Popliteal Artery Entrapment Syndrome (PAES)

Popliteal Artery Entrapment Syndrome (PAES): An Overview

Popliteal Artery Entrapment Syndrome (PAES) is a rare vascular condition that occurs when the popliteal artery, the major blood vessel behind the knee, is compressed or trapped by the surrounding muscles or structures. This condition can lead to various symptoms, including leg pain, muscle weakness, and, in more severe cases, arterial occlusion, which can affect circulation in the lower leg. Although PAES is a condition that primarily affects athletes and young individuals, it can also affect people of all ages.

In this blog, we explore the causes, clinical presentation, diagnosis, and treatment of Popliteal Artery Entrapment Syndrome. We will also delve into the latest research, including findings from relevant clinical trials.

Anatomy and Mechanism of Popliteal Artery Entrapment

The popliteal artery is a critical blood vessel that supplies oxygenated blood to the knee joint and the lower leg. In normal circumstances, the artery lies behind the knee, and there are no structural anomalies affecting its function. However, in PAES, the popliteal artery is subjected to compression by muscles, tendons, or other anatomical structures, leading to restricted blood flow.

Kim et al, 2006

There are various anatomical variations of PAES, and these can be broadly classified into two main types:

1. Type I (Muscular PAES): The popliteal artery is compressed by the medial head of the gastrocnemius muscle.

2. Type II (Fibrous PAES): The artery is compressed by fibrous bands.

3. Type III (Combined): A combination of both muscular and fibrous compression causes arterial compression.

Furthermore, of the muscular classification type of PAES, there have been 6 variants seen based on the relationship of the medial head of the gastrocnemius (MHG) muscle with the popliteal artery (Canerio et al, 2018; Kim et al 2006):

• Type I: An aberrant medial course of the popliteal artery around a normally positioned MHG

• Type II: MHG attaches abnormally and more laterally on the femur causing the popliteal artery to pass medially and inferiorly

• Type III: Abnormal fibrous band or accessory muscle arising from the medial or lateral condyle encircling the popliteal artery

• Type IV: Popliteal artery lying in its primitive deep or axial position within the fossa, becoming compromised by the popliteus muscle or fibrous bands

• Type V: The entrapment of both the popliteal artery and vein due to any of the causes mentioned above

• Type VI: The muscular hypertrophy, resulting in a functional compression of both the popliteal artery and vein

While this condition is often present at birth due to an abnormal anatomical structure, it is more commonly seen in athletes or individuals who engage in repetitive, intense physical activities such as running or cycling. The compression of the artery is often worsened by physical exertion, which increases the demand for blood in the legs.

Clinical Presentation of PAES

The clinical presentation of PAES can vary depending on the degree of artery compression. Most patients with PAES present with intermittent claudication, which is a type of muscle pain that occurs when there is insufficient blood flow during physical exertion. However, symptoms can also include:

• Pain or cramping in the calf: This typically occurs with activities such as running or walking

• Cold or numb feet: Reduced blood flow may cause the feet to feel cold or numb

• Swelling: Swelling may occur due to the reduced circulation in the leg

• Weakness: Some individuals may experience weakness in the leg due to impaired blood supply to the muscles and/or nerve impingement

A significant number of cases go undiagnosed because the symptoms can be mistaken for other conditions like muscle strains or even chronic compartment syndrome. Therefore, a high index of suspicion is necessary for accurate diagnosis. Bilateral presentation can be seen in 38-81% of patients (Sinha et al, 2012, Deveze et al, 2023).

Diagnosis of Popliteal Artery Entrapment Syndrome

Accurate diagnosis of PAES requires a thorough clinical evaluation and appropriate imaging studies. The diagnostic process generally involves:

• Clinical History and Physical Examination: Your Physiotherapist or Sports Doctor will take a detailed history of symptoms, focusing on the onset and nature of leg pain, particulary in relation to physical activity. A physical examination may reveal:

  • signs of poor circulation, such as cool extremities, or a lack of pulse in the popliteal artery and/or pedal pulse

  • swelling of the lower leg, noted by calf circumference measurement comparison to the unaffected side

• Imaging: Imaging is crucial in confirming the diagnosis of PAES. Several imaging techniques may be employed, including:

  • Ultrasound: Doppler ultrasound can be used to assess blood flow in the popliteal artery.

  • Magnetic Resonance Angiography (MRA): This is one of the most effective tools for detecting arterial compression and visualising the popliteal artery in detail.

  • CT Angiography (CTA): This imaging technique may be used to assess arterial compression and any potential damage to the vessel wall.

• Exercise Testing: In some cases, patients may be asked to engage in a physical exercise (such as repeated calf raises or running on a tredmill) to reproduce symptoms and assess changes in blood flow or pain during exercise.

A novel method of diagnosing and defining functional PAES has been described by combining ultrasonography and MRI techniques with dynamic plantarflexion of the ankle against resistance. Functional entrapment can be demonstrated and the location of the arterial occlusion identified. Combining these modalities improves definition of muscle anatomy and can guide interventions such as Botox or surgery (Williams et al 2015).

Treatment Options for Popliteal Artery Entrapment Syndrome

The management of PAES typically involves both non-surgical and surgical approaches, depending on the severity of the condition. Early diagnosis and intervention are essential for preventing permanent damage to the popliteal artery.

Non-Surgical Treatment

In less severe cases of PAES, conservative management may be sufficient. This could include:

• Rest: Avoiding activities that exacerbate the symptoms, such as running or cycling, can help reduce the strain on the artery

• Physiotherapy: Stretching and strengthening exercises can help relieve pressure on the popliteal artery and improve muscle flexibility. Soft tissue releases, joint mobilisations and progressive strengthening of the calf muscles with calf raises and single leg balance exercises form the basis of physio treatment. The addition of orthotics to footwear to aid in correcting foot biomechanics and running technique alterations should also be considered here. For more information on a detailed exercise program, please discuss this management with your physio.

• Anti-inflammatory Medications: Non-steroidal anti-inflammatory drugs (NSAIDs) can help reduce pain and inflammation

Surgical Treatment

In cases of moderate to severe PAES, surgery is often required to release the compression on the popliteal artery. The most common surgical approaches include:

• Arterial Decompression: This involves removing or releasing the anatomical structures (muscles or fibrous bands) that are compressing the artery

• Endovascular Surgery: In some cases, a minimally invasive approach is used to treat the condition through a catheter, particularly when there are underlying issues such as arterial stenosis.

The goal of surgical treatment is to restore normal blood flow to the affected leg, reduce occlusion and prevent further damage to the artery.

A recent clinical trial published in Annals of Vascular Surgery evaluated the outcomes of surgical decompression in patients with PAES over a 10 year period. The study found that surgical treatment resulted in significant improvements in pain relief and functional outcomes, with most patients experiencing a return to normal activity levels within six months of surgery (Deveze et al, 2023).

Conclusion

Popliteal Artery Entrapment Syndrome is a rare but potentially serious condition that can cause significant leg pain, weakness, impairment to athletic performance and, in severe cases, permanent damage to the popliteal artery. Early diagnosis and appropriate treatment, whether surgical or conservative, is crucial in managing this condition. Recent advances in imaging techniques have improved our understanding of PAES leading to improved management, offering hope for better outcomes for patients diagnosed with this rare vascular disorder.

References

1. Davis & Shaw. Popliteal Artery Entrapment Syndrome. [Updated 2023 Aug 28]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan. (https://www.ncbi.nlm.nih.gov/books/NBK441965)

2. Kim et al. Skeletal Radiol 35, 648–658 (2006)

3. Carneiro et al. Am J Case Rep. 2018 Jan 09:19:29-34.

4. Sinha et al. J Vasc Surg. 2012;55(1):252-262, e230.

5. Deveze et al. Ann Vasc Surg 2023 Jan:88:139-144

6. Williams et al. J Med Radiat Sci. 2015 Sep 3;62(3):226–229

The Lost Art of Breathing - from "Breath" by James Nestor

In the physio world, breathing is often a core part of managing musculoskeletal pain. Poor breathing mechanics, involving parts of the body including the spine, rib cage, attached muscles, diagphragm and neural innervation (including the SNS and PNS), are an important focus in physiotherapy management. Injuries and dysfucntion to these sturctures can result in poor movement mechanics, impaired breathing mechanics and reduced function and perfromance. What is not often looked at in muscuoloskeletal and sports physiotherapy is the “how” we can bring about a change but altering how we breathe.

