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Runners Knee!

Our knees are complex hinge joints, designed to provide stability from side to side and smooth movement forwards and back as you walk, kick and run. The patella, or kneecap, is a small bone embedded in the tendon of the quadriceps muscle that protects the knee and also provides extra leverage to the quadriceps, amplifying their strength. The patella moves up and down in a groove at the front of the knee as the knee bends and straightens. Usually this movement is smooth, with little friction, however, if something causes the patella to move in a dysfunctional way, the soft tissue between the kneecap and the knee can become irritated, causing pain in a typical pattern. This condition is often referred to as ‘runner’s knee’ or patellofemoral pain syndrome (PFPS).

What causes it?

The patella usually sits in a balanced position in the shallow groove at the front of the knee and moves easily without friction. The patella is attached to the quadriceps muscle at the top and connected to the lower leg via the patella tendon at the bottom. When the quadriceps contracts, this pulls on the patella and acts to straighten the knee. If one side of the quadriceps is stronger or tighter than the other, it can cause the kneecap to pull to one side and over time become irritated.

There can be many factors that cause knee cap pain:

• muscle imbalance or weakness
• Training Load
• Poor mechanics
• Quadricep tightness
• Hip and thigh muscular weakness
• Footwear
• Type of training eg. running hills or stair work

What causes it?

This condition is characterised by pain felt on the inside or behind of the patella with activities that require repetitive bending of the knee. There may be a sensation of crepitus, clicking or grinding. The pain is commonly felt when running, going up and down stairs or when doing squats and is relieved with rest. The pain may start as a small niggle and gradually become worse over time.

How can Physio help?

The first step in effective treatment is to exclude any other conditions and have a physiotherapist confirm the diagnosis. Your physiotherapist is able to determine which factors are contributing to this condition, which could include flexibility, muscle imbalance or poor movement technique.

Once these factors have been identified, you will be provided with a specific treatment program to best approach your condition. PFP syndrome usually responds quite well to biomechanical assessment and correction of any muscular weakness and imbalance. There are some short-term treatments, such as patella taping, dry needling, trigger point therapy, which may help alleviate symptoms quickly and keep you active while you address the other factors contributing to your pain.

If you have any problems with your knees book an appointment online or call us on (02) 4751 9127.

Written by Pat Lincoln
(Director and Physiotherapist at The Physio Depot)

DRY NEEDLING

Dry Needling is a broad term using to describe a treatment approach involving inserting a solid filament needle directly into a muscle. It utilises the same tool as acupuncture but the theories and application differ from traditional acupuncture. The aim of dry needling is to find active trigger points in a muscle (Those painful knotty bits in the muscle) and insert the needle into the soft tissue with the aim of decreasing muscular tension, create length in a muscle which can provide pain relief. Essentially muscle with normal tension should not hurt when you poke it, hence dry needling has become a popular tool to restore normal tissue homeostasis.

What causes trigger points aka knotty muscles that hurt when you poke them?

• STRESS – Increase muscular tension.
• MUSCLE GUARDING – Muscle spasm due to pain, guarding, beliefs or injury.
• ACTIVITY LOAD- Adding to much training load too quickly and the muscular system not keeping up.
• SUSTAINED POSTURES – Asking muscles to do the wrong job, in the wrong position for sustained periods of time.
• INJURY – Muscle guarding will occur after an injury or pain.

Why use it?

Our Physio’s use dry needling as part of a comprehensive treatment plan involving movement, exercise, muscle re-training and soft tissue techniques. It resets the muscle at a neural level allowing for quick pain relief, improvements in muscle range of motion and reduced muscle tension.

It provides a quick stepping stone to get people moving again as quickly as possible and this where the magic happens.

Does it hurt?

There are two types of dry needling:
Superficial: This involves the insertion of the needle into soft tissue and is a relatively painless approach which induces muscular relaxation.

Deep Tissue Trigger Point:  This involves the stimulation of trigger points and is slightly less comfortable. The goal with this type of dry needling is to create a muscle twitch response in the muscle that can create a dull ache/cramping sensation within the muscle.

