In the foot, pronation should occur naturally when we are fully weightbearing on the front leg. Pronation will appear as the foot rolling inward and the arch flattening.
What are the benefits?
Dissipates the force that the foot receives from the ground.
Allows the foot to become a stable and mobile adaptor to enhance movement opportunity throughout the body.
Loads the muscles of the extensor chain (calf, quads, glutes) to convert ground reaction forces into forward momentum so we can move efficiently and without compensation.
So why have I been told this is bad?
So as you are now aware, pronation is very normal and a critical movement to ensure we move and propel ourselves forward efficiently.
What you may have heard someone say to you is that you ‘overpronate’?
Firstly, overpronation is subjective and not as black and white as it is sometimes made out to be. Overpronation has been defined as: ‘a foot that rolls inward towards the medial (inner) arch excessively’.
What we must understand is that a pronation can only happen when the foot has a stable tripod on the ground. This means that the calcaneus (heel bone), 1st metatarsal (big toe knuckle) and 5th metatarsal (little toe knuckle) must all remain in contact with the ground when the foot rolls inwards and the arch flattens.
So, If you have been told you are ‘overpronated’ , it is most likely that your whole foot is ‘everting’ NOT ‘overpronating’.
What is Eversion?
Eversion can be defined as: ‘the process of turning inside-out’.
In pronation your heel must naturally ‘evert’ (sole of the heel will move away from the midline of the body) NOT your whole foot.
If your ‘whole foot’ everts (turns out) you will no longer have a stable foot tripod as the 5th metatarsal (little toe) will lose contact with the ground.
The key to ensuring this does not happen is to provide an environment for the bones of the midfoot (middle of the foot) and forefoot (toes) to experience the opposite motion to that of the heel. This will mean that the foot has an opportunity to truly pronate with a three points of contact on the ground.
So how can you help me do that?
At Physio fusion we can help guide you to bring your own body into alignment and create an environment in which the healing can begin.
Foot strengthening exercises.
Footwear advice.
Referral to other healthcare specialists for further assistance (e.g. podiatrists).
Plantar fasciitis is a very common cause of heel pain. It is associated with inflammation of the thick web-like ligament (plantar fascia) which runs across the base of your heel to the front of your foot. The plantar fascia provides support to the arch of your foot and is a shock-absorber, helping you walk. Hence it is obvious that this ligament experiences a considerable amount of wear and tear in your day to life.
Symptoms
Plantar fasciitis is associated with inflammation of plantar fascia triggered by the development of small tears in the plantar fascia which leads to heel pain and other symptoms. This condition mostly develops gradually and worsens over time. You may notice some swelling, redness, and warmth in the affected region. You may experience more pain in the centre of your heel, which may radiate along the sole of your foot. The pain may be achy, sharp, dull, stabbing. It is mostly experienced when initiating movement first thing in the morning or after a period of inactivity, and may ease after a period of mobility. You may have no resting as the plantar fascia is offloaded and relaxed. It generally impacts just one foot, but it may impact both feet.
Causes
The plantar fascia is a thick web-like ligament which supports the arch of your foot and absorbs shock when you walk. Excessive stress and tension on the plantar fascia may cause smalls tears. Repeated stretching and tearing may inflame and irritate the fascia, though the cause remains unclear in many cases of plantar fasciitis.
Key factors which may increase your risk of developing this condition include:
Foot mechanics: Having flat feet or very high arches or adopting abnormal gait patterns may have an impact of the way your weight is dispersed when you are standing/running/walking and lead to excessive stress on the plantar fascia
Obesity: Extra weight increases the tension on the plantar fascia
Exercises: Certain exercises such as long-distance running/walking and dancing may put more stress on your heel and plantar fascia
Age and Gender: Plantar fasciitis is more often noted in women than men, and is most common in the 40-to-60-year age group.
