has been implemented world wide. Physiotherapy management involves exercises to improve aerobic fitness, strengthening and stretching programs, and spinal mobility exercises. Similar strategies can also be implemented in the treatment of other inflammatory systemic conditions such as fibromyalgia and chronic fatigue syndrome. The physiotherapy treatment is not a cure for the condition, but rather a method by which the patient can become more functional and take a greater role in the control of their symptoms.
Current mecical management is controled by rheumatologists who are able to prescribe drugs that significantly reduce the signs and symptoms of Ankylosing Spondylitis in a high percentage of patients. Referral by your GP to a Rheumatologist for assessment and medical management is highly recommended.
- Lumbar Spine - Lumbar Disc Injuries
Lumbar Disc Injury
Research suggests that up to 80% of acute low back pain is a result of injury to the lumbar discs and physiotherapy treatment has been shown to be effective in the management of lumbar disc injuries.
Some research suggests that up to 80% of acute low back pain is a result of injury (mild to severe) of the lumbar discs. These injuries can become recurrent in certain circumstances and it is important to treat correctly to maximise patient outcomes and attempt to prevent recurrence of the injury.
Lifting, bending, putting on shoes – often there is a minor incident with minimal discomfort at the time. The following morning the patient “can’t get out of bed”. Occasionally there is a major disc injury with immediate onset of pain and disability. If there are obvious neurological signs (loss of power or reflexes), specialist review is recommended as soon as possible.
The patient may present with central, bilateral or unilateral pain, but only about 20% will have leg pain. The patient reports stiffness of the back in the morning, difficulty getting in/out of the car and difficulty with standing from sitting, and may have a slight list (stand crookedly) or a loss of lordosis (flat back).
Sitting, bending activities, coughing/sneezing, standing from sitting.
Lying down, walking and changing positions.
Often there are no palpation signs but there may be obvious muscle spasm.
Straight Leg raise
SLR testing is often positive but often only with leg or back stiffness rather than pain reproduction.
Physiotherapy treatment may include the McKenzie treatment protocol, lumbar rotations, neural mobilising techniques and patient education and home exercises. Retraining of the lumbar spine stabilising muscles has been shown to significantly decrease the chances of recurrence of low back injury (Hides J, Jull G and Richardson, C. (2001) Long-term effects of specific stabilizing exercises for first-episode low back pain. Spine, 11, 243-248.). This 3 year follow-up study demonstrated that for patients who had suffered first episode LBP, all of whom were pain free within 3 weeks, the patients who were rehabilitated with specific stabilising muscle retraining by a physiotherapist had a 50% less chance of re-injury than those who had been treated medically over that time period. Local hands on therapy commenced as soon as possible can usually improve signs and symptoms very quickly following a low back disc injury.
- Lumbar Spine - Lumbar Facet Joint Pain
Lumbar Facet Joint Pain
Lumbar Facet Joint Pain
Research has shown that Physiotherapy treatment can greatly improve function and mobility and decrease the pain associated with facet joint injuries of the lumbar spine in the acute, sub-acute and chronic phases.
The Low Back Pain Position Statement, published by the Australian Physiotherapy Association, examines current research in this area.
Lumbar facet joint pain can present as an acute joint sprain (most common in the sporting population, particularly golf and tennis) but is more often a chronic problem associated with degenerative changes occurring at the facet joints at a specific level over time. A chronic lumbar disc injury places more stress on the facet joints at that level, leading to increased wear and tear. Osteo-arthritis of the facet joints is the most likely cause of the problem if there has been gradual onset with low back stiffness in the mornings.
These patients may have local low back aching but the pain can refer into the buttock, the hips, and even as far as the knee. The pain is diffuse and difficult to localise, but may be sharp with certain movements.
Pain is aggravated by extension, walking, prolonged standing, end-of-range flexion and side flexion activities. There may even be pain as the patient moves from flexion to extension, such as when getting up out of a chair.
Pain is often eased by sitting down in a supportive chair after prolonged standing (flexion of the lumbar spine) and by gentle movement and exercises. The OA facet joints stiffen easily, particularly in the mornings, and “warm up” with gentle movement. Often the aching is worse again at the end of the day.
Distal pain is not easily reproduced with palpation. Locally however the facet joint may be tender on palpation and there may be a feeling of stiffness and swelling of the joint when it is mobilised. There may be generalised tenderness and tightness in the muscles of the lower back and buttocks.
Physiotherapy treatment includes joint mobilisations or manipulations of the injured facet, as well as joint mobilisations at levels of the spine above and below to improve general spinal mobility and take pressure off the injured segment. Exercises to mobilise, strengthen and support the lumbar spine are commenced and stretches to improve muscular flexibility of the lumbo-pelvic region are also encouraged. Dry needling may be a useful adjunct. The physiotherapist may also mobilise the hip to take pressure off the lower back, and patient education is also essential.