What conditions can it help with?

• Neck/Back Pain
• Shoulder Pain
• Tennis/Golfers Elbow
• Headaches
• Hip and Gluteal Pain
• Knee Pain
• Plantar Fasciitis
• Athletic Performance

If you think Dry Needling could help your recovery give us a call today on (02) 4751 9127 🙂

Written by Pat Lincoln
(Director and Physiotherapist at The Physio Depot)

++ANKLE SPRAINS++

Ankle injuries are one of the most common presentations to our clinic whether on the sporting field, a simple trip on a step or a boozy Michael Jackson dance move. Although they are a common injury they tend to be poorly managed and therefore have a high rate of re-occurrence. We all have that friend that must strap or brace their ankle for any task that may involve uneven ground.

The most common mechanism causing ankle sprains can be seen below.  The foot generally twists out to the side and the ligament is taken to full stretch, this force continues to eventually cause disruption to the ligament.

How do I know I have sprained ankle and not broken my ankle?
Ask yourself these questions?

• Can I walk on it?
• Does it hurt to touch these 4 spots pictured?
• Look at it and see if it has A LOT of swelling?
• Is your foot giving you pain at night time?
• Did you hear a CRACK at the time of the injury?

If you answered YES!

Get an x-ray to confirm you do not have a fracture prior to seeing a Physio 🙂

Signs and Symptoms of an Ankle Sprain?

– Bruising + swelling
– Pain
– Inability to walk normally
– Difficulty pulling the foot back towards the shin
– Tenderness over the out aspect of the foot
– Reduced ability to balance

Great. I have a sprained ankle what to do now?

Follow these basic principals for ankle injury rehab!

1. GET THAT SWELLING DOWN
   – Move the foot as soon as you can with ankle pumps (moving foot up and down).
   – Compress the foot with taping.
   – Ice.
   – Start calf raises in some way shape or form as pain permits.
2.  MOVE
   – Keep the foot moving as soon as you can to help pump that swelling out.
   – Begin strengthening the calf complex as pain allows.
   – Restore normal walking pattern.
   – Slowly build muscle capacity up around the foot and ankle.
3. GET RANGE BACK
   – Swelling after an injury can make the ankle stiff especially into dorsiflexion (bringing your knee over your toe in standing).
   – In most cases with a few exceptions this needs to be addressed immediately.
   – Calf stretches and ankle movements regularly throughout the day.
   – Physiotherapy techniques including joint mobilisation, soft tissue work and dry needling.
4. BALANCE
   – Start re-training balance as soon as you can.
   – If you don’t use it you lose it so start with simple strategies in safe positions as soon as possible.

Ensure to get assessed by a Physio as there will be different rehab protocols for different types of ligaments, grades of injury and injury location.

Ankle injuries are not just a simple ankle sprain.  A simple ankle injury will need 3 months re-training practice as a bare minimum to restore full function and prevent any re-occurrence. If you stick to MOVE, GET RANGE BACK and BALANCE your most of the way there and seek guidance from a good Physio!

Written by Pat Lincoln
(Director and Physiotherapist at The Physio Depot)

Plantar fascia pain is often described as a dull pain over the inside of the heel bone where the plantar fascia attaches onto the medial aspect of the heel bone. As seen below the plantar fascia is a thick fibrous tissue underlying the foot that inserts onto the heel bone. Heel pain is one the most common conditions affecting the foot with up to 10% of the population are affected over their lifespan.

Signs & Symptoms: 

• Pain and tenderness over inside aspect of the heel bone.
• Pain upon first steps when waking up.
• Increased pain following periods of prolonged inactivity and sudden movement eg. Sitting for an 1 hour then walking.
• Pain increased with prolonged standing, walking and running.

Causes:

• Repetitive trauma – The plantar fascia tractions at the heel bone over time generating irritation at the enthesis where the tissue connects to the bone.
• Activity loads increasing to quickly whether it be standing, walking or running training.
• Foot and ankle weakness especially calf musculature and intrinsic foot muscles.
• Limited ankle range or muscular tightness.
• Age – People aged between 40-60 tend to get hit the hardest.
• BMI – Central adiposity (Tummy Fat!) has shown to be a risk factor for getting plantar fascia pain.

