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Your first step to recovery

Knee pain from squats explained

Whether you are squatting racks of weights in the gym or squatting down to the floor to play with your children or simply squatting to sit in a chair – you are still squatting.

Truth of the matter is, squatting is more than just an exercise. If you think about it, it is a functional movement we all do many times in the day.

Knee pain from squatting is a common compliant. Although it is common, it doesn’t mean it is normal.

More often than not, the problem doesn’t only lie at the knee joint. We have to understand the complexity of our body in how our knees are directly linked with how your hips and ankles are moving. So, the purpose of this blog is not only to help you understand the basic mechanics involved in the legs when you squat, but also to help you perfect your lifting craft in the gym.

A bit on what is a squat?

Squatting is characterized as a ‘compound movement’ – fancy fitness lingo that simply means, multiple joints and muscles are moving and working in harmony to contribute to the very movement of squatting.

So here is a checklist to help you find the missing links.

Squatting check list

1.      Foot arches

Feet are the foundation to our body. From a balance perspective we can go as far to say that steady the feet, steady the rest of the body. So, what happens at our feet is extremely important to consider when we talking about knee pain in general, let alone, knee pain when squatting.

Foot stability can be best explained using the analogy of a ‘tripod’. As tripod has 3 points of contact with the ground, so should our feet ideally.

The three points of a contact, as in a tripod looks like this in our feet.

  • Ball of the big toe
  • Ball of the 5th toe
  • Heel

Keeping this in mind, lets assess the foundation of your body – Your feet with this small exercise.

Take your shoes and socks off. Stand up tall, plant both your feet flat on the ground. Take a look at both sides individually. What do you see?

  • Either of your feet collapse in?
  • Are either of your arches diminished?

Take note of it. Next, remain standing and focus on what you feel at sole of your feet.

Think about the 3 points of contact – the tripod.

  • Do you feel you have evenly distributed pressure?

Take note.

Now stand on one leg – think about the same TWO things the arch and the pressures.

  • Which way did your foot go?
  • Which points of contact in the foot had more pressure?
  • Did your toes 3-5th lose contact from ground?

If your foot caved in and the last 3-5th toes lost ground contact, then your foot pressure is likely to sit between big toe, the base of 2-3rd toes and heel, suggesting you have a narrowed base of support. This will force the knee, hip and the rest of your body to follow in the direction, creating risk of building up unwanted pressures in others areas of your body. Before you know it, unwanted pressure results in inflammation and pain.

It is important that you consider this of high value and practice on pressure control and arch control before your look at the overall picture of squatting.

2.      Ankle mobility

Your foot and ankle are closely linked – between them there are 28 bones, many muscles, ligaments and connective tissue. These anatomical structures work together to provide stability and mobility of the joints – considered KEY essentials to squatting.

Too much or too little flexibility in the ankle can be a problem. In most cases, ankle injuries result in stiffness, a hinderance to simple functional movements.

So, let’s take a closer look at your ankle with a simple mobility test.

Kneel down in front of a wall. Signal a thumbs up and measure the width of it from the wall and mark it. Place your foot on the line and drive your knee forward to the wall. Make sure you drive your knee straight forward without caving in or twisting in with your hips.

What do you see?

  • Can you touch your knee to the wall?
  • What about the other side?

Consider what you feel.

  • One side feels almost effortless, the other side doesn’t?

It is not uncommon to notice that the unaffected side may not be as flexible as you thought.

This is point to note – you have just discovered a link and a potential cause of your knee pain.

You need focus on stretching the muscles of your leg in a way that similar to ‘squatting’ – here is a good one!

  • Box ankle stretch

Use a box or a chair, plant your foot flat and rock forwards until you feel a stretch in the calf and ankle. Remember to make sure your knee doesn’t cave in or your body doesn’t twist. Do this for 20-25 repetitions, 2-3 sets. Re-test yourself.

3.      Hips

Your feet are directly tied to your hips. So, the action of your hip and feet should be working together for good purposeful movement.

Here is a quick way to check this yourself:

Stand tall, with your feet planted shoulder width apart. Drive your knees out to the side. You will notice your foot arch lifts.

It might be a very small amount, but worth taking note. Because, this is no different when you are squatting. If your knees collapse in, it may mean that you are not recruiting the key muscles of your hips that prevent the knees collapsing.

So, driving your knees out to match the alignment of your hip-ankle not only lifts the arches but begins the process of recruitment patterns of hip muscles to engage.

The common deficit contributing to your knee pain may be weak gluteal muscles.

Gluteal muscles are powerful muscles of the lower limb. They are a group of three muscles, each with slight different function

  • Gluteal maximus – hip external rotation, hip extension
  • Gluteal medius – hip abduction, internal and external rotation, extension
  • Gluteal minimus – hip abduction and internal rotation

Banded squat

Banded squats are a great way to activate your gluteus. The band not only provide resistance but provides sensory information to help you learn to push into it, therefore avoid knees from collapsing in.

If you have a lighter level resistance band, place this at knee height.

Descend in to a squat position with emphasis on pushing you knee out into the resistance band, until you reach the hip-knee-ankle alignment.

Do this 15 times, 3 sets.

For starters, work at a level that is easy for you.

Build the reps ups as you gain confidence

  • Weak or inadequately recruited muscles could be a result of stiffness hips.

To check your flexibility, try this next test:

Sit on tall on a chair. Feet planted flat on ground at shoulder width apart. Test one leg at a time. Keeping your thigh in contact with the chair, drive your knee out to the side (internal rotation). Now try going inwards (external rotation).

What do you see?

  • Can internally rotate higher? External rotation is difficult? Or vice versa?

What do you feel?

  • Takes more effort going one way than the other?

Unlock the hips with this beginner hip stretch.

Sit upright on a chair. Cross one leg over on the other. You should feel a stretch in the buttock region. If not, progress by leaning forward with an upright posture. Hold for 15-20 seconds. Repeat 3-5 times.

Perfecting your squat

Perfect practice makes perfect. Now bearing the rules of movement in mind, practice your squats.

Some tips to help you better practice:

  • Do not worry about the depth of your squat

It’s the quality not the quantity. So as you begin to learn and adapt these principles, only squat down to a level where you feel in control of your foot, ankle, knee and hip.