Occupation: which require prolonged periods of walking and standing especially on hard surfaces
Sudden and rapid change in activity levels
Footwear: Wearing high heels and/or poor fitting shoes that do not provide sufficient arch support cushioning
Muscle tightness: particularly of your lower limbs
Diagnosis
The diagnosis of this condition may be determined by your medical and occupational history, the nature, length and severity of your signs and symptoms, and the existence of localized tenderness in your heel. You may be referred on for imaging such as X-rays, ultrasounds or MRIs to aid the diagnosis and to possibly rule out other causes for your symptoms (fractures, arthritis, heel spurs etc).
Management
Initial management of this condition is focused on the reduction of pain and inflammation:
Resting is vital
Ice application
Taking anti-inflammatory medications
Wearing appropriate and supportive footwear with arch supports and shock absorbing orthotics
Getting your foot and ankle taped for sufficient support and alignment
Physiotherapy (involving a graduated rehabilitation program of stretching/strengthening exercises)
If you still do not notice any improvement in your symptoms, your doctor may recommend corticosteroid therapy. Corticosteroid medication is injected into the impacted region with the purpose of treating the inflammation directly hence, relieving your pain. Using a splint at night to avoid the Achilles tendon and plantar fascia from tightening while you sleep may also be recommended at this time. A surgical intervention is seldom recommended and is only usually opted for where the pain is severe and all other treatment has failed. Please discuss your management options with your doctors.
Prevention
Here are some helpful tips to prevent the development of plantar fasciitis and decrease the risk of reaggravating your symptoms:
Ensure you make warm ups and cool downs as part of your exercise regimes
Undertake exercises to strengthen your lower limb muscles
Regularly stretch your Achilles, calf and intrinsic foot muscles to increase their flexibility
Gradually increase your activity and exercise levels
Maintain a healthy body-weight
Wear appropriate and supportive footwear (use orthotics for support if needed)
Take regular rest breaks if standing and or walking for prolonged periods of time at work
Medial elbow pain is also known as medial epicondylitis or golfer’s elbow. It is typically associated with pain on the inside (medial side) of your elbow and can spread into your forearm and wrist. This pain is the result of overloading and damage to the tendons that flex your wrist towards your palm.
Causes
This condition is triggered by damage to tendons and muscles which control your fingers and wrist. This damage is associated with excessive or repeated stresses- particularly repetitive and forceful finger and wrist movements, incorrect lifting, hitting and throwing techniques, lack of warmups and/or poor muscle conditioning.
Key risk factors for developing medial elbow pain may include smoking, obesity, being of in age bracket of 40 years old and over and undertaking repetitive activity with your arms for at least two hours daily. High risk occupations may include chefs, office desk workers, plumbers, construction workers, painters, butchers and assembly line workers. Those who partake in sports such as golf, racket sports, rowing, weight lifting and baseball are also at a higher risk.
Symptoms
Symptoms may be triggered suddenly due to a traumatic incident or may gradually develop over time and include but are not limited to:
Tenderness and pain is typically felt on the inner side of your elbow (particularly on the bony knob), and may refer along the inner side of your forearm and down to your wrist and fingers. It often worsens with certain movements. For example, bending your wrist towards your palm against resistance, or when squeezing a rubber ball.
You may feel stiffness in your elbow, and making a fist may hurt
You may experience weakness in your forearm, wrist and hand
You may experience tingling and numbness that can radiate into one or more fingers — typically to your ring and little fingers.
Diagnosis
This condition is typically diagnosed based on your medical and occupation history and a physical exam by your doctor or physiotherapist. To evaluate stiffness, strength and pain, your clinician may apply pressure to the impacted region and get you to move your elbow, wrist and fingers in various ways. You may also be referred on for imaging such as X-rays and Ultrasounds to aid diagnosis.
Management
A mix of non-surgical treatment options are effective for the majority of medial elbow pain 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.
Prevention
Having a good comprehension of risk of injury and being conscious of your everyday activities may aid in the prevention of medial elbow pain. You should:
Adopt appropriate technique and form when undertaking repetitive activities or sporting motions
Keep up with adequate wrist, forearm, and shoulder muscle strength
Undertake gentle wrist and forearm stretches pre and post activities
Adopt appropriate posture and body mechanics when lifting heavy objects to reduce joint strain- especially if doing so repetitively
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
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
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.