How to fix your Plantar Fascia Pain

1. Rest does not get you better and exercise therapy is the primary focus to recover fully.
   – Strengthening of the plantar fascia is crucial to improve the load tolerance of the tissue.
   – Aim for isometrics 10 x 10 seconds of this exercise
   – Build slowly to 3 x 12-15 reps then add load gradually onto your body weight.
   
2. Strengthening surrounding muscle of the whole kinetic chain.
3. Passive treatments (massage, acupuncture) play a role in treatment in the symptomatic part of the condition, but will not FIX your condition.
4. Avoid cortisone injections until all avenues are exhausted.
5. Stretching of the plantar fascia and calf complex provides pain relief.
6. Shockwave Therapy can be effective for pain reduction.
7. Foot orthosis and footwear help to de-load the painful tissue as you commence your loading program.
8. Activity modification and load management – Limiting long periods of running, standing or walking which will be guided by what you do and how much you do.

The main take home from this is to strengthen the tissues so they can withstand more load and this takes time for the body and tissues to adapt accordingly. Be patient and see a good health practitioner that can guide through your rehabilitation.

Written by Pat Lincoln
(Director and Physiotherapist at The Physio Depot)

Why does the side of my hip hurt – The dreaded lateral hip pain!

Gluteal tendinopathy or lateral hip pain can be a very pesky injury that affects people in all walks of life. From elite runners, to hikers, to older people wearing out. It seems to be a common condition turning up due to the increase in people staying fit and moving more.

What is it?

Traditionally this condition was known as trochanteric bursitis (inflammation of the fluid filled sac around your hip joint), yet further research into this area has proved the tendons of the muscles surrounding the hip to be the main factor when looking at lateral hip pain. In technical terms it is a insertional tendinopathy involving the glute minimus and medius tendons, meaning there is a breakdown of tendon fibres as it attaches onto the bone of the hip causing pain, weakness and inability to generate force.

It is caused by compressive forces as the tendon wraps around the bony lip of the hip causing friction which irritates the tendon interface.

What causes it?

• Progressing your training load to quickly.
• Poor pelvic control leading to your knees rolling in as you move.
• ‘Hanging’ out on your hip – Yes, I am thinking of all those new mums out there sitting their babies on their hip.
• Woman are affected more than men due to wider hip morphology.
• Increasing hill running load to quick or running on cambered surface like the beach.
• Lack of hip strength and tight groin muscles.
• Excessive crossed legged sitting and side lying at night time.

What to look out for?

1. General ache in and around the bony part of the outer hip.
2. Pain lying on your affected hip at night time.
3. Your symptoms may improve as you warm up, this will be short-lived and your symptoms may worsen over the next 24-48 hours.
4. Pain ascending and descending stairs as you push up on one leg.
5. Pain or inability to walk or run uphills.
6. Tenderness to touch the bony part on the outside of your hip.
7. Morning stiffness after activity or walking.
8. Sitting in low chairs or crossed legged.

Great I think I have a tendinopathy… Now what?

Rehab will change depending on the duration of your symptoms, how it occurred, age, gender and stage of tendinopathy its important to seek guidance from a health professional.

1. SETTLE SYMPTOMS
   – Ice.
   – Topical anti-inflammatories (Short term use only).
   – Isometric muscle loading.
   – Deload training schedule.
2. ADDRESS DAILY IRRITATIONS 
   – Avoid crossing legs during the day and sitting in low chairs.
   – Use a pillow at night time for sleeping.
   – Stop glute stretches.
   – Address standing postures.
3. ISOMETRICS
   – Muscle contractions in a static state 3-5 x 30-45second holds.

4. PELVIC & HIP STABILITY
   – Weight bearing exercises like squats, lunges and step ups.
   – Gradually adding load to stimulate greater tendon capacity.
   – Single leg stability training is crucial.
   – Core stability and general strength programming of lower limb muscles.
5. GRADED STRENGTHENING AND GENERAL RETURN TO ACTIVITY
   – Regular exposure to heavy loads.
   – Gradual exposure to normal activity under guidance of a health professional.