  • Use a mirror

Visual learning is a great tool! It provides for a greater ability to correct your mistakes and perfect that ‘quality over quantity’ rule.

  • Start with barefoot

This allows you to connect the sensory receptors in the soles of your feet to the ground, making it much easier to learn the tripod grip.

Still having pain?

Remember, the complexity of our body and the complexity in how we move as whole can be the result of your knee pain. So, if you are still having pain – its time you get it checked.

Book yourself in for an appointment today.

Fix the grinding in your knees when you squat

There can be multiple reasons why your knees sound like popping popcorns or grating stones when you squat.

Generally popping in the knees is attributed to stiffness of the quadriceps muscle and the fascia that surrounds the knee joint. Overtime, stiffness causes pressure to build up under knee cap, which on movement can cause a sudden release causing a ‘popping’ sound. As worrying as it may be, most of the time popping noises in the knee without pain is NORMAL. However, for others the noise can be accompanied with a grinding sensation under the knee cap which is painful. This suggests there is an underlying pathology that needs to be addressed.

This is something we would clinically consider to be Patella Femoral Pain Syndrome aka Runner’s knee – an umbrella term that encompasses the idea of dysfunctional knee cap tracking.

When you straighten and bend your knee, naturally your knee cap tracks up and down between its groove (trochlea groove) – like a train moving up and down a train track.

When the quadricep muscles on the outside (vastus lateralis) and inside (vastus medialis oblique) part of the leg are working in synchronization as they should, your knee cap is able to track up and down properly. However, if the quadriceps muscle (Vastus lateralis) is overly activated and the fascia (Iliotibial band & lateral retinaculum) on the outer part of you knee cap is excessively stiff, the knee cap gets pulled to the outside.

Essentially the train is being pulled and tilted more to the outside. Eventually overtime, repetitive or violent lateral pull of the knee cap increases friction in the knee grating the smooth underside of the knee cap called, chondromalacia. Additionally, the constant pulling and stiffness of the lateral side will cause stretching on the inside of muscles. On top of that, pain and swelling will cause the muscles in the inside of the leg to shut down.

Here are two steps to managing your symptoms.


STEP ONE

  1. Foam roller or tennis ball

Instructions:

  • Lie on your front and place the foam roller underneath your leg.
  • Bend the opposite leg and bring it out to the side to help you move back and forth.
  • Roll the entire length of the thigh muscle, staying off the knee joint.

Make sure you move through the length of the muscle close to the knee cap as you can. You should be looking for stiff spots in the muscles and any sore spots you feel concentrate on it for couple of seconds and work deeper in to the tissue. You should also move in the inside and outside of the quadriceps muscles. Do this with you knee straight and then move into knee flexed position to optimize the release.

For a more concentrated release, use a tennis ball or a lacrosse ball especially at the quadriceps tendon where much of the stiffness is likely present. The reduced surface area of the ball allows you to work on specific spots a lot better to break down deeper areas of stiffness and create more mobility.

Do this mobility routine for 1-2 minutes


  1. Quadricep stretches

  • Start in a standing position. Use support if required for balance.
  • Raise one leg behind you grabbing hold of your ankle, or your lower leg.
  • Lift and hold for 20-30 second, and then repeat for the other leg.
  • Get into a lunge position with back leg flat on floor
  • Bend your knee and slowly pull your leg into a stretch
  • Hold this stretch for 20-30 seconds
  • For comfort place a rolled face towel under the knee cap

Modified quadricep stretch

For some people if kneeling down is irritating for the knee you can modify the stretch.

  • Rest your leg on the chair with your foot against the back rest
  • Make sure your stance leg is far enough in front of the chair
  • Lunge forward until stretch is felt
  • Do this for 20-30 seconds.

NOTE: Long duration stretches of over a minute and more can decrease the potential for you to create strength and power in those muscles during your workout. So, prior to your workout focus on short duration stretches.


  1. Functional mobility stretch

Deep squat sits are great to expand the stretch. If your symptoms are not aggravated, try deep squat sits for 30 seconds up to a minute.

  • Stand with feet shoulder width apart
  • Point your feet out to about 45 degrees
  • Sit in to a deep squat keeping the pressure evenly distributed across feet

STEP TWO

Now that you’ve resolved the stiffness in the lateral portion of your knee, next step is to address the muscles imbalances caused by pain and swelling. That is, turning back the firing of the quadriceps muscles.

An effective way to address this, is by doing what we call close chain exercises – these are exercises done where your feet are on the ground, such as squats. Initially you want start slow and high. Mini squats are great because they allow you to strengthen your quadriceps without putting too much compressive forces into your knee. As you get comfortable, advance to a deeper squat and slowly begin to work towards building you strength by adding on weight.

Mini bodyweight squats

  • Stand behind a chair or table and place your hands onto the back rest.
  • Keeping your back straight, bend both knees into a semi-squatting position, allowing your hands to slide forwards.
  • Your hips should travel backwards as you counterbalance by leaning your chest forwards.
  • Push through your buttock and thigh muscles as you return to standing, and repeat.

Deep bodyweight squats

  1. Hold on to the dumbbell, keeping it close to your chest.
  2. Step your feet wide apart and turn the toes out slightly.
  3. Drop down into a deep squat position, keeping your feet on the floor.
  4. Control the movement back to the start position.

Caution: Avoid deep squats especially if you have ongoing grinding pain. Do not push in to pain, as this will only increase the forces and worsen your symptoms. At this point, it is highly recommended that you come in to see a physiotherapist to examine a potential underlying pathology.

Wrist pain: De Quervains tenosynovitis

De Quervains tenosynovitis is a painful condition caused by inflammation of two prominent tendons that are located at the wrist and thumb.

The two tendons called the Extensor pollicus brevis  and Abductor pollicus longus originate from the middle of the forearm travel down towards and over the wrist to insert into the thumb. Collectively they function to extend the thumb, whilst abductor pollicus longus extends and also abducts the thumb (lifting thumb up to the ceiling).

What causes it?

The most common cause of De Quervains tenosynovitis is the repetitive overuse of thumb and wrist whether it is occupational or hobby related. For example, the repetitive thumb movement whilst using scissors by hair dressers, landscapers using shears or whilst gardening). Trauma to the tendons from injuries to the wrist or the thumb can cause inflammation of the tendons.