- Lumbar Spine - Non-Specific Lower Back Pain
Non-Specific Lower Back Pain
Physiotherapy can be successful in the treatment of non-specific low back pain, and evidence of this can be found in the Australian Physiotherapy Association’s Low Back Pain Position Statement. Move Forward Physiotherapists are up to date with current research in the area of non-specific low back pain and the APA Low Back Pain Position Statement.
There is evidence to suggest that physiotherapy treatment in a variety of forms can be beneficial in the treatment of acute, sub-acute and chronic low back pain. Physiotherapy assessment can often pinpoint the structures causing the pain and allow early commencement of appropriate treatment and rehabilitation to improve the condition.
Classification of Non-Specific Low Back Pain
There are many classifications for non-specific low back pain. Often it can be difficult to determine the exact source of the pain. Non-specific low back pain may be wide spread, diffuse, achey, or even have some sharp sensations with movement. Sometimes there may be referred leg pain when the low back pain is bad. Pain may be aggaravated by standing and walking, or bending and sitting.
Physiotherapy Treatment of Non-Specific Low Back Pain
The Physiotherapist will use clinical reasoning skills to determine the likely source or causes of the non-specific low back pain. The patient may require hands on treatment to mobilise stiff joints, stretch tight tissues, and mobilise neural structures. Specific exercise prescription may be required to retrain the lumbar spine stabilising muscles and generally strengthen and mobilise the spine. Other exercises may be commenced to retrain movement patterns to take pressure off the painful structures and teach the patient to move in the most efficient manner. The physiotherapist will also encourage patient self management so the patient can be responsible for the daily completion of their exercise program to ensure the chance of re-injury is reduced.
Contact us at one of our Movewell Clinic Locations if we can assist.
- Lumbar Spine - Ultrasound of stabilising muscles
Real-time Ultrasound Imaging of the Lumbar Spine Stabilising Muscles
The Stabilising Muscles of the Lumbar Spine
Recent research published in various medical and physiotherapy journals (including “SPINE”) has investigated the role of the deep stabilising muscles of the lumbar spine (Transversus Abdominis, Multifidus, the diaphragm and the Pelvic Floor) in low back pain. The research demonstrates that following lumbar spine injury, the stabilising muscles are significantly inhibited. The inevitable weakening and loss of control of these muscles often leads to poor or incomplete recovery from the injury and the development of chronic or recurrent low back pain.
Exercises for the Stabilising Muscles
Since the stabilising muscles of the lumbar spine do not usually recover spontaneously, specific exercises are often required to stimulate their redevelopment. Research shows that stabilising muscle function is unlikely to be improved through global exercises (i.e. general gym programs) and the most effective exercises for the stabilising muscles are often very specific and determined by the patient’s condition. Accurate assessment of the stabilising muscles with normal palpation is difficult because the muscles are very deep and their contraction is specific and subtle. In addition, patients with low back pain are often unable to contract the stabilising muscles correctly and have difficulty learning appropriate exercises for these muscles.
Real-time Ultrasound Imaging of the Stabilising Muscles
Real-time ultrasound imaging allows the physiotherapist and the patient to view the stabilising muscle contraction as it occurs and can provide an accurate assessment of the quality, timing and endurance of the stabilising muscle contraction. This allows the physiotherapist to quantify the degree of stabilising muscle dysfunction and may provide an insight into the severity of the condition through the degree of inhibition of the muscles. Since the patient may also view the video image of the muscle contraction as it occurs, ultrasound imaging can be an effective method of teaching the correct exercise techniques. Actually seeing the muscle as it contracts and lets go and feeling what the correct contraction feels like is a powerful form of biofeedback and can speed up the rehabilitation of these important lumbar spine muscles. Sometimes the patient must learn how to “detrain” muscle function first if there is a lot of muscle spasm present, before they are able to start learning how to turn these muscle on again.
The Real-time Ultrasound Imaging Service
Move Forward Physiotherapy currently offers real-time ultrasound imaging of the stabilising muscles of the lumbar spine for the purposes of assessment and treatment of low back pain at most of the clinics within our network. Belridge Physiotherapy has several therpaists trained and experienced in the use of RTUI for pateint assessment and rehabilitation.
RTUI can also be used to effectively assess and retrain the important strength and stabilising muscles around the hip, including the gluteus medius and minimus (essential for correct walking biomechanics), iliopsoas (strength and stability for the front of the hip and the SIJ) and the deep lateral rotators.
Training these muscles effectively is important in the rehabilitation of low back, hip and pelvic pain, as well as for the rehabilitation of athletes returning to sport following low back, hip, leg or pelvic inuries.
- Lumbar Spine - Spondylolisthesis
Physiotherapy treatment can significantly improve symptoms and function in patients who have a lumbar spondylolisthesis.
