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Your first step to recovery

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.

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.

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.

Ankle injuries – Your first step to recovery

Common? Oh Yes!

The ankle is the most commonly injured joint in sport. This does not exclude other people such as active hikers, beach goers and even your average Sunday stroller. Good news though – your ankle injury is highly likely to be uncomplicated.

It is still vital that your ankle is examined, evaluated and treated early. This will ensure a swift return to activity and prevent further complications.

 

The road to recovery

Planning for Resiliency and the Road to Recovery

Your clinician will ask you some questions related to how you injured your ankle, pain, instability and any past episodes of injury. The earlier you get your ankle checked, the sooner your recovery will begin.

Keeping a mental note of things like initial pain, swelling, ability to walk and balance will go a long way in assisting your clinician to making an accurate diagnosis.

 

Investigations

Ankle x-rays

In most cases, initial X – rays are done to rule out broken bones.

Ultrasounds can be used to diagnose some ligament and tendon damage.

MRI is the best form of imaging but this does come at a higher cost and higher exposure to radiation. These are usually done after failed conservative treatment or in instances where pain remains high for longer periods.

A CT scan is helpful with complicated foot and ankle fractures. It will normally be ordered by a specialist surgeon who is planning for an operation.

 

What to look out for

Ankle sprains:

This is normally a twisting injury that causes a stretch or tear of ligaments surrounding the ankle. Your health care professional will provide you with all the information and tools you need for recovery.

These heal relatively quickly when the outside border of the foot is affected and a little slower when the inside border of the ankle is affected.

You will normally feel pain on certain ankle movements, stiffness in the ankle and experience some swelling and bruising.

Ankle - Wikipedia

 

Ankle Fractures:

These normally present with swelling, bruising and pain initially – although not always. In some cases, it is too painful to put weight on the ankle.

They are usually best confirmed with X – ray and specialist referral.

Management may be surgical or non-surgical depending on the severity and site of the fracture.

Fractures generally take longer to recover compared to sprains.

 

What treatment to expect

Foot and Ankle Doctor | EmergeOrtho—Triangle Region

Acute phase:

Your healthcare professional will normally initiate techniques to minimise your pain and swelling with rest, ice, compression and elevation.

Analgesia and anti – inflammatory medication may also be used.

Strapping may be used for stability at this stage and can be done by your physiotherapist.

You will also be encouraged to increase movement and begin strengthening.

 

Rehabilitation phase:

Balance and proprioceptive exercises will be given to you by your physiotherapist.

Strengthening will continue and running will start soon.

Once running in a linear motion pain free, you will progress to sport specific exercises.

Finally, you will return to sport or previous function such as trekking with a graded program.

Strapping may continue for up to 12 months after your injury in order to prevent re–injury.

 

What can you do on the day of the injury?

Rest by reducing time spent walking or standing. This will help the ankle to heal.

Ice the ankle for up to 20 minutes every couple of hours.

Compress the ankle with a firm bandage during the day and remove the bandage at night.

Elevate the leg.

Attempt circulatory exercises such as ankle circles and foot pumps (About 10 – 30 repetitions every couple of hours).

Contact your health professional or physiotherapist in order to make appointment for assessment.

If you are unable to stand on your leg or have excruciating pain in the ankle, head on to the local emergency department for immediate investigation.

 

Remember, your injury will heal and you will recover!

 

To find your nearest Physio Fusion clinic and book an appointment call 09 6266186 or visit our website https://physiofusion.co.nz