In some cases, age related degeneration of the tendon sheath or underlying conditions such as rheumatoid arthritis increases the risk of the developing De Quervains tenosynovitis. Hormonal changes resulting in fluid build up in young mothers can commonly result in De Quervains tenosynovitis.

Symptoms

Commonly your symptoms may include:

  • Pain located at base of your thumb
  • Pain elicited by movement of thumb (gripping or making a fist)
  • Grating or snapping feeling
  • Tightness in the wrist
  • Swelling surrounding the base of thumb and wrist

How is De Quervains tenosynovitis diagnosed?

Your doctor or physiotherapist will be able to diagnose the condition based on your symptoms and after doing a thorough movement assessment to rule out any other potential diagnosis.

  • Finkelstein test is used to elicit symptoms to confirm De Quervains tenosynovitis.

How to test:

  1. Wrap your thumb with your fingers.
  2. Slowly bend your wrist down

A positive test would elicit pain at the site of the two tendons.

Radiological investigations in lights of ultrasound and an x-ray might be recommended for further investigations, particularly to confirm clinical diagnosis or to rule out any other possible causes of De Quervains such as osteoarthritis.

What treatment options are available?

Conservative (non-surgical) management

Conservative management measures are generally recommended as the first line of management for mild to moderate symptoms. This is because up to 60-70% of symptoms are likely to improve over a period of 6-8 weeks of regular physiotherapy intervention. In this period, the following strategies are recommended by your therapist to fast-track your recovery

  • Rest and application of heat or cold packs
  • Avoid repetitive use of thumb
  • Pain medications (anti-inflammatory medications) such as diclofenac or ibuprofen
  • Splints or braces
  • Steroid injection

Surgical management

In more severe cases when conservative management has failed, surgery may be recommended by an orthopaedic specialist or surgeon.

Prior to your surgery you will have the opportunity to thoroughly discuss with your surgeon the details of the surgical procedure and about the post operative rehabilitation process.

  • Surgical procedure

Surgery may be performed under general or local anaesthesia. A small incision is made at the wrist and thumb region. The covering of the tendons (sheath) is then separated and expanded to provide the tendon space to allow the tendon to move smoothly within the sheath. After this the, the incision in then sutured with a firm dressing applied over the suture site.

  • While you recover from the surgery, an information sheet with post operative guidelines will be provided to you by your surgical team. It is important that you must follow the guidelines recommended by your surgeon for optimal recovery.
  • In most cases your will have a follow up with your surgeon few weeks after your surgery to check your wound healing and your progress. You are often times referred to physiotherapy for strength and conditioning of your wrist and hand movements to facilitate your recovery.

Repetitive Strain Injury (RSI) Explained

 

RSI is typically defined as an overuse disorder- a gradual build-up of overload to nerves, tendons, and muscles arising from repetitive movements or activities. Repetitive use of the same motions leads to inflammation and damage to these soft tissues. This disorder mostly affects the upper limb- particularly the elbows, hands and wrists.

 

Causes

Possible causes of RSI include but are not limited to:

  • Undertaking the same and repetitive movements and stressing the same muscle groups
  • Working in cold environments
  • Assuming a sustained and/or awkward posture for prolonged periods of time
  • Undertaking a particular activity for prolonged periods of time with no rest-breaks
  • Frequent and prolonged use of vibrating equipment
  • Adopting poor postures from working at inappropriately designed workstations
  • Undertaking a motion which involves carrying and/or lifting heavy items

 

 

Symptoms

RSI leads to a gradual development of a broad variety of symptoms, which range from mild to severe in severity. RSI particularly affects the muscles and joints of your wrists, hands, elbows, forearms, shoulders, neck. Having said this, RSI can affect other areas of the body as well.

Common symptoms may include:

  • Pain
  • Tingling
  • Cramping
  • Increased sensitivity to heat and cold
  • Tenderness
  • Fatigue
  • Loss of strength
  • Throbbing
  • Soreness
  • Achiness
  • Stiffness
  • Struggling with typical activities of daily living, such as gripping and twisting motions, carrying light weights, writing, kitchen prepping, dressing, personal cares etc

You may develop these symptoms when you undertake a task repetitively for a period of time, and can settle when you stop. Symptoms may settle over a few hours or over the course of a few days. However, if left untreated or is poorly managed, a minor RSI may gradually progress to a nasty chronic injury.

 

Diagnosis

 

If you experience mild discomfort whilst completing particular activities at home or at your job, it is a good idea to see your GP or physiotherapist to talk about RSI. But an RSI is not always simple to diagnose as there is no particular clinical test for it. Your GP will enquire about your medical history, occupation and work environment, and other activities to attempt to identify any repetitive motions you undertake that may be the cause of your symptoms. A physical examination will be undertaken, where they will assess your movement, check for pain, inflammation, sensation, tenderness, strength and reflexes in the impacted body part. RSI may be triggered by specific health disorders like bursitis, carpal tunnel, tigger finger, ganglion cyst, or tendonitis (inflammation in your tendons). Your GP can refer you on further diagnostic tests such as X-rays, Ultrasounds, blood tests, MRIs, nerve conduction tests etc, to determine if these underlying disorders may be the cause of your symptoms. You may be also be referred onto a physiotherapist and acupuncturist for conservative treatment and management for mild-moderate issues. If symptoms persist, you will then be referred onto a specialist.

 

Management

Initial treatment options for the management of RSI symptoms is conservative. This includes:

  • Rest, Ice, Compression, and Elevation (RICE principles)
  • Taking regular breaks between tasks and looking after your posture
  • Undertaking your activities and movements with appropriate form and posture
  • Intake of Nonsteroidal anti-inflammatory drugs (NSAIDs), both oral and topical as prescribed by the GP
  • Use of cold and heat to the impacted area
  • Administration of steroid injections into inflamed joints and tendons
  • Tailored exercise prescription from physiotherapists to correct posture and strengthen and stretch affected muscles
  • Acupuncture
  • Stress reduction and relaxation training
  • Use of splints and braces to help protect and rest the affected muscles and tendons

Ergonomically appropriate adjustments to your workstation and work environment may be recommended by your physio and GP- for example resetting your desk and chair if you’re working at computer, and alterations to your equipment and activities/motions to lessen the strain and stress on your muscles and joints. Surgery may be necessary in some cases.