Spondylolisthesis is a condition where one vertebrae slips forward on the one below. The most common level for a spondylolisthesis to occur is at L5S1. Predisposing factors include the presence of bilateral pars defects (these can be developmental or the result of trauma such as stress fractures), chronic disc disease leading to loss of disc height and associated facet joint degeneration, and excessive anterior pelvic tilt (usually due to muscle imbalances around the lumbo-pelvic region) which leads to increased shear at the L5S1 spinal level.
Research has demonstrated that specific physiotherapy intervention for pateints with lumbar spondylolisthesis can significantly improve their function, decrease their pain, and decrease their need for medication.
Lumbar Spine Stabilising Muscles
Move Forward Physiotherapy offers real-time ultrasound imaging (RTUI) of the lumbar spine stabilising muscles (transversus abdominis, lumbar multifidus and pelvic floor) to correctly retrain the function of these muscles to improve spinal stability and function. This can be an essential component for successful rehabilitation of this condition.
Initial treatment for patients with spondylolisthesis includes techniques to decrease spinal pain and education on the condition and how to avoid further injury. Exercises are introduced to retrain the stabilising muscles of the lumbar spine, iand to mobilise and strengthen the spine generally. Exercises are also introduced to improve muscle length and strength around the lumbo-pelvic region as specifically indicated for each patient. Your physiotherapist will also commence movement retraining to teach you how to move efficiently without placing undue stresses onto your spine and help prevent progression of this condition.
- Lumbar Spine - Stenosis
Stenosis is characterised by leg pain or symptoms of neurological or vascular compromise in one or both legs related to prolonged standing and/or walking. Symptoms are usually relieved quite quickly when the patient sits down.
Stenosis occurs when there is a functional decrease in cross-sectional area within either one or more lumbar spine foraminal spaces or centrally within the spinal canal itself. This decrease in cross-sectional area compresses the neurovascular bundles that are contained within these spaces. The size of the space is usually decreased by a space occupying lesion such as a posterior central disc bulge, a postero-lateral disc bulge (the foramen is compromised), arthritic facet joints with large osteophytes protruding into the foramen, a spondylolisthesis, or the neurovascular bundle can functionally be irritated by an increase in chemical inflammation and the resulting increase in local pressure can block mobility within the small spaces.
Why does standing and walking cause the most problems?
The symptoms are aggravated by standing and walking activities as these movements functionally close down of the foramen (of most commonly the L5S1 segment), which in turn compresses the structures that pass through the foramen. Walking and standing also extends the lower lumbar spine which increases central compression if there is a central canal stenosis present.
Physiotherapy treatment can be highly effective to relieve the symptoms of stenosis and can include lumbar rotation mobilisations (to open the foramen), straight leg raise stretches (to stretch the affected tissues), hydrotherapy for mobility and fitness, and a home exercise program to maintain flexibility and movement and improve muscle strength and control. Patient education is also essential to assist in the recovery of function. If the patient can learn to self manage the condition and decrease the potential for aggravation, there is a much greater chance of conservative management being all that is required.
- Neural Tissues
“Slump” pain is the result of mild inflammation of the central neural tube soft tissue structures, the dura. Patients will often report gradual onset cervical, mid thoracic and/or lumbar diffuse pain or aching while sitting for prolonged periods. Bilateral mild to moderate headache which lasts for several days may also be a symptom.
These patients will often have a mildly positive slump on assessment with pain or tightness reproduced in the lower neck, mid thoracic and/or the upper lumbar region. As a result of this tightness, when sitting for a period of time in the slump position, the constant stretch on the tissues irritates the dura causing the aching to commence. The addition of straight leg raise (SLR) to the slump test position may or may not increase the pain during testing. SLR testing alone may not be significant. There are rarely any signs on joint palpation although the patient may describe general tenderness over the joints and sift tissues of the spine.
Sitting up in bed reading a book at night is a classic aggravating activity. Driving for long periods is also a position that may cause problems. Other aggravating activities include prolonged writing, sewing or knitting, or sitting at a computer, or any activity where the neck is positioned in prolonged flexion.
Pain is eased by any position out of the dural stretch position. The patient will tend to feel stiff in the morning, but can improve with daily dural stretches. These stretched must be progressed carefully as overstretching can cause an increase in pain, while under-stretching will result in no improvement in symptoms.
Physiotherapy treatment can be highly effective in mobilising and eventually stretching out the restricted tissues and improving range of motion of the cervical, thoracic and lumbar spines generally. Postural correction exercises designed to take strain off the spinal joints and encourage good muscular support are also necessary to prevent recurrence. Continuing to sit with poor posture can prevent resolution of the symptoms and result in further weakening of the muscles of the trunk due to pain inhibition and lack of use. Patients with a previous spinal injury or who have had previous spinal surgery where scarring may be present may be more likely to experience slump pain due to dural restriction. Conditions such as fibromyalgia
Chronic pain states can lead to neural sensitisation and centralisation. This complex condition results in decreased patient responsiveness to the usual treatments implemented for musculoskeletal pain and injury.
What is pain?
- Pain is an output of the brain, NOT AN INPUT!