In "Breath," James Nestor embarks on what starts out as a personal journey to explore the often-overlooked significance of breathing in our lives. Through personal anecdotes, scientific research, and historical perspectives, Nestor reveals how modern habits have degraded our natural breathing practices and how correcting these can lead to profound improvements in health and well-being.

Overview

Nestor begins by recounting his own struggles with breathing, which is made apparent while participating in a deep-sea free diving experiment. His experiences spark a deeper inquiry into how we breathe and its impact on physical and mental health. He interviews experts in various fields, including doctors, scientists, and breathing coaches, while also delving into ancient practices from different cultures that emphasise the importance of breath.

Throughout the book, Nestor highlights the physiological mechanisms of breathing, the benefits of nasal versus mouth breathing, and the negative consequences of chronic improper breathing patterns. He combines scientific data with personal experiences, advocating for a return to more natural, conscious breathing practices.

Key Take-Home Points

1. The Importance of Nasal Breathing
   Nestor emphasises that breathing through the nose is not just preferable but essential for optimal health. Nasal breathing filters, warms, and humidifies the air we inhale, activating the diaphragm more efficiently and promoting better oxygen exchange. It also stimulates the production of nitric oxide, a molecule that helps improve blood flow and supports the immune system. In contrast, chronic mouth breathing can lead to various health issues, including dental problems, sleep apnea, and diminished lung capacity.

2. Understanding Breath and Its Effects on the Body
   The book details how breath affects various bodily systems. Nestor discusses the relationship between breathing patterns and stress, explaining that shallow or rapid breathing can trigger the sympathetic nervous system (SNS) (the "fight or flight" response), leading to anxiety and heightened stress levels. Conversely, slow, deep breathing activates the parasympathetic nervous system (PNS), promoting relaxation and recovery. By consciously regulating our breath, we can significantly improve our emotional and physical states.

3. The Role of Carbon Dioxide
   Nestor highlights the often-misunderstood role of carbon dioxide (CO2) in the body. While traditionally seen as a waste product, CO2 is crucial for the release of oxygen from red blood cells to tissues (the Bohr effect). By practicing techniques that increase CO2 tolerance, such as breath-holding exercises, individuals can enhance their overall oxygen efficiency and athletic performance. This understanding shifts the focus from merely increasing oxygen intake to optimising the body’s use of oxygen.

4. Ancient Practices and Modern Applications
   The book draws parallels between ancient breathing techniques—such as those found in yoga, Buddhism, and indigenous cultures—and modern scientific findings. Nestor discusses practices like pranayama and the Buteyko method, which emphasise controlled breathing to improve health. By integrating these age-old practices into contemporary life, individuals can address a wide range of ailments, from anxiety to chronic pain.

5. The Power of Breath Awareness
   A central theme in "Breath" is the idea of breath awareness—becoming conscious of how we breathe throughout the day. Nestor suggests that simple mindfulness techniques, like paying attention to breath patterns or practicing specific breathing exercises, can lead to significant improvements in well-being. By cultivating a deeper awareness of our breath, we can learn to manage stress, improve focus, and enhance overall quality of life.

Conclusion

James Nestor’s "Breath" serves as both a compelling narrative and a practical guide, urging readers to reconsider the way they breathe. Through a blend of personal stories, scientific research, and historical insights, Nestor champions the idea that reclaiming the art of proper breathing can transform our health and lives.

By embracing nasal breathing, understanding the importance of CO2, learning from ancient practices, and fostering breath awareness, individuals can unlock a powerful tool for better physical health and greater emotional resilience. The book ultimately reaffirms the ancient wisdom that our breath is intrinsically linked to our overall well-being and encourages a conscious effort to reconnect with this vital aspect of life.

Effective Management of Plantar Fascia Foot Pain

Plantar fascia pain (heel pain) is a common foot condition characterised by inflammation in an acute setting and often as a result of poor loading strategies in persistent cases. This condition can cause intense heel pain and discomfort (usually first thing in the morning), impacting daily activities and overall quality of life.

The plantar fasciia is a is a band of tissue connecting your heel bone to the base of your toes. It helps support the arches of the foot (medial and lateral) and helps absorb shock when walking. This condition is often mistakingly attributed to the presence of heel spurs that have been found on xray. Managing plantar fascia pain involves a comprehensive approach that combines lifestyle and activity modifications, targeted exercises and pain management strategies.

What is the cause?

Plantar fascia pain often occurs due to a combination of events such as:

1. increased/decreased loads - more or less training, recent holiday/break from exercise

2. changes in regular physical activity - length of run, different terrain, new shoes etc

3. previous subsequent injury

4. background of altered loading or mechanics

While it is important to address these changes with short term activity modification, identification of factors influencing movement are essential. Muscle strength, tissue tolerance/capacity and biomechanics play a large role in the successful management of plantar fascia pain. A whole body understanding of loading mechanics including the knee, pelvis and trunk make up an often-overlooked part of the rehabilitation process. Your physio should definitely be assessing these areas in chronic cases that have become recurrent in nature.

Strengthening Exercises:

Strengthening the muscles in the foot and calf often are the primary goal of rehabiliation and can contribute to improved stability and support for the plantar fascia. Exercises such as toe curls, marble pickups, and calf raises can be incorporated into a daily routine.

In addition, other areas that should be addressed when managing plantar fascia pain include:

• ankle and knee stiffness

• ability to control movement through the hips and trunk and thorax

• assessing tissue capacity and assist in developing improved loading mechanics

Pain management strategies:

Additionally, massaging the foot with a tennis ball or a frozen water bottle can provide temporary pain relief with acute flare ups. The use of ice can provide a short-term analgesic response and is best used during flare ups or post exercise.

Other treatment options that should be conisdered for acute foot pain are:

• manual therapy to help manage stiff and tight joints and muscles

• use of tape to help unload/reload the foot

• heel raises or off-the-shelf orthotics for temporary support

• use of non-steriodal anti inflammatory (NSAIDs) medications and creams

Effectively managing plantar fascia pain involves a combination of lifestyle adjustments, targeted exercises, and, in some cases, medical interventions. It is essential to consult with a physiotherapist to determine the most appropriate and personalised treatment plan. By incorporating these strategies, individuals suffering from plantar fasciitis can experience significant relief and regain control over their foot health.

Running with Knee Pain

Knee injuries are a common concern for runners due to the repetitive nature of the activity. Two common knee injuries that runners often encounter are patellofemoral pain syndrome (PFPS) and iliotibial band syndrome (ITBS).

Patellofemoral Pain Syndrome (PFPS), commonly known as "runner's knee," refers to pain and discomfort around or behind the patella (kneecap). It is often caused by factors such as overuse, muscle imbalances, improper running mechanics, or a sudden increase in training intensity. Runners with PFPS typically experience a dull, aching pain during or after running, particularly when descending stairs or squatting. The pain may also worsen with prolonged sitting or inactivity. Treatment for PFPS typically involves a combination of resting the affected area and non-steroidal anti-inflammatory drugs (NSAIDs) for pain management.

Physiotherapy can help manage PFPS by providing manual treatment to the joints and muscles affected, taping the knee, providing exercises to help strengthen the quadriceps and hip muscles, and assisting with modifying running techniques or footwear to reduce stress on the knee joint.

Iliotibial Band Syndrome (ITBS) is another common knee injury among runners. The iliotibial band is a thick band of connective tissue that runs along the outer side of the thigh, from the hip to the shin. ITBS occurs when the band becomes irritated or inflamed, resulting in pain on the outer side of the knee. Runners with ITBS typically experience a sharp or burning sensation during activities that involve repetitive bending and straightening of the knee, such as running downhill or on uneven surfaces.

Treatment for ITBS includes rest, ice, and anti-inflammatory medication to reduce pain and inflammation. Physiotherapy can help by focusing on advice with stretching and strengthening exercises for the hip muscles (TFL and Glute Max) and quadriceps. Modifying running routes to avoid downhill running, improving glute activation patterns and using proper footwear can help prevent ITBS from recurring.