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
Hold on to the dumbbell, keeping it close to your chest.
Step your feet wide apart and turn the toes out slightly.
Drop down into a deep squat position, keeping your feet on the floor.
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.
Osteoporosis is a condition which results in weak and brittle bones- to such degree that a fall or even mild stresses like coughing or bending over may result in a fracture. Bones are living tissues which are continually being broken down and replaced. However, your bones become osteoporotic when the formation of new bone does not keep up with the loss of old bone. This condition typically develops over time without any pain or other major symptoms, and is generally not diagnosed until you have sustained a fracture. The hip, pelvis, upper arm, spine and wrists are the most common structures affected by osteoporosis- related fractures.
How do you know if you have Osteoporosis?
Because there are no obvious early warning signs and symptoms, it is difficult to pre-diagnose osteoporosis. You may be unaware that you have this condition perhaps till you have one of the following:
Sustained a fracture from an incident more easily than you should have- like a simple fall or a bump
A decrease in the height of your spinal vertebrae over time
Change in posture – stooping or bending forwards
Back pain, due to a fractured or collapsed vertebra
Please see your doctor if you experience the following:
If you are over the age of 50 and have sustained a fracture
Sustained a spine, wrist, or hip for the first time
Sustained a fracture more easily than you should have (a simple fall or after a slight bump)
Risk factors
Key factors which may increase your risk of developing osteoporosis include:
Females- particularly post-menopausal Caucasian and Asian women
Over the age of 50
Excessive consumption of caffeine or alcohol
Smoking
Having a smaller or petite body frame
Poor physical activity levels and leading a very sedentary lifestyle
Family history of osteoporosis
Having low levels of vitamin D and poor dietary calcium intake
Decreasing levels of testosterone with ageing in men
Estrogen deficiency in women (irregular periods, early (before turning 40) or post-menopausal, surgical removal of the ovaries)
Use of long-term medication such as thyroid and epilepsy medications, corticosteroids
Having medical conditions such as gastrointestinal diseases; endocrine diseases; rheumatoid arthritis; cancer; and blood disorders
How will you be diagnosed?
Your doctor will review your signs and symptoms, family and medical history. You may be referred on for a specialized X-ray or CT scan to evaluate the bone density to help diagnose osteoporosis. Your bone density will be classified by comparing it to the typical bone density for a person of equivalent gender, size, and age.
How is Osteoporosis treated?
The treatment pathway chosen for the management of this condition is dependent on results of your bone density scan, gender, age, medical history and severity of the condition. Potential treatments for osteoporosis may include exercise, making positive lifestyle changes, vitamin and mineral supplements, and medications. Please consult your doctor for appropriate advice and treatment options.
How can Physiotherapy help?
Your physiotherapist will help you strengthen your bones and your muscles through a personalized and graduated rehabilitation program. Components of this rehabilitation program may include weightbearing aerobic exercises, resistance training using free weights/resistance bands/bodyweight resistance, and exercises to enhance posture, balance and body strength. Your physiotherapist will work with you to find activities that suit your needs and as per your physical activity level.
Piriformis syndrome refers to the dysfunction of the piriformis muscle which irritates the sciatic nerve. It is characterized by deep buttock region pain that radiates down leg and foot often accompanied by pins and needles and numbness traveling along the path of the sciatic nerve.
The simplistic reason for this widely distributed pain comes down to the piriformis muscle itself – Their close proximity means that direct trauma to the buttock region or the supporting structures can result in inflammation and muscle dysfunction which can compress and irritate the sciatic resulting in referred symptoms.
Piriformis syndrome symptoms may include:
Localised deep buttock region pain
Pain with continuous sitting or standing for 15 mins or over
Pins and needles along the leg down to the outer foot
Numbness in outer leg or foot (often resolves on movements)
Deep squatting or bending
Pain on direct palpation
Anatomy
The piriformis muscle originates from the outer surface of a large fused bone of our pelvis called the sacrum. It travels adjacently and inserts into the top of the hip joint. The piriformis muscle is a very active muscle involved in stabilizing the hip and pelvis during majority of our activities (walking, running, standing, sitting or standing, turning in bed). When the piriformis muscle contracts it helps the hip rotate outwards (external rotation) and lift thigh out and up (abduct).