- Pain is only one of many outputs of the brain that combine to defend us, heal us and allow us to perform.
- Tissue damage, pain and pathology do not usually correlate.
- Pain depends on how much DANGER your brain THINKS you are in.
- Pain is a protector, not an offender.
- Education and movement are the best liberators of pain.
What Can Physiotherapy Offer?
With these patients, physiotherapy treatment of the central structures related to the appropriate neural pathways is necessary. For example, neural mobilisations of the brachial plexus can be of assistance in settling chronic elbow pain (tennis or golfers elbow), and straight leg raise stretches combined with lumbar rotations can assist in the treatment of chronic Achilles Tendonitis or RSD of the lower leg. Specific home or gym based exercises are also prescribed, and self management is encouraged.
Pain Management May Be Required
Central sensitisation also occurs with chronic spinal injury, and in these cases, if conservative physiotherapy management is not relieving the pain, the assistance of pain management (facet joint injections, nerve sleeve blocks, epidurals etc) may be necessary. You may also be aware that in extreme cases, spinal stimulators are implanted to try to block the continuing abnormal efferent input influencing the perception of pain. These can be very effective in relieving pain in patients where the usual pain management techniques have failed.
Chronic pain patients can also benefit from psychological counselling from a specialised pain management psychologist. Techniques to improve coping mechanisms and pacing are introduced, together with cognitive behavioural therapy. The STEPS program at the Fremantle Pain Clinic has had significant success educating people with chronic pain and significantly reducing their symptoms and improving their function. Understanding the condition and thinking differently about pain can reduce pain and allow the patient to return to normal activities. Your Move Forward Physio can refer you directly to this service.
- Pelvis and Groin - Osteitis Pubis
Osteitis Pubis has become a common condition in Australian Rules Football Players. It is a condition characterised by oedema of the bone marrow within the pubic rami. This can be confirmed with MRI and is usually a unilateral condition, but may be bilateral in some players.
The player presents with groin pain aggravated by running and kicking activities. Treatment of the adductor muscles does not improve the condition. Any rotational activity can aggravate the pain, so often the player decreases running activities and increases cycling activities to maintain fitness, believing that the non-weight bearing cycling may be less painful. However, cycling, although less aggravating than running, still increases pain and the player comes in to be assessed. Resting for a few weeks can also settle the pain, but upon return to sport, the pain returns immediately.
Physical assessment reveals a positive squeeze test (the player strongly squeezes their legs against your closed fist which is positioned between their knees) which is the clinical test for osteitis pubis. Tight rectus abdominis and tight and weak adductor muscles in the leg are nearly always present. These two muscle groups through their attachments onto the pubic ramus cause great strain to occur as the running (rotational) activities impart strong forces onto the pubic bone. These forces result in oedema (swelling) forming within the pubic ramus, and being an enclosed space, the oedema increases pressure and causes pain. Weak gluteus medius and poor core strength (mainly transversus abdominis) are major contributors to the development of this condition, as is limited hip rotation (usually internal).
Conservative management is usually the first plan of attack if the condition is not too severe. The player rests from all weight bearing rotational activities until the squeeze test is negative, and meanwhile the physiotherapist commences a program of stretching tight muscles, releasing overactive muscles, strengthening weak muscles, and biomechanical correction to enable the athlete to return to sport. Return to sport must be closely monitored with weight bearing rotational activities introduced slowly and carefully.
Current surgical options involve drilling small holes into the pubic ramus to release pressure from the swollen bone marrow. Sometimes, a conjoint tendon repair is performed simultaneously to strengthen the whole anterior groin area. Post surgical rehabilitation mirrors that of conservative management and should be closely monitored by a physiotherapist.
- Pelvis and Groin - Sacroiliac Joint Pain
Sacroiliac Joint Pain
Sacroiliac joint (SIJ) dysfunction is often associated with pregnancy or post partum mums, but can also be related to overuse injuries (repeated bending activities) or sporting incidents. The SIJ does not have a very large range of movement, but is an integral central component of the skeleton in full weight bearing (walking and running), and it is therefore essential that biomechanically the joint is moving in a coordinated fashion bilaterally.
The SIJ is part synovial and part fibrous, and gains stability from both force closure (muscle actions around the pelvis) and form closure (the shape of the joint itself, including the irregular shape of the joint surfaces).
Pain is often local to the SIJ but may refer into the buttock and even down the posterior thigh. Groin pain is possible particularly if there is a pubic symphysis problem.
Pain is often aggravated by standing, walking and running, although this is not always the case. A common complaint is pain when rolling over in bed.
Lying supine with the knees bent can take pressure off the joint. If there is frank instability, such as in the later stages of pregnancy, a SIJ compression belt can offer a lot of relief. SIJ compression belts can also relieve pain during functional activities in patients who are being treated for SIJ dysfunction for a variety of other causes, and is often considered by the physiotherapist.