Preventing knee injuries in runners involves maintaining a balanced training program, gradually increasing running distance, incorporating strength and flexibility exercises, and addressing any muscle imbalances or biomechanical issues. It is essential for runners to listen to their bodies, pay attention to any early signs of discomfort, and seek appropriate attention from their physio. Working with a physio familar with running injuries can help runners develop strategies to prevent and manage knee injuries, allowing them to continue their running journey with reduced risk.

Time to throw out the ice baths?

There has been a lot of information recently suggesting that ice slows healing, causing us to question whether cryotherapy still plays a role in initial injury management. It was the topic of discussion in a recent SMH article about why inflammation might beter better for you that you think. The articles discusses whether icing and injury (or during recovery) was suppressing insulin growth factor 1 and hence altering the bodies hormonal response to healing.

“Pain kicks that hormone off - thats how the body knows - so when you suppress pain you stop that healing”

— Laird Hamilton - Elite Athlete Trainer

All health professionals have been taught the RICER (rest, ice compression, elevation, referral) principle at some point in their careers. Is it still relevant? One such study (1) has shown that there is little to no effect of the RICE principle on acute injuries. So our practice is still largely based on THEORY.

Regarding cryotherapy, there are two main theories:

• Reducing swelling and inflammation improves function and therefore hastens recovery

• Reducing inflammation limits tissue healing and the natural response of the body, therefore prolonging recovery

It is not clear if intermittent icing on an acute injury actually impedes or slows healing. One particular study (2) showed that “icing attenuated or delayed the infiltration of inflammatory cells… and change in vessel volume in muscle following injury. However, these effects were not sufficient to reduce capillary density or prevent effective muscle regeneration.” That is to say, ice slowed initial inflammatory responses but had no effect on muscle tissue healing in the medium to long term.

Another recent study (3) backs up this sentiment, noting that whilst initial icing reduced inflammatory markers, it did not affect tissue remodeling.

It should be noted that both of these studies were looking at muscle tissue injuries. Take, for example, one of the most commonly iced injuries: an ankle sprains. Well, surprisingly or not, there’s not much evidence at all. A few studies compared different icing techniques, and others included too many confounding treatments such as exercise. A systematic review (4) from 2004 found that ice plus exercise was the most effective treatment for acute lateral ankle sprains. It should be noted that no studies found showed a harmful effect of icing on ankle sprains.

Bottom line:

If icing your injury reduces pain, allows you to move better, and do more exercise, then the minor (and short-term) reductions in inflammation seem to negligible, and certainly not harmful – ice away!

References

1. Van den Bekerom MP, Struijs PA, Blankevoort L, Welling L, van Dijk CN, Kerkhoffs GM. What is the evidence for rest, ice, compression, and elevation therapy in the treatment of ankle sprains in adults? J Athl Train. 2012;47:435–443. doi: 10.4085/1062-6050-47.4.14. 

2. Singh DP, Barani Lonbani Z, Woodruff MA, Parker TJ, Steck R, Peake JM. Effects of topical icing on inflammation, angiogenesis, revascularization, and myofiber regeneration in skeletal muscle following contusion injury. Front Physiol. 2017;8:93. doi: 10.3389/fphys.2017.00093.)

3. Vieira Ramos, G., et al., Cryotherapy Reduces Inflammatory Response Without Altering Muscle Regeneration Process and Extracellular Matrix Remodeling of Rat Muscle.Sci Rep, 2016. 6: p. 18525.

4. Bleakley C, McDonough S, MacAuley D (2004) The use of ice in the treatment of acute soft- tissue injury: a systematic review of randomized controlled trials. Am J Sports Med 32:251–261

Wrist Injuries in Golf

“Understanding how a wrist moves in golf can prevent an injury from occurring at all.”

The wrist provides the penultimate link in the kinetic chain of the golf swing. The professional game of golf has become increasingly focused on the bodies ability to generate power and club head speed to gain an advantage. During the swing the lead side of the body is the predominate generator of this power. It is no wonder then that the lead wrist is the second most common site of injury in professional golfers (behind the lumbar spine) with an incidence as high as 30%. In this population they are commonly injured by either overuse or impact related mechanisms and occur more frequently in younger golfers with lower handicaps. This is in comparison to low back injuries which are more frequent in older players with higher handicaps. The lead wrist is where the majority of injuries occur (29-67% of all problems) and the site of injury will mostly be ulnar sided.

Worth pointing out is that in amateur, non-professional, golfers the lead elbow is the second most common injury. The causes for wrist injuries in amateurs will be a bit different to those mentioned below. Most wrist studies have been done on professional golfers and ones in amateurs are awaited.

Clinical Picture

For a great overview on clinical assessment the wrist, check out this great video “Examining the wrist: A guide for sports physicians and physiotherapists” https://www.youtube.com/watch?v=GRxY6ghU3eg

The help localise wrist pain we can generally group symptoms into 3 distinct locations; Ulnar-sided (along the little finger side), Radial-sided (along the thumb side) and Dorsal (back of the wrist) pain. Common conditions seen at these sites include:

• Ulnar wrist pain:

  • Extensor carpi-ulnaris (ECU) subluxation or instability

  • ECU tenosynovitis

  • Triangular fibrocartilage complex (TFCC) injury

  • ‘Fat shot’ pain

• Radial wrist pain:

  • De-Quervains tenosynovitis

  • Intersection syndrome

  • 1st Carpometacarpal (CMC) joint injury

  • Hamate fractures

  • Carpal Tunnel syndrome (CTS)

• Dorsal wrist pain:

  • Ganglia

  • Extensor synovitis

Dorsal view of wrist showing TFCC in green

Palmar view of wrist showing Hammate in green

(image courtesy of 3D4 Medical Images: Essential Anatomy)

Wrist Biomechanics DURING the golf swing

During the swing the lead wrist will begin in an ulna-deviated position and move into maximal radial deviation at the top of the back swing. As the swing commences the wrist rapidly moved back into ulna-deviation by impact. One explanation for why a lower-handicapped golfer will experience lead wrist pain more commonly is through the process of "playing through the ball" (Hawkes et al, 2013). The trail wrist follows a completely different motion, beginning in neutral and moving into maximal extension at the top of the back swing and returning to neutral at impact.

Understanding the different wrist movements can help understand injury patterns in golfers and the mechanisms that can help manage them.  

Causes of wrist pain

Can be both acute or chronic in nature. Injuries are often the result of:

• Hitting off hard surfaces (such as mats or hard grounds) can create an inflammatory reaction within the tendons, commonly ECU

• ‘Fat shot’ (where too much of the turf is taken while playing a shot) will increase compression of the TFCC and can result in injury

• Hitting immovable objects such as tree roots or rocks. This is the most common way to sublux the ECU tendon from its sheath in the lead wrist and generally requires surgical management

• Biomechanics:

  • Extreme wrist angles at top of back swing and again at impact can be overload tendons and ligaments resulting in inflammation or injury

  • Kinetic chain problems. The presence of swing faults (such as those listed below) can often lead to an overload and/or excessive motion at the wrist that can result in chronic or overuse symptoms

• Grip - strong (closed) vs neutral vs weak (open). A good swing will start with a good grip so it is best to discuss your grip technique with you golf coach as different grips will serve different purposes. A rule of thumb (pun intended!) is that a weaker grip will result in more injuries to the wrist due to the excessive motion that is associated with it.

What SWING FAULTS cause the wrist to be the site of injury?

• TFCC injuries from excessive ulnar deviation can be the result of early extension and the golf club becoming more vertical during the down swing. Excessive ulnar deviation can also occur from having a weak grip

• Fractured hamate can arise from club position and having an increased palmar grip. In combination with hitting an immovable object or fat shot the hamate is vulnerable to fracture through the neck

• Scooping, Casting and Chicken Winging all increase wrist stress through creating excessive, unwanted, radial and ulnar deviated motion

• 1st CMC degeneration and radial tendon injuries can arise from having a long thumb position (along the club) combined with a weak grip. This can place increased tension on the EPL and APB tendons resulting in De Quervains or Intersection syndromes and/or increased joint stress.

