News Archive
Worse in the morning?
This is always a key question I ask when someone comes in and I love it when the answer is: yes!
That's because I know I can help.
Being worse in the morning is a key indicator of a joint stiffness problem. So if you’re neck or your shoulder or your back or whatever is worse in the morning, it’s because you’ve been asleep and not moving much, allowing the joint to get more stiff. Any joint that doesn't move properly will give you pain.
The answer to making those joints move better is to loosen them up and that is what I do all day via manual therapy.
Exercises Exercises Exercises!
At least weekly I see a new client who says to me: “I’ve never had this type of treatment before”, despite having seen one or more Physios previously.
My treatment always involves manual therapy of various methods, principally aimed at increasing the range of movement of the body joint involved with the problem.
Almost all musclolo-skeletal pain is because something (a joint) doesn't move properly. When you ask a stiff joint to move and it can't, it hurts.
That's why manual therapy is generally very effective. It is making the joint move. Then the joint goes where you ask it to and subsequently it doesn't hurt.
Why so many Physios, especially of more recently trained Physiotherapists, concentrate their efforts (and treatment time) on demonstrating and instructing exercises to their clients without physically addressing the joint with restricted movement is very strange in my view!.
Now I agree exercises have great value in assisting people to improve and maintain a condition, but when a joint is not moving properly manual therapy is the first and best choice in addressing the problem in my view.
If your treatment involves lots of exercises and you’re struggling to get better maybe you should call!
PLANTAR FASCIITIS / FACSIOPATHY
Plantar fasciitis or fasciopathy is an annoying and restrictive foot pain.
The plantar fascia is a thin film of connective tissue that runs from the heel to the ball of the foot. Imagine a layer of cling wrap between the skin of your arch and the muscles under your foot bones. It supports the arch of the foot and helps with the mechanics of foot movement.
Pain is often sharp on weight bearing, usually close to the heel. Commonly worse in the first few steps in the morning or after prolonged sitting.
TREATMENT:
Physiotherapy has been shown to be effective (Hasegawa et al, 2020).
Good physiotherapy treatment should involve careful assessment of the foot.
In my experience disfunction in foot mechanics are frequently involved. Stiffness in the important joints of the foot can lead to extra load on the fascia and subsequent injury. Manual mobilisation (loosening) of any stiff joints often gives rapid improvement by easing the burden on the fascia. It is wonderful when a client says they can walk again!!
Taping can be helpful. Advice on stretching of foot and calf muscles and strengthening is of value.
Orthotics and footwear should be considered in some cases.
References:
Hasegawa, M., Urits, I., Orhurhu, V. et al. Current Concepts of Minimally Invasive Treatment Options for Plantar Fasciitis: a Comprehensive Review. Curr Pain Headache Rep 24, 55 (2020). https://doi.org/10.1007/s11916-020-00883-7
BONE BRUISING
All the tissues in our body can bruise. We’ve all had one. Sometimes heavy compression on joints can damage the surfaces of bones causing bleeding inside the bone surface. In simple terms, this is a bone bruise where the bone is injured but not fractured.
Fat Pad Impingement
Keen soccer player Ms. K presented with sharp pain just under the kneecap. It was very sore when running and going up and down stairs. She had fat pad impingement of her knee.
The fat pad is “cushion” structure sitting below the big tendon that joins the kneecap to the shin bone. It can become swollen from the kneecap squashing into it through sport or impact. Although not a severe structural injury, it can be very restrictive due to the pain. “Fat pad impingement” is a common presentation for stop start sports participants. In the old days it was common with the staff in English castles who were scrubbing floors (housemaid’s knee!).
Simple taping is usually very effective, and I often enjoy the look on the sufferer’s face after they go up a step after being taped (and it doesn’t hurt!). Management of knee stiffness, strength, relative rest and return to normal activities then begins.
Untreated it can persist for a long time and will invariably lead to loss of strength in the knee and possible further problems from this.
Avoid power activities of the knee that hurt: stairs, ladders, hills, squatting and sprinting as well as kneeling (AND no scrubbing floors!).
Guided Spinal Injections
These procedures involve injection of steroid type chemicals close to spinal nerves (nerve root injections) or the space around the spinal cord (epidurals). The Radiologist positions the needle by viewing on CT scanner into the right spot.