Movement and Palpation Signs
It is often difficult to reproduce pain with movement testing unless specific SIJ tests are performed by a skilled practitioner. The patient is often tender over the SIJ’s and may demonstrate weakness of glut max and glut med with active movement testing.
There are a variety of treatment options available to the physiotherapist which will depend upon the assessment findings but will most likely include mobilisation and/or stabilisation, correction of lumbo-pelvic muscle strength and length imbalances, and core stability exercises, bracing, taping, and RTUI for retraining lumbo-pelvic muscle function.
- Shoulder - Rotator Cuff Injuries
Rotator Cuff Injuries
Rotator Cuff Injuries are quite a common occurrence in both the sporting and the older populations. These injuries can range from a minor local inflammatory reaction to a partial to full thickness tear (single rotator cuff tendon/muscle involvement to multiple tendon/muscle involvement). Physiotherapists are able to treat rotator cuff injuries throughout the healing phases.
If the rotator cuff tendons are swollen due to impingement, physiotherapy treatment can assist from the acute phase through to end stage rehabilitation or return to sport. Early treatment involves decreasing local inflammation and improving biomechanics to decrease impingement potential. Treatment will include posterior gleno-humeral joint capsular stretching, muscle stretching and strengthening, thoracic and cervical spine mobilisations, and correction of sporting technique if appropriate. Taping and dry needling may also be trialed.
If there has been a minor tear of the rotator cuff, conservative management, similar to that for subacromial impingement, will generally lead to excellent results. For larger tears that may require surgical repair, physiotherapy treatment post surgery is essential to strengthen the weakened tissues and to correct any biomechanical dysfunctions that may have originally contributed to the tear, to not only prevent recurrence of the injury, but also to ensure that the best possible post-surgical outcome is achieved. Returning to full shoulder range and strength following surgery will allow the patient to be fully functional even to the point of return to high level sporting endeavours. Physiotherapy treatment post surgery can start immediately to decrease the potential loss of the muscle tone of the scapular stabilisers (particularly lower trapezius and serratus anterior) and to prevent cervical/thoracic complications due to wearing the shoulder sling and brace. Most orthopaedic surgeons have their own post operative treatment protocols, and these treatment protocols are gradually becoming more accelerated.
Arthroscopic surgery can be used effectively for a variety of surgical procedures, including cleaning out arthritic shoulder joints, repairing tears that are suitable for surgery, removing spurs on the lateral process of the acromium to increase the subacromial space, removal of the bursa, and even to repair the labrum. Failure of conservative management for minor shoulder conditions, or patient presentation with major pathology, is usually followed by referral to an orthopaedic surgeon with an interest in upper limb conditions.
- Shoulder - Subacromial Bursitis or Impingement
Subacromial Bursitis or Impingement
Sub-aromial impingment is the most common cause of shoulder pain and physiotherapy treatment can greatly assist recovery and is often essential to prevent recurrence.
Shoulder impingement occurs when the subacromial space becomes too small to allow easy passage of soft tissue structures during functional activities. This space can be narrowed due to anatomical variants or postural changes. The soft tissues can become swollen (acute phase) and thickened (chronic phase) resulting in further pain and disability.
The Australian Physiotherapy Association has published the Shoulder Pain Position Statement which reviews current literature relating to shoulder treatment and rehabilitation. Physiotherapy intervention has been found to be extremely beneficial in the treatment of shoulder problems, particularly subacromial impingement.
A forward hshoulder position increases the tendency for impingement to occur. A forward humeral head can be caused through prolonged poor sitting postures, sporting activities with repetitive overhead movements (swimming, tennis), and stiffening of the thoracic spine can also lead to shoulder protraction as good thoracic extension and side flexion is required to allow the glenohumeral joint to move through full range unrestricted.
The patient will present complaining of sharp shoulder pain with overhead activities and reaching for things. They may have difficulty sleeping on that shoulder at night and the shoulder may ache in the evening. The pain is usually experienced at the deltoid insertion, but may also travel closer to the front of the shoulder. If the pain extends into the upper trapezius muscle, then the cervical spine is usually involved. Impingement tests (such as Hawkins and Kennedy) will be positive.
Physiotherapy treatment for shoulder impingement in the acute phase includes local electrotherapy to decrease tissue inflammation, and commencement of postural correction to take pressure off the impinged structures. Postural correction will involve thoracic spine mobilisations to improve thoracic ranges, lower trapezius exercises to encourage scapular retraction, stretching and releasing tight anterior structures such as the pectoral muscle groups, stretches for the posterior capsule of the glenohumeral joint (if this is tight the humeral head is forced forwards), stretches for scalenes and levata scapulae muscle groups, and cervical spine treatment (C5/6/7 segments) if indicated (cervical spine pathology can maintain impingement signs due to referral patterns). Strengthening of general shoulder muscle groups, such as the rotator cuff, will also be implemented.