Treating wrist pain

Seeking an opinion from a Sports Physiotherapist or Sports Physician is a good first place to start. These specialists can assess the anatomy and movements of your wrist to determine what is causing the pain. MRI, xray and ultrasound imaging may be requested to determine the extent of injury that has occurred and to confirm a diagnosis.

Once the problem has been identified physiotherapy management may address joint and soft tissue mobility issues with some manual treatment (soft tissues releases and joint mobilisation) and taping (to limit unwanted movements). This is followed by prescribing an appropriate strengthening exercise program that can improve grip and general upper limb strength. Exercises can be varied (and should be specific to the injury) but the following youtube link demonstrates some simple strengthening exercises using resistance bands and a golf club for weight are a good place to start.

Several training aides exist that can be useful to help manage wrist related injuries. It is important to note that these aides should be used under guidance from your physio, doctor or golf coach as incorrect or excessive use can cause further damage and injury.

• Specific splints include:

  • A dorsal blocking splint can be used during training to prevent excessive wrist extension (such as SKLZ Smart Glove).

  • A wrist widget is a very useful and effective splint that can alleviate ulna sided wrist pain due to excessive ulnar deviation or TFCC injury. These can be worn whilst playing and are generally used until symptoms have resolved.

  • A swing correction tool can be used to help set the correct hinge position at the top of the back swing. While not useful during a round of golf, it can be incorporated into range sessions to gain a feel for where excessive unwanted movement occurs during the swing. This then can train and prevent certain movement patterns at the wrist that result in injury.

Wrist injuries can be serious and are devastating to a golfer and their game. As most of these injuries are overuse in nature prevention is the best cure. If you begin to feel symptoms of pain, swelling or weakness get it assessed early and you will limit your time spent off the course.

Hawkes R, O'Connor P, Campbell D. The prevalence, variety and impact of wrist problems in elite professional golfers on the European Tour. BJSM 2013;47:1075-1079.

Campbell D, Campbell R, O'Connor P, et al. Sports-related extensor carpi ulnaris pathology: a review of functional anatomy, sports injury and management. BJSM 2013;47:1105-1111.

O'Connor PJ, Campbell R, Bharath AK, et al. Pictorial review of wrist injuries in the elite golfer. BJSM Sep 2016, 50 (17) 1053-1063.

Joint and Muscle Flossing

Have you heard of this relatively new treatment technique commonly called "flossing"? 

The rise in popularity of floss bands (or compression band therapy, CBT) can be largely due to interest from the Cross Fit world where it is a popular mobility tool for athletes pre competition and training. The idea and frequency of use in a clinical physiotherapy setting post injury or surgery is limited with a lack of good clinical trials currently available. Potentially, common injuries such as sprained ankles, torn muscles and post-operative surgery stiffness can benefit from such techniques.

The proposed benefits include:

• increasing joint range of motion (ROM)
• improved muscle mobility
• decreasing pain levels
• potentially speed up recovery through effect on myofascial release, occlusion and reactive hyperemia

Application

The practical use is generally limited to the joints and muslces of the periphery (the legs and arms for ease of application) though other areas have been "flossed". Stiff joints and/or tight muscles can be the target. Once shown this technique, floss bands can be self-administered as part of a warm up for training and competition to help tissue mobility. The process involves:

1. Firmly overlap wrap the floss tape (2.5-7.5cm wide latex rubber band) around the limb (muscle or joint) from proximal to distal (although direction has not been scrutinized)
2. Keep on for 2-4 minutes for treatment
3. The joint or muscle is moved through active or passive ROM (such as a squat/lunge/calf raise) (Figure 1)

An video example for floss application for a knee can be seen here

note: Neurovascular precautions should be observed during application to avoid numbness, pins and needles or excessive changes to blood flow

Figure 1. Ankle application and ROM

Research

Research into use of floss bands is limited, with scientific explanation of mechanisms and reliable research outcomes generally lacking. Bohlen et al. (2014) examined the effect of knee CBT on blood flow occlusion of the lower leg and found, while there was some improvement in strength, that reactive hyperaemic arterial blood flow showed no change. This would suggest that CBT does not alter blood flow significantly, though quality of this study was poor with a small sample tested (n=5). A search of several databases for clinical studies using floss bands or CBT revealed:

• RCT on shoulder ROM (Kiefer, Lemarr, Enriquez, & Tivener, 2017) 
• Case report on Achilles tendinopathy (Borda & Selhorst, 2017) 
• Crossover study on ankle ROM and jump performance (Driller & Overmayer, 2017) -  1.8cm improvement in ankle dorsiflexion ROM post application

The primary theory of CBT is credited to fascial shearing or re-perfusion of blood to muscle (though as mentioned above the latter is less likely). The role of fascia is varied and can act to restrain motion, as a connective structure for skin or provide lubrication or gliding movement (Guimberteau, Delage, McGrouther, & Wong, 2010). The same group of researchers looked at fascial sliding in the hand during surgery with a visual description seen in Figure 2. Perceivably, with peripheral joints lacking bulky overlying tissue, this sliding of the superficial fascia is possible with CBT but yet to be researched. Another purported mechanism has suggested some psychological benefits following application of CBT to the shoulder (Kiefer et al., 2017).

Figure 2. Three-dimensional model of continuity between the skin and tendon provided by the sliding system (Guimberteau et al., 2010)

Conclusion?

At this stage any conclusions are merely anecdotal. Application of CBT/floss bands can potentially be a useful adjunct to current treatment techniques for acute joint sprain stiffness and restoring ROM. In my experience there seems to be a consistent effectiveness with ankle and knee ROM in the short term. Further review for the effectiveness with knee ROM post-surgery is warranted due to the increased presence of knee stiffness that is often seen. More studies are still needed though to get a better understanding of the proposed mechanisms of floss band treatment.

For more information or to give it a try ask one of your physiotherapists next time you see them!

References

Bohlen, J., Arsenault, M., Deane, B., Miller, P., Guadagno, M., & Dobrosielski, D. A. (2014). Effects of applying floss bands on regional blood flow. International Journal of Exercise Science, Conference Proceedings, 9(2). 

Borda, J., & Selhorst, M. (2017). The use of compression tack and flossing along with lacrosse ball massage to treat chronic Achilles tendinopathy in an adolescent athlete: a case report. Journal of Manual & Manipulative Therapy, 25(1), 57-61. doi:10.1080/10669817.2016.1159403

Driller, M. W., & Overmayer, R. G. (2017). The effects of tissue flossing on ankle range of motion and jump performance. Physical Therapy in Sport, 25, 20-24. doi:10.1016/j.ptsp.2016.12.004

Guimberteau, J. C., Delage, J. P., McGrouther, D. A., & Wong, J. K. F. (2010). The microvacuolar system: how connective tissue sliding works. The Journal of hand surgery, European volume, 35(8), 614. doi:10.1177/1753193410374412

Kiefer, B. N., Lemarr, K. E., Enriquez, C. C., & Tivener, K. A. (2017). A Pilot Study: Psychological Effects of the Voodoo Floss Band on Glenohumeral Flexibility. International Journal of Athletic Therapy and Training, 1-16. doi:10.1123/ijatt.2016-0093

Knee pain whilst cycling: Does your bike fit?

Do you get an increase in pain at the front of your knee after a ride? Has your bike ever been fitted to your bodies dimensions? This blog gets a bit into the science of how cycling related knee pain is caused and what you can do to prevent it.

The knee joint is one of the most common joints suffering from overuse injuries in cycling, accounting for more than 25% of injuries reported. The likelihood of knee pain (known as patellofemoral pain syndrome or PFPS) can be attributed generally to two factors:

• Intrinsic factors:
  • changes in under or over-active musculature
  • mechanical variances such as increased Q angle
  • knee joint morphology
  • female gender
    • (Bailey, Maillardet, & Messenger, 2003; Dettori & Norvell, 2006; Ward, Terk, & Powers, 2005)
• Extrinsic factors:
  • bike geometry and setup can increase patellofemoral joint (knee cap) stress resulting in knee pain
  • mileage and training load
    • (Asplund & St Pierre, 2004; Bini, Hume, & Croft, 2011)

The two primary causes of knee pain commonly seen in cycling by a physiotherapist are problems with muscle activation patterns and bike setup.