 

Prevention

Minimizing repetitive actions particularly if they involve the use of heavy machinery or vibration. Improving your working posture and work-environment as well a taking regular breaks. Employers often undertake risk-assessments when you join a company to determine that the work area is ergonomically fit, comfortable and appropriate for you. You may be able to request for an assessment if you have not had one or are having issues with your work environment

Managing your Medial Knee Pain: MCL injuries

What is it?

Although your knee has free movement going forwards and backwards, its’ sideward movements are restricted by the robust collateral ligaments on either sides of your knee. The medial collateral ligament (MCL) is situated on the inner part of your knee, but on the outside of your joint. The MCL connects the top of your shinbone (tibia) to the bottom of your femur (thighbone). It helps hold your bones together, provides stability and prevents your knee from bending sideways away from your body.

Injuries to the MCL are from the result of a direct blow to the outer part of your knee- and is most commonly seen in contact sports such as football and soccer. These injures may either over-stretch or cause a tear in the ligament. Whilst surgery may be needed in some severe cases, it is not always the go-to form of management.

Read on to know how physiotherapy can help manage your MCL related-knee pain.

 

 

Mechanism of Injury

Injury to the MCL typically occurs when a force drives the lower leg in a sideward direction away from your upper leg and body. Awkwardly landing from a height, twisting of your knee with your foot fixated to the ground, or from a direct blow to the outer part of your knee- most commonly seen in contact sports, are frequent causes of injury to the MCL.

 

 

Grading of MCL Injuries

MCL injuries are often graded using the system below:

Grade 1: Regarded as a minor injury- means that the MCL has been overstretched but not torn

Grade 2: Regarded as a moderate injury- means that there is a partial tear in MCL, and presents with some degree of instability in the knee

Grade 3: Regarded as a severe injury- means that the MCL has completely ruptured/torn, and presents with noticeable joint instability

 

Often 3 MCL injuries are associated with concurrent medial meniscus and ACL ligament damage, which may need surgical intervention. But, the good news is that most MCL injuries may be treated well with conservative physiotherapy management. It usually takes between 2-8 weeks for Grade 1 and 2 MCL injuries to heal, and a graduated rehabilitation programme is highly commended for prevention of future injury.

 

 

Signs and Symptoms

Because injury to the MCL may present with similar symptoms as with other knee injuries such as ACL damage, it is vital to have a medical professional such as your physiotherapist evaluate your injury.

Common symptoms of an MCL injury may include:

  • Tenderness and pain along in the inner part of your knee
  • Swelling in the knee
  • Experience catching and locking sensations in the knee joint
  • A ‘pop’ sound at the time of injury
  • Actual or feeling of giving way of the knee (often indicate grade 2 or 3 injury)

 

 

Diagnosis

Your physiotherapist will discuss your injury and its presenting symptoms, past medical history (including a history of any prior knee injuries) and will also undertake a thorough physical examination. During the physical examination, your physiotherapist will assess the structures of your injured knee and compare them to the non-injured side. The range of motion, strength and stability of your knee will be assessed. You may be referred on for imaging such as X-rays and Ultrasounds to help aid the diagnosis. For more severe MCL injuries, and if your symptoms do not resolve with conservative physiotherapy management, you may be referred onto a specialist who may consider referring you for an MRI to get a deeper look at your knee.

 

Management

The management options for MCL injuries will be dependent on the severity of the injury. In the initial stages of injury, management is focused on controlling swelling and pain, whilst allowing your body to initiate healing processes via inflammation. This is typically achieved through the P.O.L.I.C.E. principles (Protect, Optimal Loading, Ice, Compression and Elevation).

Over the counter medication such as ibuprofen and paracetamol may be taken to reduce pain. Other stronger painkillers and NSAIDs may be prescribed by your doctor to help reduce swelling and inflammation as well.

After assessing your knee, your physiotherapist will frame a rehabilitation programme with exercises tailored to your needs. The purpose of physiotherapy is to help restore your knee’s range of motion, stability and strength, which in turn will then allow you to safely return to your usual day-to-day and sporting activities as soon as possible.

Management of most MCL injuries usually only involves knee bracing and physiotherapy treatment. However, in some cases, surgery may be recommended. Particularly if there is damage to more than one ligament or structure in your knee or if you continue to experience instability in spite of physiotherapy.

EASY STRETCHES DESK STRETCHES

Sitting at a desk working, studying or surfing the net for long hours at a time makes it extremely difficult to maintain proper posture. That’s because our bodies are not designed for hours of idle sitting. So as the clock gets ticking many of us have the tendency lean forward, slouch our shoulders and hunch our backs.

Unfortunately, this increases pressure on multiple areas in your body. This explains why most of us experience pain and stiffness in our neck, shoulders, back and in some cases your tailbone!

So what do I need to do you ask?

The answer is simple, STAND, MOVE AND STRETCH!

It sure does sound easier said than done, especially if you are pressed with time to complete set work tasks. BUT the good news is that stretching or moving is a buildable habit that can be easily implement as you work. It doesn’t take long!

For starters set an alarm to take micro 2–3-minute break for every 20-30 minutes. Use this time to stand up, walk over to a colleague, go for a toilet break, drink water or make yourself tea or a coffee.

Or try out these simple easy stretches while you sit or stand at your desk

So let’s get started!

SPINAL TWIST:

  • Sit up tall, relax your shoulders
  • Cross one leg over the other, then place your opposite elbow on your top thigh.
  • Take a deep breath and as you exhale slowly twist your body (not your neck) and look over your shoulder.
  • Hold for 10 seconds.
  • Slowly return to resting position and repeat on the other side.