Written by Pat Lincoln
(Director and Physiotherapist)

Shoulder pain is a common problem that affects people in all walks of life.

Everyone has heard about the rotator cuff BUT what does it do and where is it?

The rotator cuff is a group of 4 muscles that reside on the shoulder blade and attach onto the top of the arm bone. Their primary job is for stabilising and controlling the arm bone within the socket.

Shoulder pain can manifest in a variety of ways. From insidious onset over time, a large disruption to the shoulder following trauma, overuse injuries or instability after a dislocation. A large proportion of people attend our physio clinic with no idea of how their shoulder pain started and it gradually worsens over time.  I tend to triage a shoulder injuries into 3 distinct areas in which, each treatment will differ drastically

The Three Buckets

The Stiff + Painful Shoulder

These shoulders lack sufficient range of motion to move appropriately causing pain and dysfunction.
It is associated with a hitching pattern in which, the shoulder cannot reach full range of motion when lifting to the front, the side and behind the back. It typically effects shoulders of the older demographic with osteoarthritis or post trauma. Frozen shoulder can create a stiff and painful shoulder, this generally affects the 40-60 year old demographic, mostly females.

What to look out for:

• Pain whilst doing you bra up or reaching behind your back.
• Difficulty reaching across your body to wash the opposite shoulder.
• Movement restriction even when arm is supported.
• Night pain lying on the affected shoulder.
• A deep clunk sensation is a sign of an osteoarthritic shoulder.
• Bunching of the shoulder as you lift it up in front.

The Wobbly Shoulder

These shoulders lack the appropriate neuromuscular control to keep the shoulder joint centred in the socket. This will affect the younger population between 18-25 years old. They’re more likely to dislocate their shoulder during sport. People with hyper-mobility is another cause for the wobbly shoulder, so if you’re naturally a bendy person then your more likely to fall into this bucket.

What to look out for:

• No restriction in movement.
• Clicky feeling in the shoulder upon movement.
• Perhaps a vague nerve sensation down your outer upper arm when playing contact sports.
• Pain throughout the extremes of movement and a feeling of ‘looseness’.

The Weak + Painful Shoulder

General weak shoulder stabilisers/muscles that create pain and dysfunction associated with upper body exertion. These shoulders tend to lie in the 30-60 year old demographic and it is the inability for the shoulder to keep up with the what you are asking it to do and therefore gets sore. It is associated with a shoulder that can move relatively well but gets ‘catchy’ throughout the movement. This shoulder will probably hurt after the gym if you’re training and perhaps give you a fair bit of grief at night time when you lie on that side.  There is generally focal tenderness on the outer aspect of the arm that may radiate into the upper arm and is associated with either acute or chronic rotator cuff tendon tearing.

What to look out for:

• Painful at night lying on affected side.
• A painful arc when lifting the arm to the side, meaning there is a period of pain when you lift up to the side that generally subsides by the time you reach the top.
• Difficulty lifting arm up to the side without pain or catching
• Pain after activity or exertion generally 24-48 hours after.
• Intermittent pain over upper outer arm.
• Insidious onset with no direct mechanism of injury.
• Very rarely do these shoulders hurt when you’re not using them.

Can you figure out which bucket your shoulder fits into?

Can Physio help or do I need surgery?

Each shoulder needs to be assessed individually and then triaged into what bucket the shoulder fits into. Taking into account age, gender, activity levels, patient symptoms, goals and general conditioning the management will change according to the patient. For example: A 30 year old male with a rotator cuff injury from bench pressing cannot be rehabbed the same as 50 year old women with a stiffening shoulder.

The premise is to find YOUR deficit and restore THAT deficit in line with what goals you have.