Muscle Activation Patterns

Muscle activity of the lower limb during pedaling has been studied, with the onset and offset of EMG activity in relation to crank position during pedaling shown in the figure below (figure 1). This shows the activation of the gluteals (GMax) and quadriceps (VM, VL, RF) (known as the power muscles) initiating before top dead centre (TDC) which are then followed by the hamstrings (SM, BF) and calf (GM, GL, Sol) (known as the coordination muscles). The power phase continues until bottom dead centre (BDC). Mechanical efficiency during pedaling is somewhat reliant on the activation and coordination of all active leg muscles and is not simply the result of any single muscle in particular. 

Figure 1. Duration of EMG during pedaling (Hug & Dorel, 2009)

The power muscles will generally increase in activation with increases in workload (i.e. go faster = work harder) whereas the co-ordination muscles change little but optimise a smooth transmission of power at TDC/BDC positions. Weakness of your glutes can lead to an increase in quadriceps workload and possibly increased kneecap stress. Riders with poor pedaling co-ordination are also likely to increase use of their power muscles at lower loads which can eventually lead to:

• fatigue 
• less efficiency
• greater potential for stress throughout the kinetic chain(common in recreational cyclists)

So, if you are getting this kind of pain a few tips that are important to know include:

1. Higher quadriceps forces --> higher knee cap compression forces --> greater risk of kneecap pain (PFPS) 
2. Correct strengthening of power muscles can prevent this
3. How to effectively time hamstring and calf muscle activity throughout TDC/BDC whilst pedaling to improve technique

Bike Setup

Several studies have looked at seat height as a causative factor in predisposing the knee to injury. The correct seat height will allow effective recruitment of your glutes and calf muscles as well as unloading the overstretched hamstring and neural structures. Common bike setup measures are shown in figure 2 below.

Figure 2. Common bike setup measurements (Wisbey-Roth & Visentini, 2016)

Measurement of correct seat height can be done with two common methods:

1. Seat height (L5 measure in figure 2) as a percentage (usually 95-98%) of total leg length (measured as vertical distance of greater trochanter to floor) plus cleat sole height
   • This can involve a crank length (L6) adjustment
2. Knee angle when the foot is at BDC and the cyclist is seated
   • For PFPS prevention the accepted angle is 25 degrees, slightly greater (30-35 degrees) for tendinopathies or ITB syndrome

A lower seat height (often seen in recreational cyclists) has been shown to increase contact forces at the kneecap joint and will often be the most likely cause of pain.   

Take Home Message

• Seeing a sports physiotherapist can help identify if there are muscle weakness or activation problems and give you advice on how to correct these. This can lead to improved efficiency and reduction in pain. 
• When treating cyclists with knee pain it is important to consider an optimal bike setup and riding position that is conducive to the ranges of the cyclist’s biomechanical limitations. This can not only minimise injury but also improve performance.
• There are many elements to setting up your bike that can be altered (seat height is just one!). So if you suffer from pains in other parts of your body whilst riding (back, neck, shoulders etc) discuss this with your physio who can perform a bike-fit assessment or refer you to someone that can.

References

Asplund, C., & St Pierre, P. (2004). Knee pain and bicycling: fitting concepts for clinicians. The Physician and Sportsmedicine, 32(4), 23. 

Bailey, M. P., Maillardet, F. J., & Messenger, N. (2003). Kinematics of cycling in relation to anterior knee pain and patellar tendinitis. Journal of Sports Sciences, 21(8), 649. 

Bini, R., Hume, P., & Croft, J. (2011). Effects of Bicycle Saddle Height on Knee Injury Risk and Cycling Performance. Sports Medicine, 41(6), 463-476. 

Dettori, N. J., & Norvell, D. C. (2006). Non-Traumatic Bicycle Injuries. Sports Medicine, 36(1), 7-18. 

Hug, F., & Dorel, S. (2009). Electromyographic analysis of pedaling: A review. Journal of Electromyography and Kinesiology, 19(2), 182-198. 

Ward, S. R., Terk, M. R., & Powers, C. M. (2005). Influence of patella alta on knee extensor mechanics. Journal of Biomechanics, 38(12), 2415-2422. 

Wisbey-Roth, T., & Visentini, P. (2016). Optimising Biomechanics in Cycling (Course Notes). 

Low Back Pain in Golf

The who/how/why of low back pain in golf

Not an entirely uncommon occurrence following a round of golf for many of us, but this does not have to be the case.

Low back pain is generally considered to be the most common complaint by golfers. It has been reported that actual injuries to the low back occur in 11% of male golfers while the actual incidence of low back pain, in the same cohort, is 52% (Batt 1992). The Titleist Performance Institute (TPI) report that 28% of all players deal with low back pain after every round (TPI, 2015). Causes of low back injuries can vary and can include disc or facet irritation, stenosis with associated nerve impingement, degenerative joint disease and occasionally spondylosis (TPI, 2015).

"28% of all players deal with low back pain after every round"

The movements of the golf swing (figure 1) are generally referred to in phases of backswing, early and late downswing and early and late follow through (McHardy and Pollard 2005).  This large amplitude of movement involves rapid and forceful generation of power incorporating the hips/pelvis, trunk and upper limb transferring energy from the ground to the club resulting in considerable stress within the spine. 

These forces involve a downward compression, side to side (or lateral) bending and sliding (or back to front shearing) with the compressive loads at the 3rd and 4th lumbar vertebrae (L3/4) segment shown to peak at up to 8x body mass (Hosea et al 2010). Range of movement of the torso covers a large amplitude beginning in 30 degrees of forward flexion and by the end of the swing finishing in 30 degrees of extension (TPI, 2015). It is no wonder then that the discs that occupy the spaces between these vertebrae become vulnerable to damage.

Figure 1. Phases of the golf swing. (A) Address position; (B) early back swing; (C) late back swing; (D) top of swing; (E) down swing; (F) acceleration; (G) early follow through; (H) late follow through. (McHardy and Pollard, 2005)

Lindsay and Horton (2002) looked at spine motion in elite golfers with and without low back pain and found that those WITH low back pain were inclined to have:

• Increased spine forward bend when addressing the ball
• Increased left side bend during the backswing (in right handed golfers)
• Decreased trunk rotation in neutral resulting in a “supramaximal" rotation during the swing

They also showed that in golfers WITHOUT low back pain there was increased trunk flexion velocity during the downswing, implicit that increasing abdominal muscle activation, strength and force production during this movement may possibly be a protective mechanism (Lindsay and Horton 2002). 

Physiotherapy and Golf Injuries 

When having a physiotherapy assessment or screening, the questions usually asked should be sports specific questions relating to golf and golf pathology. These can include:

• When does the player get pain (during or after a round of golf)?
• What is the nature and intensity of the pain?
• Past history of similar injuries?
• What other injuries or aches and pain are present? (a painful Achillies tendon can speak volumes...)
• Do they have lessons with a golf coach? If so, what are the common swing faults that have been identified? (biomechanical causes)
• Volume of balls they hit per week? (overuse and load-monitoring)

When performing a physical assessment, areas that should be addressed first are often the dysfunctional non-painful movements. In other words, these are movements that the golfer is simply unable to do. This can be an inability to fully squat or having increased stiffness with thoracic rotation (click here for more info about the role the thorax has to play). They tend to be the biggest problems diagnostically and are generally the cause, not the site, of pain.

The physical assessment should also include a look at equipment and set up. Looking at the address position (golf stance) and posture can help determine likely causes and injury patterns and will usually identify when a poor movement pattern is present. What does their grip look like? What do their shoes look like? (including use of orthotics and wear patterns on the sole). Use of video analysis if possible can help identify common swing faults. These swing faults will also shed light on several injury inducing mechanics that can include: 

• Increased Torque by not letting go of the lower body in the follow through and allowing the feet freedom to move
• Excessive Right Side-bend at follow through will add to right side facet injuries and lateral rib stress injuries. This occurs by hanging back or having an increased closed club face
• Early Extension of the hips can increase spine extension range and lead to facet compression
• S-posture (likely associated with a lower cross syndrome) is usually a sign of tight hip flexors and inhibited abdominals and gluteals
• Reverse spine angle (the spine should lean away from target not towards) creates unnecessary trunk movement and will increase the ROM (and subsequent velocity) of the spine during the swing that results in increased stress on facets and discs, more commonly in the right side of the lower back (in right handed golfers). Sway can exacerbate this fault

To discuss any of these issues or to have a golf specific screen get in touch to find out more.