I thought I’d share what one of Melbourne’s best spinal surgeons told me about them (as he referred me for one!)
He told me in his experience for people he referred to have nerve root injection, approximately 60% described some effect from the injection. More specifically though, roughly 20% of people felt good improvement, 20% fair and 20% slight.
Not great numbers I think you’ll agree, but probably worth a try for unbearable or unchanging leg pain if your doctor thinks so.
He also said that he felt epidural injections were a “shot in the dark”.
In more general conversation I’m glad he agreed with me that increased back pain first thing in the morning is a key sign for non-invasive treatment. Simply put, more pain in the morning is most likely due to back joints getting stiffer overnight. This is good for someone like me, because stiff joints will usually respond to appropriate manual therapy which I can provide.
So even if your CT or MRI is awful, if you are worse in the morning it is worth trying some (manual) Physiotherapy. You should get some improvement.
SIT-UPS
Recently a patient said to me: “can you believe a friend of mine did his back doing sit-up’s?
"That’s right I think” he said when I asked if his mate did the sit-ups with his feet locked under underneath something.
Now abdominal crunches are one of the easiest and best postural strengthening exercises but if you lock your feet when you’re doing them it’s risky.
The reason is a muscle called Psoas major which makes your hip bend up but it’s also attached to the front of your lumber spine bones. So it also pulls your spine toward your hip if your feet are locked under something.
It’s a little hard to explain in words but hopefully my dodgy stick men below illustrate what I mean. (If you can't see them clearly in your browser, click on the box / link below). From the blue arrows you can see the abdominal muscles pulling the chest towards the pelvis in the first diagram (resulting in downward pressure (red) on the lower back while lying). In the second diagram you can see the Psoas muscle pulling the back towards a fixed leg (blue) resulting in upward force on the spine (red). Two opposing forces on the spine result in compression down the spine. If you’ve got an unstable spinal disc, there is potential to hurt you.
So don't stop your crunches (with bent knees) but keep your feet free!
Exercises Exercises Exercises!
At least weekly I see a new client who says to me: “I’ve never had this type of treatment before”, despite having seen one or more Physios previously.
My treatment always involves manual therapy of various methods, principally aimed at increasing the range of movement the body joint involved with the problem.
In my opinion this is a very simple Physiotherapy approach and is very effective.
I’m perplexed at the propensity, especially of more recently trained Physiotherapists, to concentrate their efforts (and treatment time) on demonstrating and instructing exercises to their clients without physically changing a joint with restricted movement.
Now I agree exercises have great value in assisting people to improve and maintain a condition but when a joint is not moving properly manual therapy is faster and more effective in addressing the problem in my view.
If your treatment involves lots of exercises and you’re struggling to get better maybe you should call!
ARTHRITIS:
"I've got arthritis, there's nothing you can do about it"
If I had a dollar for every time someone..........
As long as I didn't have to fork out a dollar for my response: "how long have you been like this for?"
Osteoarthritis/degeneration/wear and tear (as distinct from inflammatory arthritic diseases) is part of the ageing process and in some people and some joints it happens faster than in others, sometimes for a reason, but often for no reason. The only way any of us will avoid getting it in every joint is if we die before it happens!
It doesn't necessarily mean you can't be helped via Physiotherapy. Sure, we're pushing uphill in someone who has central canal stenosis and has had gradually increasing leg pain over years. Or someone with no chondral cartilage in their knee.
But what if their pain level has spiked only recently? Maybe via an incident or not but if they've only been adversely affected for a month or less I start to get interested.
The injury almost certainly looked the same on x-ray, CT or MRI three months before. If they weren't too bad before they flared up, then it's not just their radiology or, logically, they should have been crummy back then! There's a good chance joint stiffness and/or weakness for whatever reason is now contributing to their increase in symptoms.
Joint stiffness we can change.
And of course muscular/proprioceptive support via increased strength around a joint will always have value in the patient prepared to put in, as instructed!
Sydney shoulder Surgeon Professor George Murrell reported some interesting findings at a conference I attended where he had called back all his patients 8 years after reconstructive surgery to assess how their shoulders had lasted via ultrasound and MRI.
Amazingly, 80% of them had RE-TORN their tendon!
What was interesting? Nearly all of these people were pain free, without any movement problems!