• Restoration of joint range through manual therapy and a mobility plan.
• Improve shoulder neuromuscular control and joint stability with rotator cuff activation exercises and stabilisation drills.
• Improve shoulder rotator cuff strength in a isolated fashion then progress to global conditioning.
• Referral on if indicated to a surgeon: This occurs when there is trauma, gross loss of strength, copious amounts of pain, large amount of shoulder dysfunction and an abundance of night pain.
• Ultrasounds and MRI scans are hit and miss – There is a place for imaging a shoulder when indicated. But there is a very low correlation for imaging and shoulder pain. Meaning what we see on an MRI may have everything to do with why your shoulder hurts, but a large percentage has nothing to do with why your shoulder hurts.

What we hear all the time is  “How is Physio going to help if I have torn rotator cuff?”

What we do know is most people over the age of 30 in non-symptomatic shoulders will show a raft of changes on an MRI including rotator cuff partial/full thickness tears and bursitis so take your scan with a grain of salt and get on with your rehab if you want results 🙂

If you need any help with your shoulder rehabilitation come see us at The Physio Depot!

Written by Patrick Lincoln
(Physiotherapist)

WHAT IS CADENCE + WHY DO PEOPLE KEEP TALKING ABOUT IT?

For runners of all abilities I imagine most of you have been asked about your cadence by someone whether it be a physio, a friend or colleague.

CADENCE is defined by the number of steps you take per minute when you run. In an ideal world we would like to see this number up around 180 when we run. If there is ONE indicator I get a runner to monitor throughout a run it’s this number.

There is no one size fits all regarding cadence but the general consensus is running with a higher cadence can provide the following benefits:

• Improved running efficiency due to less breaking forces with each step.
• It leads to a short stride length meaning our hips stay directly over our feet instead of landing out in front of our body.
• Decrease peak landing forces at the joints of the lower limb.
• Lowers ground reaction forces with each step as it utilises the bodies natural springs called the ‘stretch-reflex’ phenomenon.
• A 5% increase in cadence reduced 20% of joint loading. 

Hence we can running more efficiently and reduce our likelihood of overuse injuries.

How do I increase my Cadence?

• START SLOW – Try sections of your runs and self-assess how you feel
• LISTEN – Your foot landing should be quiet
• Use a metronome or smart watch which can give you feedback
• Use music playlist or run cadence

Written by Patrick Lincoln
(Physiotherapist)

Strength Training + Running

One of the most common things I find in clinical practice is runners loving to run, but not like doing much else. The two biggest factors in being an injury free runner and maintaining this status is doing strength training regularly and monitoring your training loads. It’s imperative we are maintaining a foundation of strength training to be able to run more, handle more load increases and improve running efficiency. A common misconception is that strength training will ‘bulk’ me up and reduce my running economy.

What the research say:

1. Improves running economy.
2. Reduces the risk of injury by up to 50%.
3. Increased maximal time to exhaustion.
4. Improved power output.
5. Improved VO2 Max.

What to do next:

• STRENGTH train 2 x week.
• 2-4 Sets of 4-10 reps HEAVY & SLOW.
• Long rest periods of up to 1-2 minutes.

Exercises

1. Squats
2. Deadlifts
3. Calf Raises
4. Lunges

This should compliment a sound training plan designed specifically for your running goals. Therefore when and how you implement this into your training plan is going to be different for each athlete.

Happy Running 🙂

Pat Lincoln (Physiotherapist)

The Physio Depot

References:

• Beattie, K, Carson, BP, Lyons, M, Rossiter, A, and Kenny, IC (2017). The effect of strength training on performance indicators in distance runners. J Strength Cond Res 31(1): 9–23.

Do I have a frozen shoulder?

Frozen shoulder or adhesive capsulitis is a condition affecting the shoulder joint capsule. It is characterised by a global stiffening of the shoulder that occurs spontaneously without any due cause. Frozen shoulder is often misdiagnosed in it’s early stages as it can appear to have very similar symptoms to other conditions of the shoulder.

What causes it?

Medical mystery! We are still yet to know the the TRUE cause of a frozen shoulder but we can narrow down some risk factors and sub groups that it typically affects.