References

Batt, M. E. (1992). A survey of golf injuries in amateur golfers. Br J Sports Med, 26(1), 63. doi:10.1136/bjsm.26.1.63

McHardy, A., & Pollard, H. (2005). Muscle activity during the golf swing. Br J Sports Med, 39(11), 799-804. doi:10.1136/bjsm.2005.020271

Hosea TM, Gatt CJ, Galli KM, et al. Biomechanical analysis of the golfer's back. In: Cochran, A. J. (2010). Science and Golf (Routledge Revivals). Florence: Taylor and Francis. Retrieved from http://ebookcentral.proquest.com/lib/latrobe/detail.action?docID=592967

Lindsay, D., & Horton, J. (2002). Comparison of spine motion in elite golfers with and without low back pain. J Sports Sci, 20(8), 599-605. 

TPI (2015). Course notes Level 2 Medical and online lecture material, Titleist Performance Institute.

Running with Hip Pain - Femoral Neck Stress Fractures

Stress fractures commonly occur in sports where the movement demands of the sport produce repetitive loads on the body. Sports involving running, jumping and dancing place the individual at a higher risk of a bone stress injury. The incidence of stress fractures in the femur can range from 2.8% to 33% of all stress related injuries (both to the shaft and neck of femur). Management of these injuries requires an accurate diagnosis, often long periods of activity modification and rehabilitation (generally <4 months). The rehab program requires the close monitoring of a gradual and structured increase in load to allow the individual to return to full activity.

Stress fractures to the femoral neck are quite rare and are seen most commonly in long distance or marathon runners. While only accounting for a small percentage of all stress fractures they are considered to be quite serious given the length of time required for recovery and tendency to require surgical fixation if not addressed early. Differential diagnosis should therefore also consider other possible causes such as:

• Bursitis
• Tendonitis
• Muscle strain or injury
• Avascular necrosis
• Slipped capital femoral epiphysis
• Sacroiliac injury
• Acetabular and pelvic fractures
• Hip joint arthritis
• Perthes disease
• Femoroacetabular impingement (FAI)

What is a stress fracture?

A stress fracture can occur as the result of fatigue failure of bone where the amount of microscopic damage from repetitive load exceeds the bones ability to repair and remodel. The femoral neck is particularly vulnerable due to the fact that the majority of vertical compression forces load through the femoral head, falling medially to the shaft of the femur. This creates a compressive load medially and tension load laterally.

A stress reaction, or fracture, occurs when there is a failure of the bone to remodel adequately with the addition of repetitive sub-threshold stress. This ability of bone to adapt to pressure, or lack of it, is known as Wolff’s Law and refers to the bones anisotrophic ability to manage load along multiple axes. Cortical bone, of which the majority of the skeletal system is comprised, is heavy and has a slow metabolic turnover which can increased the likelihood of stress related injuries. Especially when there is inadequate recovery time after exercise and loading.

Mechanical load on the bone in the form of intrinsic loading (stress) or mechanical deformation (strain) is required for bone remodelling to occur. When a stress injury occurs the bone is unable to cope with the excess amount of stress or strain.

Factors to consider when determining the effect a load may have on the skeletal system would include:

• Amount of load (volume, rate and frequency of load application)
• Bone health and geometry (bone mineral density and anatomical cross sectional area can be used as measures of this)
• Activity of surrounding muscle (where muscle strength and balance can have a protective effect on shearing loads) 

Load on a bone can be classified as compressive, tensile or shear. When a bone bends it will experience a compressive load on one side and a tensile load on the contrary side.  Usually a failure of bone integrity will occur on the tensile side. This can result in microscopic damage accumulating and fatigue failure of the bone occurring, described as “crack initiation” (Knaeding et al, 2005). Without adequate rest and recovery time, this process will continue towards a “crack propagation”  which results in a macroscopic failure of the bone.

Causes

Risk factors for developing stress fractures can broadly be categorised as intrinsic or extrinsic in nature.

Intrinsic factors:

• Endocrine deficits (particularly in female athletes)
• Bone geometry and density
• Poor patterns of loading and pathomechanics
• Inadequate nutritional profile
• Vitamin D deficiency 
• Overall physical fitness

Extrinsic factors:

• Recent changes to training variables (such as increased frequency, intensity and duration)
• Poor biomechanics
• Poor set up 
• Poor or incorrect equipment use
• Footwear
• Environmental considerations 

Diagnosis

Diagnosing a stress fractures of the femoral neck requires:

• A thorough history exploring known risk factors:
  • Medications
  • Diet
  • Occupation
  • If female, menstrual history
  • Sudden increase in physical activity involving repetitive sub-maximal loads
• Pain in the region of the groin or proximal femur (and occasionally asymptomatic knee referred pain)
• Palpable pain of the hip joint and pain at the extreme end of range with passive hip joint movements
• An active straight leg raise and log roll test may elicit groin pain
• Functional tests such as single leg hopping have been shown to be positive in almost 70% of patients 
• Imaging to confirm diagnosis:
  • Plain x-rays, while often negative in the early stages may show periosteal callous formation and intraosseous sclerosis. Plain x-ray sensitivity has been shown to range from 12-56% (Wright et al, 2016)
  • Gold standard is with MRI and/or bone scintigraphy. Sensitivity for bone scintigraphy is slightly less (50-97%) compared with MRI (68-99%) (Wright et al, 2016)

Table 1. Classification grade of stress fractures on MRI.  *STIR – short tau inversion recovery

Femoral neck stress fractures can be classified as compression or tension type:

• Compression injuries generally occur at the inferomedial cortical bone of the femoral neck have better outcomes due to the reduced risk of displacement. These are usually managed conservatively with good outcomes
• Tension injuries generally occur at the superolateral aspect of the femoral neck have been shown to have poorer outcomes and display greater rates of displacement. Due to this increase risk they must be diagnosed early in order to prevent poorer outcomes. These can often progress to a displaced fracture and inevitably end up with surgical internal fixation

Delayed diagnosis has been shown to be associated with poorer outcomes in athletes. A study of 23 athletes with femoral neck stress fractures with follow up over 6 years following injury noted the most significant aspect of management was a delayed diagnosis with 13 athletes requiring internal fixation. The average time to confirming the diagnosis was 14 weeks after initial onset of symptoms. The injuries requiring fixation were career ending for all elite athletes in the study (Johansson et al, 1990).

Management and Rehabilitation

Successful conservative management of femoral neck stress fractures requires:

• early diagnosis
• a graduated return-to-sport protocol -  guided by pain

The most important determinant to be made with femoral neck injuries is the site of stress. Lateral femoral neck injuries are considered a high-risk stress fracture compared with medial sided compression stress. As a result, a slower, more cautious conservative rehab approach should be taken with a longer recovery time for lateral sided compression injuries.

Management should be done in collaboration with a sports medicine physician who can address other possible intrinsic causes. Physiotherapy treatment is paramount as this will guide the athlete back to a sporting performance level. A guideline for time frames and loading is summarised in table 2.

Table 2. Time frames and guidelines for return to activity (Wang et al, 2015;  Kaeding et al 2005) 

Evidence for return to activity with femoral neck stress fractures is poor, lacking any substantial randomised control trials, and limited only to expert opinion based articles and case series (Wang et al, 2015). General consensus shows that a minimum period of 4-6 weeks of strict non-weight-bearing must be carried out until pain free. This can then be upgraded to partial weight-bearing, weight-bearing as tolerated and then followed by full weight-bearing. 

Continual and regular assessment is important to ensure the pain does not return and that suitable loading and subsequent healing has occurred. Follow up radiographs can be done to ensure adequate healing without progression of a fracture line. Non-impact exercises can then be gradually introduced followed by low impact and finally running exercise is allowed. Progression through such loads is only allowed in the absence of pain. Regression of load is needed if pain returns.

If you are a runner and have noticed a gradual increase in hip pain with running training, contact us at The Physio Lab for an opinion and discussion on what the possible causes might be and further management options to prevent a potentially serious injury from occurring. 