The sciatic nerve originates from where the very base of the spine and the sacrum join known as the lumbosacral region (lower back and saddle region). In this region five separate branches of nerves travel outside of the bony openings of the spine called the nerve roots and connect into a single large nerve – the sciatic nerve. It then travels through the pelvis deep into the buttock region close proximity the piriformis and gluteal muscles. In some individuals the piriformis muscles can travel through the piriformis muscle subjecting them to piriformis syndrome.
Diagnosis
There are no specific tests to diagnose piriformis syndrome. Diagnosis of piriformis syndrome is made by the report of symptoms and by physical exam using a variety of movements to elicit pain to the piriformis muscle. In some cases, a contracted or tender piriformis muscle can be found on physical exam.
In cases where there is underlying pathology (such as disc injury, arthritis, sacroiliac dysfunction or hip injury) resulting in true sciatica – piriformis syndrome may develop to become an additional muscular dysfunction that is required to be addressed. Because symptoms can be similar in other conditions, radiologic tests such as MRIs may be required to rule out other causes of sciatic nerve compression, such as a herniated disc.
Consultation with a physiotherapist in this case is highly recommended as they will perform a comprehensive clinical examination to identify the root cause of your symptoms.
Exercises for piriformis syndrome
Corrective exercises with a combination of strength and flexibility regimen is an essential way to treat true piriformis syndrome (without involvement of other underlying pathologies).
The exercises outlined below follow a phase-by-phase progressive regimen to strength key muscles of the hip, buttock and legs.
As you work through these exercises expect to feel some pain during and after your exercise. Pain you may feel during the exercise is an expected sign of muscle activity. Pain you may feel after the exercises is an expected sign of muscle healing and recovery. However, if you are unable to participate in the exercises due to symptom deterioration – it is highly recommended you consult your physiotherapist to rule out other potential causes.
Otherwise, to help you gauge the correct amount of pain you should expect during exercise – use this scale. The ideal range should be 2 to 5. If your baseline pain is over 6 or 7 – it is recommended that you consult your doctor for pain relief appropriate to manage your pain, followed by a consult with a physiotherapist. Your physiotherapist will be able to modify the following exercises or prescribe alternative exercises best suited based on your current level of function and symptoms.
Symptom noting – is a great way to keep track of your progress and symptom behaviour.
Take a diary
Note down pain before you begin the exercise.
Note down the pain rating after each exercise.
Note down pain at the end of the day
Repeat the pain recording process for the next 4-5 days
Examine the trend in your symptoms.
Interference with everyday tasks – Your participation or level of exertion with everyday activities may interfere with your symptoms impacting your exercise tolerance. It is therefore important to note any of these interferences’ contributory to your pain.
Phase 1 – is a beginner stage.
This phase is intended for gently priming muscle activation. It will demand your concentration on technique and compliance to change the possible compensation your body has been used to as a result of pain. This phase can last between 1-2 weeks.
Instructions:
3 sets of 10 repetitions. Hold each repetition for 8-10 seconds. Rest 10-15 seconds between sets, 30 seconds between exercises. Do this exercise 1-2 times per day.
Bridges
Lie on your back.
Bend both knees and place your feet flat on the bed.
Lift your buttocks from the bed.
Place your buttocks back on the bed.
Repeat this exercise and remember to continue to breathe properly.
Clam shells
Lie on your side with your feet, ankles and knees together.
Bend the legs a little and tighten your core stability muscles.
Keeping the feet together, lift the top knee up.
Make sure you don’t roll your body back with the movement.
Control the movement as you bring the knee back down to the starting position.
Phase 2 – intermediate stage
The intermediate phase is similar to the beginner stage with the difference of using changing elements of progression to challenge the muscles capacity further. In this stage you may choose to progress the exercises by choosing to change ONE factor:
Increase repetitions
Increase hold time
Increase sets
Add appropriate resistance
Instructions:
3 sets of 10-15 repetitions. Hold each repetition for 10-15 seconds.