BACK ARCHES

  •  Sit tall, set your feet flat on the ground hip-width apart.
  • Rest your hands behind your hips, then slowly arch your back as you gently tilt your head back.
  • If you experience pain or discomfort in your neck or tingling in your arms – do this stretch without head tilt.
  • Hold for 10 seconds, return to start and repeat

ARM REACHES 

  • Sit up tall with your feet flat on the ground.
  • Interlace your fingers and stretch your arms straight as you turn your palms up to the ceiling.
  • Hold this position for 10 seconds and repeat

SHOULDER CIRCLES

  • Sit or stand up tall, feet hip width apart
  • Relax your arms and shoulder, begin by rolling your shoulder backward in a circular motion.
  • Do this 5 times, repeat forward circles

NECK CIRCLES

  • Sit or stand up tall, with feet planted flat on floor
  • Slowly begin to roll your head in a clockwise position
  • Do this 20 seconds, then repeat in a counterclockwise direction

CHEST STRETCH

 

  • Stand close to wall or a door frame
  • Place your forearm in a 90-degree angle at shoulder height.
  • Take one step forward on the leg closest to the wall and slowly rotate your chest away until you feel a stretch across your chest.
  • Do not hunch or round your shoulders.
  • Hold the stretch for 20 seconds, repeat
  • Do this both for both sides

BACK EXTENSIONS

  • Stand with your legs at hip width apart and straight.
  • Place your hands on your hips.
  • Lean your body backwards, trying to arch in the lower back as much as you can, lifting your chest up towards the ceiling.
  • Try to avoid allowing your hips to swing forwards too far.
  • Hold this position for 10 seconds, return to start position & repeat 5 times.

 FLOOR REACHES

  • Sit on a chair with upright posture
  • Slowly bend forward to plant your hands on the floor.
  • Hold for 10 seconds, return to start

SHOULDER BLADE SQUEEZE

  • Start in an upright position.
  • Practice bringing your shoulder blades back and down.
  • Picture gently drawing your shoulder blades towards the centre of your lower back.
  • This is a subtle movement, ensure you do not over strain your shoulder blades when performing this action.
  • Hold for 10 seconds, repeat 3-5 times

SHOULDER BLADE STRETCH

  • Clasp your hands together and hold them in front of your body.
  • Push your arms as far forward as you can whilst rounding your shoulder blades.
  • Gently drop your chin down to your chest.
  • Hold this position while you feel a stretch between your shoulder blades.

 WRIST STRETCHES

  • Stretch out your arm straight in front of you with your palm facing away
  • Use your opposite hand to gently pull your palm back
  • Hold for 5 seconds, repeat with your palm facing your body

Dealing with De Quervain’s

De Quervain’s tenosynovitis is categorised as an overuse disorder which affects the tendons in your wrist that you use to straighten your thumb. It is associated with swelling in the two tendons around the base of your thumb, which then causes the sheaths encompassing these tendons to become inflamed. This results in increased pressure on surrounding nerves as well, resulting in symptoms such as numbness, tenderness and pain. You are likely to have these symptoms when making a fist, gripping or grasping something, pinching, twisting your wrist, and/or laterally bending your thumb.

Symptoms

The key distinguishing symptom of De Quervain’s tenosynovitis is tenderness and/or pain at the base of your thumb. You can experience pain referring up or down your forearm. You may notice the pain gradually develop or appear suddenly, and worsen when using your wrist, thumb and hand. Painful movements include making a fist, gripping or grasping something, twisting your wrist, pinching, and/or laterally bending your thumb.

Other key symptoms include:

  • Swelling at the base of your thumb
  • Experience numbness along the back of your index finger and thumb
  • ‘Snapping’ or ‘catching’ sensation experienced when you move your thumb

Causes

De Quervain’s tenosynovitis is typically associated with the chronic overuse of your thumb, hand and wrist. When undertaking movements like gripping, grasping, clenching, pinching, or wringing items in your hand, the two tendons in your lower thumb and wrist usually glide in a smooth manner via the small tunnel which attaches them to the base of your thumb. However, when you repeat a certain movement day in day out, it irritates the sheath around these two tendons, resulting in swelling and thickening which restrict their movements.

Factors which may increase your risk of developing this condition are:

  • Being in the age bracket of 30 to 50 years old
  • Pregnancy
  • Found more commonly in women.
  • Baby care: Lifting, carrying and/or holding your child repetitively with using your thumbs as leverage.
  • Hobbies or occupations which involve repetitive wrist and hand movements

Diagnosis

Your doctor or physiotherapist will discuss your medical and occupational history, and carry out a physical assessment of your wrist and hand.

The physical examination will include palpation for pain when pressure is applied to the thumb side of the wrist, as well as clinical test called the Finkelstein test. This test requires you to bend your thumb across the palm of your hand and bend your fingers down over your thumb. You will then bend your wrist towards your little finger. If this causes pain on the thumb side of your wrist, you are likely to have this condition.

Whilst X-rays are usually not needed for the diagnosis, however, you may be referred on for ultrasound imaging.

Management

The aim of the management for this condition is to reduce pain caused by the irritation and inflammation of the tendons, preserve movement in the wrist and thumb, and prevent its reoccurrence. If treatment is commenced early, the symptoms should subside in 4-6 weeks. If your symptoms arise during pregnancy, they may settle around the end of the pregnancy or post the breast-feeding stage.

  • Splints may be utilised to immobilise and rest your wrist and thumb
  • Ice application to the affected area
  • Your doctor may recommend the use of anti-inflammatory medication to ease swelling and decrease pain
  • Avoiding pinching with your thumb when moving your wrist from side to side
  • Avoidance of aggravating repetitive movements and activities
  • Administration of corticosteroid injection into the tendon sheath can ease pain and decrease swelling if recommended by your GP
  • Physiotherapy: Your physiotherapist will examine how you use your wrist and provide suggestions on how to make technique modifications to relieve stress on your wrists. They will teach you strengthening exercises for your wrist, hand and arm to help decrease pain and limit tendon irritation
  • Surgery may be recommended by your specialist in more severe cases and if conservative management fails

Carpal Tunnel Syndrome – What is it?

Have you been experiencing pain, pins and needles or numbness in your wrist and hands, especially after using the keyboard, chopping up a few veges, reading a book, using your mobile phone or with driving?

If you answered yes – then you are most likely to have Carpal tunnel syndrome.

What is Carpal Tunnel Syndrome?

Carpal tunnel syndrome is the most common condition in the arm. It is caused by compression of one of the three major nerves in the forearm – the median nerve, which travels through the wrist into the hand and fingers. Entrapment of the median nerve usually due to inflammation, occurs in the wrist commonly resulting in tingling of the wrist and hand (in some cases forearm), numbness, pain and weakness of the hand.