A local injection of steroid can significantly improve pain if the condition is not settling with conservative management. However, even if a local steroid injection can temporarily settle the pain of an inflamed subacromial bursa, if the biomechanics that have caused the impingement are not corrected, the pain and disability will return before too long.
- Shoulder - Swimmers Shoulder
Swimmers Shoulder is a general term used to describe impingement pain occurring at the shoulder as a result of swimming.
Swimmers Shoulder can occur in both social and serious swimmers and is not an uncommon problem, with the USA Olympic team in the 1980’s having more than 90% of their squad affected by swimmers shoulder at the one time.
What is Swimmers Shoulder?
Swimmers Shoulder is pain occurring around the front shoulder region as the result of repetitive overuse with usually the overhead strokes (freestyle, butterfly and backstroke). The major contributing factor is often restricted internal rotation of the glenohumeral joint that leads to over protraction of the shoulder complex to compensate for this decreased range during the pull through. Swimmers shoulder (impingement pain) can also occur at other points through the range, and a thorough biomechanical assessment of the upper quadrant (cervical spine and shoulder joint complex) is required for an accurate diagnosis.
Physiotherapy assessment takes into account the aggravating movement to assist with diagnosis of the biomechanical faults leading to the problem. There is often an upper cervical spine component to the injury (due to breathing crookedly to one side with freestyle, or due to excessive upper cervical extension with butterfly), and therefore the cervical and thoracic spines must also be assessed. The scalene muscles of the neck are often tight, and the C1/2 joint complex (50% of rotation occurs here) is often stiff. Shoulder joint rotation is also a key factor, and the Hawkins Kennedy Impingement tests are usually positive. Good thoracic extension range is also a requirement of correct biomechanical form while swimming and thoracic spine stiffness can also be a contributing factor. Decreased hip extension range can also put increased pressure onto the back and therefore the shoulder.
Localised treatment to the area of pain to settle inflamed or irritated soft tissues is the first aim of physiotherapy treatment. However, treatment to correct the underlying biomechanical faults must commence as soon as possible to prevent further aggravation and to prevent future reccurrence of the injury. Sometimes, the swimmer must have some time out of the water to enable healing of the swollen or injured structures, but at other times, modified swimming training is able to be continued. Stroke correction may also be required and the physiotherapist will liase with the coach to discuss what components of the stroke are leading to the shoulder pain so stroke correction can be specifically concerned with preventing the condition from returning.
Contact us at one of our Clinic Locations if we can assist.
- Rib Injuries
Rib Injuries – Physio Treatment
Physiotherapists can effectively assess and treat rib injuries from the acute presentation through to chronic rib lesions. Acute rib injuries are usually traumatic and occur most commonly as a result of a sporting incident. However, rib injuries may also be of insidious onset and gradually get worse without any specific incident of note.
With an acute rib injury the patient usually presents experiencing sharp fairly localised pain with deep breathing and coughing. Pain may be felt at the costovertebral joints in the middle back, the sternocostal joints at the front of the chest, or right through the chest wall. A rib fracture will be painful over the site of the injury, which is usually on the side of the chest wall.
A localised acute inflammatory condition, chondritis, can also occur at the sternocostal joints at the front of the chest, particularly in females. Often there is palpable swelling and extreme tenderness over one or more joints.
Chronic rib injuries can be the result of repetitious activities placing stress upon the costo-vertebral or costo-sternal joints over a period of time, eventually leading to pain and dysfunction.
Treatment of rib injuries varies depending on the diagnosis and severity of the condition, and whether the condition is acute or chronic.
Acute rib injuries respond well to ice and anti-inflammatories combined with physiotherapy treatment. Physiotherapy treatment involves mobilisations, contract/relax resisted muscle activity, and taping. Ice is usually the most relieving home treatment combined with gentle muscle and joint exercises as prescribed by the physiotherapist.
Chronic rib injuries also respond very well to joint mobilisations or manipulations.
Chronic rib injuries may indicate that there is an underlying biomechanical dysfunction of the thoracic region. Treatment in these cases will also involve addressing the biomechanical imbalances (usually restricted joint ranges and muscle weakness) related to the rib injury. However, the lumbo-thoracic junction (usually too much movement) and the cervico-thoracic junction (usually too stiff) are also areas that can be prone to developing rib problems above or below the region.
Please contact us at one of our Clinic Locations if one of our physios across Perth can assist.
- Thoracic Spine
Thoracic Inlet Syndrome
The thoracic inlet allows unobstructed passage of the neurovascular bundle (nerves, arteries and veins) from the root of the neck to the axilla (from the neck to the arm pit).
Signs and symptoms of thoracic inlet syndrome occur if there is some restriction of the passage of the neurovascular bundle between the shoulder and the neck. There are many factors that may be involved, including tight neck muscles or abnormal muscular attachment onto the ribs, cervical ribs (either calcific or fibrous), or postural causes.