What we do know:

• It affects 2-5% of the population
• 40-60 year olds are most at risk
• Higher prevalence in females
• Commonly affects the non-dominant arm
• Higher prevalence in patients post surgery
• Diabetic patients are at greater risk
• 20% of people tend to develop it in the other shoulder at some point
• Family history of frozen shoulder

I have a FROZEN shoulder NOW WHAT?

Frozen shoulder will take on average 12 months to 2 years to recover.
It generally will move through three distinct phases which include:

1. Inflammatory Stage
   – Associated with a spontaneous onset of shoulder symptoms
   – Difficulty sleeping at night
   – An inflammatory process creating a very painful shoulder
   – Subtle stiffening of the shoulder into rotating the arm outwards and reaching behind your back
   – It will tend to not respond to treatments
   – Tends to be a constant dull pain in top part of upper arm
2. Freezing Stage
   – Global loss of movement into ALL directions
   – Fortunately slightly less pain and feels stiff into all directions of movement
3. Thawing-Out Phase
   – A spontaneous return of normal joint motion

7 Tips to best manage your condition:

1. The pain in your shoulder is self limiting and is not causing ‘damage’ to your tissues.
2. Let nature run its course as this condition will spontaneously resolve with time.
3. Physiotherapy can help at the right stage of treatment especially in late freezing to thawing stage. In the initial phases of this journey hands on treatment tends to worsen your shoulder symptoms.
4. Pain relief can be achieved by using anti-inflammatories or a corticosteroid injection into the joint capsule. *Beware this will not improve your shoulder motion just dampen the pain!.
5. Keep it moving as much as you can within what you can do – There is nothing wrong with the strength of your shoulder so keep it strong.
6. Listen to your shoulder and when it wants to start to move then you can start a gentle stretching program under your Physio’s guidance.
7. Passive techniques massage, acupuncture, dry needling DO NOT have long term benefits until the right stage of your frozen shoulder journey so do not waste that health fund rebate to quickly!.

Hope this helps you with your shoulder recovery!!

Patrick Lincoln
(Physiotherapist)

The Illiotibial Band (ITB) has long been plagued the bad guy of the lower limb, the scapegoat for a plethora of injuries – ITB friction syndrome, runners knee, trochanteric bursitis and as far down as medial tibial stress syndrome to name a few.

WHAT IS THE ITB?

The ITB is thick piece of fascia some compare with big thick elastic band. It originates from the Upper Glute Max and Tensor Fascia Lata at the hip, then creates septum down the leg between the outer quadriceps and the hamstring finally inserting into the girdy’s tubercle below the knee.

WHY DOES IT GET TIGHT?

The ITB creates problems for activities requiring repetitive hip and knee movements and is generally problematic in runners or cyclists. It is associated with the knee falling inwards and creating excessive tension where the band inserts onto the knee usually to poor motor control at the hip and pelvis.

A common “quick fix” is using a foam roller to alleviate pain and “loosen” the fascia. This is generally counter productive, only further compressing the ITB into it’s painful position.

SOME TIPS TO HELP YOUR ITB

Avoid stretching and foam rolling

Thomas Test – Assess hip flexor passive restriction

• Find a table, hug one knee to chest and lie down keeping the opposite leg on the table
• A positive test for this is when the bottom knee does not fall pass the line of the table and therefore stretching the hip flexor may be indicated

Check hip muscle control (pictured below) – Which is working harder – your glutes or outer upper quads? Your glutes should be doing most of the work. You can use the simple, quick tests below to check your hip-muscle control.

• Single leg stance – check for uneven hips and dropping on one side
• Single leg squat – check for uneven pelvic drop by using the waistline on your pants as a guide
• Single or Double leg bridge – sustain a 30 second hold, a good clue here is to consider what is working the most performing this task – if it is your lower back, hamstrings, groin or quads we can infer that your glutes aren’t pulling their weight.

Hip and Trunk disassociation – Can you rotate your trunk without dropping or twisting at the hip?

Get strong at the hip and the foot – The knee often becomes the meat in the sandwich with a dysfunctional hip and a weak foot

It is time to re-think the common misconception that the ITB can be at all lengthened and start looking behind the scenes at other common culprits.