Signs and Symptoms

Often unrelated to a specific incident or an injury, symptoms of carpal tunnel syndrome usually develop gradually overtime. Symptoms may be worse in the morning and night. Many people find that the frequency and duration of symptoms increase as the conditions worsen.

Signs and symptoms may include:

  • Tingling, numbness or burning sensation of the thumb, index, middle and ¾ of ring fingers of the hand
  • Electric shock like radiating pain through the hand into thumb, index, middle and ¾ of ring finger
  • Weakened grip, loss of dexterity and fine movements such as picking up a hair pin, buttoning clothes.
  • Hypersensitivity or in other cases lessened sensation of hand to pressure, heat or cold temperatures
  • Swollen wrist

Let’s take a closer look at the anatomy!

As its name suggests – a group of small bones aka carpal bones form a tunnel like passageway in the wrist (palmar view). This unique architectural design allows for the tendons of the forearm muscles and the all-important median nerve to pass through the narrow tunnel through the wrist and into the hand and fingers, supplying sensation and motor function.

Causes

Common causes and risk factors that increase the likelihood of carpal tunnel syndrome include:

  • Repetitive wrist & hands movements – during work related tasks or leisure activities may irritate the tendons in the wrist, resulting in inflammation that irritates the nerve.
  • Wrist or hand injury – recurring sprains, swelling and reduced wrist movements reduces the space in the carpal tunnel
  • Pregnancy and menopause – hormonal changes can increase fluid retention in body increasing pressure in the carpal tunnel compressing the median nerve
  • Genetic history – petite
  • Medical conditions (rheumatoid arthritis, diabetes, hyperthyroidism)

Interesting facts about carpal tunnel syndrome

  • Women are 3 times more susceptible to develop carpal tunnel syndrome than men. This can be due to hormonal changes during pregnancy or menopause and also because women tend to have smaller carpal tunnels.
  • Not all fingers are affected. Median nerve supplies movement and sensation in the thumb, all fingers except the little finger.
  • Computers/keyboard are not the only reasons to blame – repetitive nature of any work related or leisure word increases risk of developing carpal tunnel syndrome

Diagnosis

Carpal tunnel syndrome is fairly easily diagnosed by your physiotherapy, doctor or a hand therapist.

Your health practitioner will gather information on your general health, history and nature of your symptoms. They will then carefully conduct a thorough clinical assessment to assess the movements of your hand and wrist, strength and use a collection of tests in effort diagnose your symptoms. In some cases, your therapist may examine your neck, shoulders and arms to rule out other potential causes.

You may often hear the physiotherapist or hand therapist mention that they want to conduct a functional assessment – A functional assessment is activity specific, where the therapist will watch you perform the activity that aggravates your symptoms the fastest. For example, if using a keyboard is generally when you feel your symptoms start – the therapist may observe you performing the very task to examine your overall posture.

Referral to scans or nerve conduction tests may be arranged by your doctor or therapist depending on the severity or complexity of your symptoms.

Scans

Referral to scans or nerve conduction tests may be arranged by your doctor or therapist depending on the severity or complexity of your symptoms.

  • Xray – provides key information on bone health, when dealing with a potential injury, or arthritis
  • Ultrasound – can examine potential soft tissue injury or inflammation compressing the median nerve
  • MRI – this advanced imaging provides in depth review of your wrist and hand. Usually arranged by your doctor or a specialist
  • Nerve conduction study – studies the electrical activity of the median nerve. This test will help you doctor examine the severity of your problem.

Treatment

In most cases, carpal tunnel syndrome will progressively worsen overtime. So, the key is early intervention!

Conservative management

Mild symptoms can be easily managed with a conservative approach.

  • Wearing splints or braces – keeps your wrist straight to prevent repetitive use of hands, thus reducing pressure or inflammation in the carpal tunnel.
  • Non-steroidal anti-inflammatory medications – such as celecoxib and ibuprofen as prescribed by your doctor may decompress the median nerve by reducing the inflammation in your body and wrist.
  • Activity modification: your physiotherapist will play an important role in providing you with advice around to modifying your activities to reduce your symptoms. They will also prescribe you with effective stretches and exercises to help manage your symptoms while safely aiding your recovery.
  • Steroid injections: your physiotherapist or doctor may recommend a ‘cortisone’, also known as a ‘corticosteroid’ injection to control your symptoms. It contains an anti-inflammatory substance that is injected into your carpal tunnel. The effects of the steroid injection may be temporary and can vary person to person depending on many factors (cause of symptoms, stage of your condition).

In mild to moderate cases, the effects of injection may last between 3-6months.

Surgical intervention

If non-surgical approaches have failed to relieve your symptoms, surgery may be required.

By this stage you would have consulted an orthopaedic surgeon. Your surgeon will thoroughly examine your overall health, symptoms, results from the scans and the nerve conduction study to help you decide on the best treatment approach.

If you decide to undergo surgery – the surgical procedure your surgeon will perform is called ‘carpal tunnel release’.

Recovery and outcomes

  • After your surgery you may be given a splint or a brace for a period of time specified by your surgeon. While in the splint or brace you will be encouraged to move your fingers to prevent stiffness and swelling.
  • Expect to experience minor pain, stiffness and swelling for a couple of weeks to months after your surgery. Pain medications provided by your surgeon must be taken as prescribed.
  • You may be encouraged to see your physiotherapist, who will work closely with your surgeon to help meet post-operative outcomes.
  • You will have regular 6-8 weekly follow ups with your surgeon as required to assess your healing and discuss gradual return to light activities and return to work.
  • If you have underlying medical conditions such as arthritis, except that your recovery may be slower than otherwise expected. It is important that you follow post-operative protocols your surgeon, doctor and physiotherapist recommend.

Tennis Elbow Explained

What is Tennis Elbow?

Tennis elbow, or also known as lateral epicondylitis, is a painful disorder of the elbow triggered by overuse. This disorder is characterised by inflammation or, in some cases, micro-tearing of the extensor tendons which link the forearm muscles on the outer part of the elbow. This leads to pain and tenderness on the outside of the elbow, spreading through to the forearm and wrist.