The patient will normally present with numbness and pins and needles through one or both arms. Neurological symptoms (pins and needles and pain) predominate in 90% of people and vascular in 10%. They may also complain of incoordination, muscle weakness and pain particularly in the hands and fingers. The symptoms are generally worse with sustained overhead activity and positions. It is quite common in weight lifters and carpenters, or in people who are overweight or with very poor posture.
What is observed depends on whether there is a predominance of vascular or neurological causes. Typically one will observe some form of numbness, muscle weakness and in the later stages, wasting especially of the intrinsic finger muscles and thumb muscles. If the cause is primarily vascular a decrease of the radial pulse may be felt in sustained shoulder abduction, a blush discolouration in the hand when down by the side and venous symptoms may also be present such as oedema (swelling).
Physiotherapy treatment will address faulty neck/back postures and joint mobility with mobilising of joints and posture correction exercises. Tightness of neck musculature, in particular the scalenes, can be decreased through stretching and retraining of shoulder girdle muscles. The stabilising muscles of the neck and thoracic spine (such as longus colli, lower trapezius and serratus anterior) are also retrained and strengthened. Modifying household activities and exercise routines is important for positive long-term outcomes. Initial manual physiotherapy can speed recovery and is best combined with a prescribed home exercise programme. Results from conservative treatment can be very successful with 70-90% resolution of symptoms.
TMJ – temporomandibular joint
The dysfunctional temporomandibular joint is a notoriously poorly managed condition that is characterised by a variety of symptoms, including jaw and face pain, headache, ear symptoms, tooth ache, and poor sleep patterns.
An acute TMJ dysfunction may occur following dental work such as wisdom teeth removal, following an excessive opening injury such as biting into a large apple, following a local impact injury resulting in pain and swelling, or due to biomechanical dysfunction following fixation due to a jaw fracture or a new set of dentures. Chronic TMJ dysfunction can occur due to postural influences (chronic bruxism, forward head posture), due to biomechanical changes following whip lash injuries (muscle length changes around the head and neck), or due to gradual biomechanical changes related to changes in occlusal pattern (braces, tooth removal, capping). Chronic TMJ dysfunction is almost always associated with an upper cervical joint dysfunction with associated muscle and neural mobility changes.
The Physiotherapist assesses the TMJ as they would any other dysfunctional joint in the body. The joint is palpated, the range of motion is assessed, and muscle function around the jaw, head and neck is also assessed. The cervical spine must also be assessed specifically as due to the close association of the structures, the TMJ and cervical spine function do influence each other. Biomechanical faults are noted, limitations or excessive ranges are examined, and a plan of treatment and rehabilitation is developed.
Symptoms are varied and can include headaches, jaw pain, tenderness of the occlusal muscle groups, upper cervical spine pain, poor sleep patterns, blocked ear, and difficulty eating some food groups. Sometimes the patient has high stress levels that may need to be addressed to decrease bruxism and improve sleep patterns. The physiotherapist will enlist the assistance of the GP in these circumstances. Bruxism can also be alleviated with the addition of a suitable night splint, and referral to a dentist specialised in this area may be required.
Generally speaking, a hypo-mobile joint is mobilised, and a hyper-mobile joint is stabilised. Obviously it is not quite this simple, but treatment may include mobilisations to the TMJ directly and the cervical spine facet joints, appropriate muscle exercises to strengthen and re-coordinate the jaw function, relaxation exercises to take pressure off the occlusal muscles, trigger point treatment and releases, and the Rocabado program of rehabilitation for TMJ dysfunction.
Contact us at one of our Movewell Clinic Locations if we can assist.
- Womens Health
Latest Research into the Pelvic Floor and Physiotherapy
The Pelvic Floor Muscles consists of four pairs of muscles which sling across the bottom of the abdomino-pelvic cavity.
They are important for:
- supporting abdominal & pelvic viscera
- patients with low back pain
- sexual response
Problems with the pelvic floor may lead to:
- Urinary Symptoms (frequency, nocturia)
- Voiding dysfunction (hesitancy, straining)
– Genuine stress incontinence
– Urge incontinence / urge
- Ano-rectal symptoms
- Back pain
Pelvic Floor Muscle exercises prescribed by a physiotherapist form the mainstay of conservative treatment for women with pelvic floor dysfunction such as urinary incontinence or pelvic organ prolapse.
Research has shown that many women are unable to contract the correct muscles on verbal instruction. An effective pelvic floor muscle contraction increases the urethral pressure without significant Valsalva effort (Note: A Valsalva effort (breath holding or bearing down) may have negative long term implications for prolapse and continence as the increased intra-abdominal pressure can actually depress, and therefore further weaken, the pelvic floor muscles.)
Studies have shown that on testing pelvic floor contraction (with verbal instruction) in women with urinary incontinence and prolapse:
– 26-49% could produce an effective contraction
– 25-39% used a Valsalva effort (incorrect contraction)
A recent study in 2003 of 104 women with incontinence and prolapse, asked to draw in and lift their pelvic floor muscles, resulted in 38% elevating, 19% not changing, and 43% depressing the pelvic floor (Thompson and O’Sullivan ’03).