Rest 10-15 seconds between sets, 30 seconds between exercises.
Do this exercise 1-2 times per day.
Bridges with resistance
Tie a resistance band around both thighs, just above your knees.
Lie on your back with your knees bent and legs hips width apart.
There should be tension in the band.
Raise your hips up into a bridge, keeping the knees hips width apart.
Control the movement back down to the start position, maintaining constant tension on the band.
Clams with resistance
Lie on your side and place a band above your knees, approximately an inch or two above the knee joint.
Bend your legs a little, keeping the feet in line with your back.
Use your core stability muscles to keep the body stable.
Keeping your feet together, lift the top knee up against the resistance of the band.
Ensure you stay on your side and do not roll your hips and your body back with the movement.
Lower the knee back down, controlling the resistance.
Phase 3 – advance stage
Body weight squats
Start position is standing straight with the arms out in front and bent at the elbows, the fists should be clenched and the palms facing inwards.
Move downwards into a squat position so that the knees are aligned over the toes and the heels are in contact with the floor, make sure the back is straight.
Keep the head and chest upright and the gaze horizontal.
Hold for 2 seconds and return to the start position.
Lunges
Stand straight with your arms to the side or on your hips.
Take a large step forwards on your affected leg, then drop your hips directly down between both feet, bending your hips and knees to a 90 degrees.
Push back up to the starting position, and repeat.
Make sure you take a large enough step that your front knee does not travel over your foot, and ensure your knee travels directly forwards.
Keep your body up straight throughout the movement.
Crab walks
Place a band around your ankles and gather some tension.
Side-step keeping constant tension on the band.
Make sure you do not bring your feet too close together and keep your toes and knees pointing forwards.
Phase 4 – return to activities
Stretching
Do you always need to stretch the muscle? The answer is NO. While stretching is an important tool to improve muscle elasticity. You may not always need to stretch a muscle if it is NOT tight. Thus, stretching is recommended to be limited to areas you feel are TIGHT when you perform a given movement. Check the affected side and unaffected side – don’t need to stretch a muscle that doesn’t need to be stretched.
Seated piriformis stretch
Start in a seated position.
Cross the symptomatic leg your ankle is resting on, to the opposite knee.
Apply gentle pressure to the knee as you lean forward, increasing the depth of the stretch.
Hold this position, you should feel a comfortable tension with no pain.
Pigeon stretch
Start on your hands and knees.
Cross the symptomatic leg underneath you, then lower your hips down to the ground.
Rest your body forwards on your arms.
You should feel a stretch across the buttock.
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.
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
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
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:
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
Lean forward with one arm hanging freely. Use your unaffected arm to brace against a chair for support.
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.
Slowly return to a standing position.
Repeat 4-5 times a day
Shoulder pulley (Flexion)
Put a chair against the door and sit so you are facing away from the door.
Grasp the door pulley handles with both hands.
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.
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)
Put a chair against the door and sit so you are facing away from the door.
Using door pulleys slowly pull down with your unaffected arm so that your affected arm raises up and to the side without effort.
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
Stand upright and hold a stick in both hands
Cup the top end of stick with affected hand
Using your unaffected arm hold the stick midway and drive the affected arm forward and up.
Ensure your elbow is straight throughout
Hold for 5 seconds and return to the starting position.
Repeat 10 times.
Wand Abduction
Stand upright and hold a stick in both hands
Cup the top end of stick with affected hand
Using your unaffected arm hold the stick midway and drive the affected to the side as high as able.
Ensure your elbow is straight throughout.
Hold for 5 seconds and return to the starting position.
Repeat 10 times.
Strengthening exercises with band
Flexion
Stand on one end of the band while holding the other end with your affected side.
Whilst keeping your elbow straight, lift the band up to 90 degrees to shoulder level.
Hold at the top for 1-2 seconds then lower slowly to starting position.
Attach the resistance band to a secure anchor at belly button height.
Stand with unaffected arm perpendicular to the anchor.
Place a towel between your elbow and your torso to stabilize your elbow
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.
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
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
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 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
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 websitehttps://physiofusion.co.nz