Elbow Pain - Do I have Tennis Elbow? - Oh My Arthritis

Causes

Tennis elbow is characterized as an overuse and muscle strain injury. It is caused by repetitive and/or vigorous contractions of the forearm muscles which is used to straighten, extend, and lift the wrist and hand. The repetitive motions and stress to the tissues can result in a string of tiny, microscopic tears in the tendons which attach your forearm muscles to the bony prominence on the outside of the elbow.

Tennis elbow may result from number of activities including but not limited to:

  • Typing and repetitive computer mouse use
  • Cutting/chopping motions
  • Manual work that involves repetitive turning or lifting of the wrist, such as plumbing, or bricklaying.
  • Gardening
  • Using hand tools such as scissors, clippers, screwdrivers, plumbing and carpentry tools
  • Playing racquet sports, such as tennis, badminton, or squash
  • Throwing sports, such as the javelin or discus
  • Painting
  • Sewing/knitting

Tennis elbow may also occur after a sudden knock or bang to the elbow, if you undertake activities that you are not used to excessively and aggressively, and sometimes there is no apparent cause for it.

Risk Factors

Factors which may increase your risk of tennis elbow include:

Your age: Whilst this disorder impacts people of all ages, it is mostly prevalent in adults in the age group of 30-50 years old.

Your occupation: Those who have jobs which entail repetitive movements of the wrist and arm are more likely to develop this disorder. Examples include but are not limited to painters, computer users, plumbers, butchers, carpenters, and chefs.

Sports: Partaking in racket sports increases the risk of tennis elbow, particularly if you use poor form and technique.

Common Signs and Symptoms

Tennis Elbow - Symptoms, Causes, Treatment & Exercises

Pain noted around the bony knob on the outside of your elbow is the most common characterising symptom of tennis elbow. This knob is where the injured tendons connect to the bone. The pain is often depicted as “burning” in nature. Your elbow may be tender and sore to touch, and the pain can refer down to the forearm. The pain often increases with gripping, grasping, or rotating motions of the wrist and forearm. Bending and straightening your elbow may also be painful.

The severity of your pain may vary from a mild discomfort to severe pain that can interfere with your sleep and day to day activities. The pain typically starts gradually and then worsens over weeks or months.

Diagnosis

During your physical examination your physiotherapist will attempt to produce your pain in your elbow via specific tests and movements. They will assess your range of motion in your elbow, wrist, and shoulder joints. Referrals for X-rays and ultrasound scanning may be indicated to further support your diagnosis and to rule out other potential sources of your pain

Management

A mix of non-surgical treatment options are effective for the majority of tennis elbow cases, and self-resolves over time. You should rest your elbow and painful activities should be avoided. But it is very vital to maintain gentle movements of the forearm, elbow, and wrist through its range of motion.

Potential treatment options include:

  • Ice
  • Rest
  • Physiotherapy and acupuncture
  • Anti-inflammatory medications as recommended by your doctor or pharmacist
  • The use of a wrist and forearm brace or splint to support and rest your forearm

As your initial elbow pain lessens, your muscles around the elbow, forearm and wrist should be safely strengthened and stretched under guidance of a physiotherapist. Your physiotherapist will advise you on particular exercises, give you appropriate symptom management advice and take you through a personalised graduated rehabilitation program. If you continue to experience pain after 6-8 weeks of treatment, your physiotherapist can refer you back to your doctors, to consider administration of a cortisone injection into the elbow to help reduce pain and inflammation, and further referral onto see a specialist to seek guidance on other treatment options.

Helpful Exercises

Rotator cuff injury

Rotator cuff injuries are the most common source of shoulder problems. They can range from minor sprains causing impingement type symptoms, to massive tears resulting in severe loss of function and pain. They commonly occur as a result of acute injuries (sports, falls), chronic overuse (repetitive loading) or due to gradual aging.

Anatomy of shoulder

The shoulder joint (glenohumeral joint) is the most mobile joint in the human body. It comprises of the humeral head (top portion of upper arm bone) which fits in the glenoid cavity of the scapula (shoulder blade) to create a ball and socket configuration. This anatomical configuration results in limited bony contact between the humeral head and the glenoid fossa, which reduces the stability of the joint.

Several passive and active structures stabilize and maintain proper biomechanics of the shoulder joint.

  • Passive stabilizers include the ligaments, joint capsule, cartilage and the bony concavity of glenoid fossa. Thick cartilage known as labrum lines the glenoid fossa to further deepen the groove by about 50% which is advantageous in stabilizing the shoulder joint during the articulation.

  • Dynamic stabilizers of the glenohumeral joint is gained from the coordination of rotator cuff muscles that compress the passive structures providing stability and mobility as whole.

The rotator cuff muscles include:

  • supraspinatus

  • infraspinatus

  • subscapularis

  • teres minor

Rotator Cuff Disorders: The Facts | OrthoBethesda

 

 

Injury to any or all these four muscles, including the tendons that attach the muscles to bone can result movement dysfunction and severe pain.

Other important joints of the shoulder complex include:

  • sternoclavicular joint

  • arcomioclavicular joint

  • scapulothoracic joints

Types of rotator cuff pathology

Tendinitis and Tendinosis

More often than not the term tendinitis and tendinosis are interchangeably used to describe a similar tendon pathology. However, the factor that differentiates the two is the time of injury (acute or chronic).

Tendinitis results from acute injury to the tendon which sets off an inflammatory process characterized by pain, swelling, and redness. On the other hand, tendinosis is a chronic pathology that does not involve an inflammatory process. It is characterized by degeneration of collagen fibers in response to persistent micro-trauma, vascular compromise and aging.

Acute rotator cuff tear

  • Acute tears result from sudden forceful lifting of the arm against resistance or in an attempt to cushion a fall (for example, heavy lifting or a fall on the shoulder).

Chronic injuries

  • Most commonly resulting from occupational or sports requiring excessive repetitive overhead activity.

Signs and symptoms

Symptoms of a rotator cuff injury are due to the inflammation that accompanies the strain. Swelling that forms within the small space of the joint prevents the normal mechanics of the shoulder, resulting in the clinical picture of pain and decreased range of motion.