In order to retrain a correct Pelvic Floor Muscle Contraction we need to know whether the bladder neck is elevating, depressing or not moving. There are two methods for assessing this – Digital vaginal palpation and Real-Time Ultrasound Imaging (RTUI).
RTUI (trans abdominal) has the following advantages;
- Immediate visual feedback to therapist and patient,
- Assesses for an ‘elevating’ contraction of the pelvic floor muscles,
- Totally non-invasive (trans abdominal),
- Picture easy to understand,
- Improved proprioception for the patient (easier to learn the contraction)
We offer real time ultrasound imaging with specifically trained and qualified staff. If you suffer from incontinence (when you laugh or run), urge (desperately needing to go) or frequency (having to go again ten minutes after you have just been), or if you have a prolapse, then pelvic floor retraining with RTUI may be able to assist you. Breathing retraining may also be part of your rehabilitation program.
- Wrist and Hand - Colles Fracture
Colles’ fracture is a fracture of the distal radius and ulna (the bones of the forarm), which occurs after a fall onto an outstretched hand. It is most common in the older population but can also occur in young sports people. In the younger person, because the force required to fracture such strong bones is great, young athletes often also suffer intra-articular (inside the joint) fracture with this injury.
Confirmation and Treatment
Fracture is confirmed with X-ray and the treatment involves anatomical reduction and immobilisation for 6 weeks in a cast that covers the distal half of the forearm, the wrist and the hand, leaving the metacarpophalangeal (MCP) joints, or the knuckles, free. If the reduction is not accurate or if there is imperfect alignment of joint surfaces or inadequate restoration in length, internal fixation (surgery) is required. X-rays are usually taken every 2 weeks to ensure that the position in the cast is maintained.
Following Cast Removal
Once the cast is removed the wrist is usually very stiff with restricted range of movement in all directions. There is also marked weakness of the wrist muscles in all directions, and patients will have trouble opening doors or jars, or lifting coffee cups. Often the hand itself is also stiff and weak with grip strength is also greatly diminished.
Leaving the patient to rehabilitate their wrist on their own following a Colles’ fracture can lead to delayed and incomplete recovery. Physiotherapy treatment can assist the rehabilitation of the wrist in many ways. Specific mobilisation to the carpals and the inferior radio-ulna joint can improve joint range in all directions. Active assisted, active, and active resisted exercises are introduced to enable the patient to perform self joint mobilisations at home on a regular basis. Exercises are also prescribed to increase strength through all ranges, particularly pronation and supination which are essential for simple every day activities such as turning a door-knob. Exercises to improve grip strength are also able to be performed at home by the patient
- Wrist and Hand - Scaphoid and Hamate Fractures
Scaphoid and Hook of Hamate Fractures
Scaphoid fractures most commonly occur as a result of a fall onto an outstretched hand. These fractures notoriously heal poorly and require quite significant immobilisation and rehabilitation following removal of the plaster cast. The Hook of Hamate fractures are almost exclusively a golfing injury, and injury to the distal end of the ulna nerve are not uncommon.
How does the patient present with a scaphoid fracture?
The patient presents with thumb sided wrist pain following a fall onto an outstretched hand. There will be acute tenderness on palpation in the anatomical snuff box. Often, initial x-rays do not show the fracture if it is not a complete fracture of the neck of the scaphoid. The radiographer must be alert to finding the best image to view the bone to ensure the fracture is visualised. Even if the fracture cannot be seen, usually the wrist will be immoblized.
What is the treatment?
The wrist is plastered in the correct position of slight wrist extension and the ability of the knuckles (the metacarpal-phalangeal joints) to fully flex. If there is limitation of finger movement, the plaster should be cut down to allow the MCP joints to move freely. After 6 weeks the wrist is re-x-rayed. If there is non or delayed union, the plaster is reapplied for a further 6 weeks.
How does the patient present with a Hook of Hamate #?
The most common history is of hitting the ground during a golf shot, with the handle of the club being forced into the palm of the left hand for a right handed golfer during the resulting jolt. The patient presents with acute pain in the hyper-thenar eminence, and usually tingling into the 4th and 5th digit as a result of injury to the distal end of the ulna nerve that wraps around the hook of hamate.
What is the treatment?
The wrist is usually put in a plaster for 6 weeks followed by a thermoplastic splint of there is delayed union. Often, however, the displaced hook has to be surgically removed to take pressure off the ulna nerve.
What exercises are required following plaster removal?
Following any immobilisation of the hand and wrist, there is usually loss of supination and pronation strength and range, as well as loss of intrinsic muscle strength and control. Specific physiotherapy exercises are required to address this, and the entire upper limb may also need retraining to ensure good proximal stability returns to the upper limb complex, particularly if returning to sporting activities.