Kaeding, C.C., Yu, J.R., Wright, R., Amendola, A., Spindler, K.P. (2005). Management and return to play of stress fractures. Clinical Journal of Sports Medicine. 15(6), 442-7. doi: 10.1097/01.jsm.0000188207.62608.35

Wright, A.A., Hegedus, E.J., Lenchik, L., Kuhn, K.J., Santiago, L. and Smoliga, J.M. A (2016). Systematic Review with Evidence-Based Recommendations for Clinical Practice Diagnostic Accuracy of Various Imaging Modalities for Suspected Lower Extremity Stress Fractures. Am J Sports Med. 44(1), 255-263. doi: 10.1177/0363546515574066

Johansson, C., Ekenman, I., Tornkvist, H., & Eriksson, E. (1990). Stress fractures of the femoral neck in athletes: The consequence of a delay in diagnosis. Am J Sports Med, 18 (5), 524–528. doi:10.1177/036354659001800514

Wang, T., Matheson, G., and Safran, M.R. (2015) General Treatment Concepts for Stress Fractures. In Miller, T.L. and Kaeding, C.C. Stress Fractures in Athletes: Diagnosis and Management. Springer International Publishing, Switzerland doi: 978-3-319-09238-6

Breathing and Chronic Neck Pain

Stress can play a significant role in ischaemic muscle pain (a restriction in blood supply to muscle tissue) and/or neck pain. With this, the role of of breathing should be brought into the clinical equation. This is not only due to the proximity of the respiratory muscles to the thorax (rib cage) and neck, but also due to the connection breathing has with various emotional states in our lives. Think of how you hold your breath in reaction to shock or suspense or how your breathing is effected by anxiety or stress.

When I see patients that present with neck pain I would usually sub-classify them, in my own terms, as either ‘pathological necks’ (those with symptomatic pathology such as boney, muscular or neural) or ‘stress necks’. Not the most accurate descriptions, and often not so clean cut, but this basically enables me to identify that a 'stress neck' will probably not respond as well to traditional manual therapy techniques and is usually better off with modalities such as dry needling, generalised upper body exercises, breath work and general advice on stress management.

"Does a poor, weak, posture cause respiratory dysfunction?"

When managing neck pain that is the result of stress, a focus on breathing and breath work exercises can have a two-fold effect. Firstly, it can mobilise the ischaemic muscles that are, at least in part, the result of a static cervicothoracic spine. Many cervical muscles have their origins on the thorax and are associated with respiration. The effects of breathing can therefore result in improvements in neck and thorax posture. Secondly, there is a resultant stress reduction due to an increase in mindfulness surrounding the pattern and rate of breathing. Breathing techniques that slow down the out breath can help stimulate the parasympathetic part of the nervous system which can reduce stress levels in the body.

The respiratory system is involved in our bodies response to stress. Its role is to breathe faster to increase oxygen and blood circulation throughout the body. This system can be impaired by static postures - think of those hours sitting at the computer or in work meetings and the stiffness that occurs in the neck and upper back. The dysfunctional muscle patterns and poor breathing mechanics that result from these static postures will therefore be a contributory element in the way that the body reacts to stress and in its ability to bring the body back to a state of calm and rest. 

Dimitriadis, Kapreli, Strimpakos & Oldham (2016) recently reviewed the role a dysfunctional respiratory system can play in chronic neck pain. They extrapolated causality quite nicely in this model (figure 1) looking at the various mechanisms and manifestations of neck pain and how they relate to poor respiration. Interestingly they point out that drug use to manage pain can reduce respiratory drive, while on the other hand, noxious stimuli can increase respiration and alter rib cage mechanics. Both these changes lead to dysfunctional breathing patterns that can alter blood chemistry and result in hypocapnia (low carbon dioxide levels). This is often seen in patients with chronic neck pain. They do note that while changes are seen in respiratory function, they are not at a level that can be classified as pathological at this stage. More good quality trials are needed to better understand this relationship.

Figure 1

The same group of researchers (Dimitriadis, Kapreli, Strimpakos & Oldham, 2013) also showed that patients with chronic neck pain (noted as having pain for a period of at least 6 months with weekly episodes) compared to healthy matched controls, showed significant reductions in maximal inspiratory and expiratory pressures most likely related to poor global and local muscle systems. This may raise a chicken and the egg dilemma: Does a poor, weak, posture cause respiratory dysfunction or is it the other way around?

A simple method to teach diagphragmatic (or abdominal or belly) breathing is as follows:

• Assume a comfortable position, usually lying flat on your back with your knees bent up, in a quiet and calm environment
• Begin by relaxing your shoulders and arms
• Place one hand on your chest and the other hand on your belly/naval region
• Inhale slowly through your nose for 5-8 seconds
  • As you breathe in, your belly should rise and your lower ribs should expand outwards with minimal upper chest movement
• Exhale slowly through your mouth relaxing your chest wall and abdomen, usually for the same duration (or slightly longer) than your breath in

The link between stress and neck pain is very important. Posture also plays a significant role in neck pain. This is where I think that bridging these two areas is necessary. Attention to the role of breathing mechanics and respiratory rate within the context of good alignment of the spine, is something were we, as physiotherapists and educators, can have a big impact on patients with stress related chronic neck pain.

For more information on physiotherapy management techniques of chronic neck pain please seek an opinion from your physio. 

Dimitriadis, Z., Kapreli, E., Strimpakos, N., and Oldham, J. (2016). Respiratory dysfunction in patients with chronic neck pain: What is the current evidence?, Journal of Bodywork and Movement Therapies, Article in press. Available online 8 February 2016. doi.org/10.1016/j.jbmt.2016.02.001.

Dimitriadis, Z., Kapreli, E., Strimpakos, N., and Oldham, J. (2013). Respiratory weakness in patients with chronic neck pain. Manual Therapy, 18(3), 248-253. doi.org/10.1016/j.math.2012.10.014

Running Pains

So you have finally decided to follow through with one of those new year resolutions. After dusting off the running shoes the kilometers are slowly starting to pile up and things are taking shape for the up coming running season. Only you notice a niggle, a slight ache creeping into your daily movements. Here we outline 5 areas where pain shouldn't be ignored. If this sounds like you, check in with your physio or sports doctor who can shed some light as to its possible cause and how to resolve it.

1. Iliotibial Band (ITB) pain

Probably one of the most common running injuries. Why should we worry about ITB, or lateral (outside) knee pain? Lots of runners get into trouble when they push on with this problem. The ITB is a thick band of fascia that extends from the outer side of the hip and pelvis to the outside of the knee acting as a stabiliser for knee mechanics during activities such as running. It extends from the tensor fascia late (TFL) and superior gluteus maximus muscles.  The quality of ITB pain is usually a relentlessly predictable pain on the outside of the knee which comes on every time you reach 'x' kilometers. It is pointless attempting to push on through the pain (many try and fail) and why should you when there is plenty you can do about it.

Using a foam roller, the go to treatment for this condition, is rarely enough. Most will often only roll the band itself without addressing the associated TFL or glute max tightness. It usually is a little more multifaceted where you may need gait retraining to change some non-optimal biomechanics. For example you might have:

• a stiff hip
• poorly utilised glutes
• reduced thoracic control and movement
• inappropriate foot wear

Many people have a gait pattern that is too narrow and their feet aren't widely spaced enough, this leads them to scissor across at the mid line during running resulting in a tightening of the this tissue. If there is a focal ITB problem (swelling or thickening), you might end up needing a ‘rescue injection’ just before that marathon (which still might not guarantee you’ll get around comfortably). This will require a visit to a qualified sports physician. The moral of the story is, get help early with an experienced running physiotherapist, who can help you make these changes.

2. Hip and Groin Pain

There is really no such thing as a “Groin Strain” and despite what we might be told, its actually not that common to have a true hip flexor problem. Groin pain often results from the many structures around the hip and pelvis. Whilst you might be tight in your hip flexors, more often pain at the front of the hip is due to hip impingement (a.k.a. ‘FAI’), overload of the pubic bone area or problems at the back of the pelvis at the sacroilliac joint (SIJ).

Probably the most serious cause of groin pain in runners is a stress fracture involving the neck of the femur. It can have disastrous consequences if not managed properly. You might have the beginnings of a stress fracture if:

• You can feel pain in the groin every time your foot strikes the ground
• You have ‘random’ pain which ‘comes and goes’ and seems to move around
• If you are “aware” of your niggle at night time.