This little piece of news reinforces what I've thought for many years now: Radiology is helpful sometimes but it's not everything. Although these people looked bad on ultrasound, their shoulders were doing fine for them. I'm sure many people that come in to me with a sore shoulder and resolve quickly would have tears if investigated.
Effective Physiotherapy, by increasing range of movement via manual therapy, will almost certainly decrease someone's pain, in this case in the shoulder.
Of course, with structural damage this is not always possible and that's where injections and/or surgery should be considered.
But Physiotherapy's worth a try! I saw an old bloke last year who hadn't moved his arm for twelve months after a failed reconstruction. In his rotator cuff he had ruptured supraspinatus, ruptured subscapularis and partial tear to infraspinatus. That is, he only had 1 and a 1/2 muscles out of four!
TENDON PAIN
Tendonitis, tendonosis, tendonothapthy?
These are common conditions in the shoulder, elbow, wrist, hip, knee and ankle. Tendon injuries usually are due to overload. This might be too much load for too long or it might be a change in what load your tendon is used to (eg: sudden change in exercise routine).
Microdamage in the tendon occurs due to the overload stress with resulting local inflammation and swelling. Managed early and properly tendons will often settle quickly. Remember though, tendons are tough and take a long time to complain to the point where we notice them. In the same way they can take a long time to settle down after flaring up. They need to be managed carefully through this period.
In addition to examining the tendon and joint close to it, proper assessment should include examination of the neck or back (depending on the tendon) to define any nerve contribution to the tendon problem. Subsequent treatment may involve mobilization of the spine as well as local treatment of the tendon.
While they don't like being overloaded, they love being loaded properly, so exercises which include progressive isometric and eccentic programs are vital. Again, these exercises need to be advised and managed correctly!
HEADACHE:
Recent studies have confirmed specific Physiotherapy techniques to be very successful in treating most types of headache. If your headache can be reproduced by careful assessment of your neck by Brendan, it is extremely likely your headache will be treated effectively. Treatment involves specific guided pressure type techniques on the spinal joints of your upper neck.
True manipulation (cracking the neck) is NOT and should not be used.
Exercises specific to helping prevent reoccurrence will be advised.
Studies also indicate increased release of serotonin (a natural chemical in the blood stream) is helpful in decreasing the severity of headache. Serotonin can be increased by general physical exercise and by eating foods containing tryptophan (an amino acid) which the body uses to build serotonin. Foods include eggs, most dairy, soy and some seafood, especially cod.
DYNAMIC TAPE:
This tape is relatively new. It is a semi rigid tape which, when correctly appied, can "unload" a muscle which is injured or sore. This can assist in healing time or in sporting performance (you may have seen athletes wearing this tape - often with a "tribal" pattern).
Recently Patient A presented the day of her netball Grand Final with a sore back and calves which she felt was from over-training. Her back was loosened up easily via Physiotherapy treatment although she still had soreness in both calves when springing on her toes.
She had no other indication of muscle damage so I appied Dymamic Tape, hoping to get her through her Grand Final. Once taped she was pain free and wih a very pleasing end result: Another flag!
(Her sister actually reported Patient A was "the game changer"!)
GLUCOSAMINE:
There are many good studies which indicate glucosamine is more effective than a placebo in decreasing pain and / or increasing function for people with chronic joint conditions. (See Research)
In my experience it does not work for everyone but it is worth trying.
My advice is to give your sore area a score out of 10 every day for a week before you you start taking Glucosamine. Hide the scores!
Commence the recommended dose for three months and then repeat the scoring process. Most people know if Glucosamine is helping but sometimes the average score is lowered surprisingly. If there is no change in your scores then you may as well not buy it. Good luck!
IRONMAN:
Interstate visitor Client D came in two days before the Melbourne Ironman. Despite treatment interstate he had persisting leg soreness which had stopped him running for a week and had serious doubts on finishing, let alone doing well enough to earn him what he entered for: a qualifying position in the Hawaiian Ironman.
He had some back joint stiffness and lateral hamstring trigger point muscle spasm and after loosening these up he felt better. However running a full marathon after the 3.8 kilometre swim and 180 kilometre cycle would be a massive test!
The news post race was that he had got though the event and even with a puncture on the cycle grabbed a spot in Hawaii!
Well done to him! (And a bit to me too!)