  • Acute rotator cuff tears
    Tearing sensation
    Immediate severe localised pain
    Reduced strength
    Symptomatic clicking
    Reduced and worsening pain with movements
    Affects daily activities (personal care, lifting, reaching etc)

  • Chronic rotator cuff tears
    Generalized deep dull ache, sharp onset of pain with movements
    Global shoulder weakness
    Reduced movements and daily activities (especially moving to the side, reaching behind back)

When to seek medical treatment

See your doctor or a physiotherapist if you experience any of the following symptoms in the shoulder:

  • Pain, especially pain that does not improve with rest

  • Swelling, redness or tenderness around the joint

  • Shoulder weakness

  • Reduced shoulder movement

For more severe rotator cuff injuries, you may require immediate medical attention.

Seek immediate medical attention if you experience the following symptoms:

  • Sudden, severe pain

  • Visible joint deformity

  • Inability to move or use your shoulder joint

  • Sudden swelling, discoloration

Diagnosis

To diagnoses an injured rotator cuff, your physiotherapist will begin with a thorough subjective and physical examination of your shoulder.

  • Subjective assessment

Your physiotherapist will begin with a thorough subjective assessment inquiring about your signs and symptoms of an acute injury as well as any symptoms that may suggest a more long-term problem.

  • Physical assessment

The physical examination often involves observation to look for muscle wasting, deformities, and/or changes in appearance of the injured shoulder to the unaffected side. Your physiotherapist will also palpate different areas of the shoulder complex to find the area of pain or tenderness. Further examination will involve assessment of movement and strength to establish injury to muscles or tendons.

  • Radiology

In addition, your physiotherapist may refer you for imaging tests to diagnosis the cause of your symptoms:

  • Ultrasound: examines soft-tissue structures (muscles, tendons, bursa)

  • X-rays: examines bone health, calcification

  • MRI: provides detailed imaging of areas injured (referred by doctors, specialists or surgeons)

Treatment

Early diagnosis and treatment of a rotator cuff tear may prevent symptoms such as loss of strength and loss of motion from setting in.

Initial treatment of rotator cuff tendinitis involves managing pain and swelling to promote healing. This can be done by:

  • avoiding activities that cause pain

  • applying cold packs to your shoulder three to four times per day

  • taking anti-inflammatory medications like ibuprofen and naproxen

Rehabilitation plays a critical role in both the nonsurgical and surgical treatment of a rotator cuff tear.

When a tear occurs, there is frequently atrophy of the muscles around the arm and loss of motion of the shoulder. An individualized physiotherapy program is necessary to regain strength and improve function in the shoulder.

Physical therapy

Physiotherapy will initially consist of passive exercises to help restore range of motion and ease pain.

Once the pain is under control, your physiotherapist will prescribe exercises to help regain strength in your arm and shoulder.

Steroid injection

If you have persisting symptoms, your physiotherapist may recommend a steroid injection. This is injected into the tendon to reduce inflammation, which reduces pain.

Surgery

Surgery is recommended if you have persistent pain or weakness in your shoulder that does not improve with nonsurgical treatment. In which case, your physiotherapist will refer you to surgeon for an opinion of surgical intervention.

Exercises

Range of movement exercise

Pendulums

  1. Lean forward with one arm hanging freely. Use your unaffected arm to brace against a chair for support.

  2. With your affected side, gently swing the hanging arm from side to side, forward and back, and in a circular motion for 15-20 seconds each direction.

  3. Slowly return to a standing position.

  4. Repeat 4-5 times a day

 

Shoulder pulley (Flexion)

  1. Put a chair against the door and sit so you are facing away from the door.

  2. Grasp the door pulley handles with both hands.

  3. Pull down on the pulley with your unaffected arm. This will lift your injured arm up over your head. Pull it as high as you can.

  4. DO NOT FORCE THE MOVEMENT. Your affected arm should be relaxed. The unaffected arm does the work.

Hold for 5 seconds. Relax and repeat 10-15 times, 3 sets.
Three times a day.

Shoulder pulley (Abduction)

  1. Put a chair against the door and sit so you are facing away from the door.

  2. Using door pulleys slowly pull down with your unaffected arm so that your affected arm raises up and to the side without effort.

  3. Your affected arm should be relaxed. The unaffected arm does the work.

Hold for 5 seconds. Relax and repeat 10-15 times, 3 sets.
Three times a day.

Wand flexion

  1. Stand upright and hold a stick in both hands

  2. Cup the top end of stick with affected hand

  3. Using your unaffected arm hold the stick midway and drive the affected arm forward and up.

  4. Ensure your elbow is straight throughout

  5. Hold for 5 seconds and return to the starting position.

  6. Repeat 10 times.

Wand Abduction

  1. Stand upright and hold a stick in both hands

  2. Cup the top end of stick with affected hand

  3. Using your unaffected arm hold the stick midway and drive the affected to the side as high as able.

  4. Ensure your elbow is straight throughout.

  5. Hold for 5 seconds and return to the starting position.

  6. Repeat 10 times.

Strengthening exercises with band

Flexion

  1. Stand on one end of the band while holding the other end with your affected side.

  2. Whilst keeping your elbow straight, lift the band up to 90 degrees to shoulder level.

  3. Hold at the top for 1-2 seconds then lower slowly to starting position.

  4. Repeat 10-15 repetitions, rest 20-25 seconds, complete 3 sets.

Abduction

  1. Stand on the band while holding the band with affected hand.

  2. Keep your elbow straight, lift the band up to 90 degrees to shoulder level.

  3. Hold at the top for 1-2 seconds then lower slowly to starting position.

  4. Repeat 10-15 repetitions, rest 20-25 seconds, complete 3 sets.

External Rotation

  1. Attach the resistance band to a secure anchor at belly button height.

  2. Stand with unaffected arm perpendicular to the anchor.

  3. Place a towel between your elbow and your torso to stabilize your elbow

  4. Grab the band using your affected side and then slow pull the band away from your body by squeezing your shoulder blade in towards the middle of your back.

  5. Slowly return to starting position.

  6. Repeat 10-15 repetitions, rest 20-25 seconds, complete 3 sets.

Internal Rotation

  1. Attach the resistance band to a secure anchor at belly button height.

  2. Stand with affected arm perpendicular to the anchor.

  3. Place a towel between your elbow and your torso to stabilize your elbow

  4. Grab the band using your affected side and then slow pull in to your body

  5. Slowly return to starting position.

  6. Repeat 10-15 repetitions, rest 20-25 seconds, complete 3 sets.