 It’s really important that you get checked out early, and you may need an MRI scan to do this. X-rays are not sufficient to detect stress fractures. 

3. Foot pain

Metatarsal stress fractures are common in runners who present with foot pain, usually with a history of a gradual onset of symptoms that are slow to settle. Pain in the ball area of the foot might also be the result of a neuroma or sesamoiditis (inflammation of two pea sized bones under your big toe).

A neuroma feels like a lancing or knife like pain, between the heads of the metatarsal bones. It occurs when a nerve gets pinched, often between the 3rd and 4th toes, and results in a local swelling and inflammation around the nerve. It is often more common particularly if the arch across the front of your foot is flattening out. Neuromas can be made better with certain taping techniques, some appropriate orthotics from a podiatrist, alterations and gait pattern re-education. Some may even benefit from a cortisone steroid injection by a Sports Physician.

Sesamoiditis feels like an intense pain under the ball of your big toe felt at push off or in pivot sports such as golf. It is easily managed with so simple orthotics or padding to offload the effected area in combination with some load management strategies.

Running with a foot stress fracture (seen mostly in the navicular or head of the 5th toe) can grind you to a halt requiring an extended period of rest and possibly surgery. These injuries often require a period of rest (sometimes in a boot) to allow the bones to settle. Appropriate imaging is needed to get an accurate diagnosis to plan bow best to manage them. 

Always seek a proper diagnosis with these symptoms. All may not be lost and seeking advice early is the best bet.

4. Heel pain

Sometimes plantar fasciitis isn’t plantar fasciitis! Sometimes pain in the area of your heel can be a calcaneal stress fracture or nerve irritation. Plantar fasciitis needs a proper biomechanical work up (usually from head to toe as the problem does not start in the foot but merely finishes there). Questions that should be asked include:

• Do you have a stiff ankle or foot, which reduces its ability to re-distribute ground reaction forces, which overloads the plantar fascia? 
• Are your foot intrinsic muscles working correctly?
• Do you have a poorly functioning thoracic rotation movement pattern or reduced hip mobility?
• Do you have weak soleus calf muscles, or a tight calf complex?
• Maybe you simply need some different footwear or orthotics?

Shockwave therapy has been shown to be helpful in some resistant/specific cases of plantar fasciitis. Great Physiotherapy work will help you to resolve this more swiftly than you imagine, so don’t push on through the pain. Identifying where your body is failing to load correctly is often the most effective management strategy in the long term.

5. Shin splints

Particularly if these are severe you might actually be running the risk of a tibial stress fracture rather than just overload of the junction between the soft tissue and the bone. It is not uncommon to see patients post-marathon who actually have run (in agony) with a tibial stress fracture, whilst believing that they had simply a ‘bad case’ of shin splints. DON’T be tempted to run through this.  It can end in a very, very length rehabilitation process (or even surgery) to fix the bone. Addressing poor foot intrinsic muscle function a control is a great place to start. Stand up and try to bend and flex your big toe in isolation from your other toes while standing... having trouble getting the message across? 

Get proper physio advice for this and other intrinsic exercises is a good place to start managing painful shins. They can assess the injury to determine how to best manage such problems. If there is any doubt, they can then recommend you seek the specialist attention of a Sports Physician early on who can get appropriate imaging and blood tests to determine if there is an underlying cause.

All of these conditions, if given early attention, can typically be resolved swiftly and conclusively. So don’t grit your teeth and jog-on with pain. Get it sorted!

Note: This article was adapted with approval from a previous version written by Dr Cath Spencer-Smith - an Exercise and Sports Medicine Doctor based in London UK (more about Cath at http://www.sportdoclondon.co.uk/ )

Concussion in Sport - The "Sprained Brain"

If you are happy to take 2-4 weeks off the field when you sprain your ankle, why then would you not do the same if you sprain your brain?

There has been increased awareness regarding concussion injuries in contact sports over the past few months with the start of the upcoming football season. Indeed head injuries are a weekly sight when watching professional NRL, AFL and Super Rugby matches. Management of these injuries are well scrutinised and we look to these professional codes to set a safe example for local sporting clubs to emulate on weekends. The advent of recent litigation cases resulting as a consequence of players prematurely retiring from professional football due to recurring head injuries and subsequent side effects has created much needed discussion about what is best practice when it comes to the management (short and long term) of such injuries.

The main issue causing concern is how to manage a concussion, or head injury, if and when they occur. It can happen at elite level as seen with the on-field assessment and management of the professional players that get 'knocked out' during a game. Rules and regulations have tightened over recent years with medical and coaching staff coming under close scrutiny for how and when they can let a player return to the field of play. But it can also happen at the weekend local under 8's game of rugby league where there is often no medically trained people available.

What is a concussion 

The meaning of the word concussion comes from the Latin word 'concutere' ('to shake violently') which fittingly describes how this most common form of traumatic brain injury occurs. The brain literally shakes inside the skull that can create a coup and contracoup style of injury. This can cause trauma to the cerebral brain tissue, the suspensory ligaments and the fibres that hold it in place resulting in an alteration in metabolic state that can last for up to 4 weeks. It can be associated with a variety if physical, cognitive and emotional symptoms that may or may not always be recognised, especially if they are subtle. 

Signs and symptoms to look out for 

• Headache
• Disorientation
• Dizziness
• Vomiting, and/or nausea
• Poor balance
• Possible loss of consciousness
• Post traumatic amnesia
• Confusion or irritation
• Altered or blurred vision
• Tinnitus or ringing in the ears

How to manage a concussion

As a general rule always following the first responder procedure learnt in basic first aid is the first priority. This being the DRSABC (Danger, Response, Send for help, Airway, Breathing, Circulation). Once this has been cleared then a safe assessment and management of the concussion can follow:

• Make sure there is no associated neck injury, if suspected call an ambulance and do not move the injured player
• Monitor signs and symptoms for at least 6 hours as these can be latent 
• If symptoms begin to worsen seek medical attention at hospital immediately
• Physical AND cognitive rest for 7-10 days (longer in children and adolescents) - such as time out from phone/TV/computer screens
• Medical assessment and be symptom free prior to returning to physical training with a graduated return to activity

As with as a sprained ankle, you are more susceptible to another concussion following initial injury, especially if you have returned to sport before the symptoms have fully settled. Repeated concussions can have long term detrimental effects and have been shown to increase the risk of dementia, Parkinson's disease and depression later in life.

If in doubt, and you suspect a concussion injury, consult your doctor or sports physiotherapist for a thorough assessment and advice with management. The athlete should be totally symptom free before returning to play and a rough guideline for a safe return to sport should follow:

• First Concussion - Review with doctor and minimum 2 weeks rest from contact sport 
• Second Concussion - Mandatory review with Sports Medicine Specialist for a thorough neuropsychological assessment followed by 4-6 weeks rest from contact sport
• Third Concussion - Repeat neuropsychological assessment, appropriate medical imaging of the head. Extended rest and/or no sport for the remainder of the season (3-6 months)

Post-Concussion Syndrome 

In recent years only has it become apparent in professional sport that a history of repeated and recurring concussive events can have a lasting and detrimental effect on the brain and its function. Post-concussion syndrome (PCS) has been described in the literature where features relating to concussion last for weeks, months or even years following the traumatic event. It is generally accepted that PCS can occur in up to 15% of those suffering from one concussion.

Symptoms of PCS can be similar to those experienced with an acute concussion but may also be less obvious such as behavioral, cognitive (such as memory loss and poor attention) and increased irritability and as such can often be misdiagnosed or overlooked. There is no treatment of PCS as such but instead treatment is symptom based and may require physiotherapy, behavioral therapy or medication.

For further information see http://sportconcussion.com.au/ or download the "First Responder" App to your phone for use on game days.

Do you know how to activate your core?

So often we go to the gym or an exercise class and hear the words “turn on your core”. How many of us actually know what these words mean and how effective are we really being at using the muscles that stabilise our spine when we move? 

Unfortunately the term ‘core’ has become generic for anything abdominal. Just because we are doing regular abdominal strengthening exercises, does not mean we have an effective core. In fact, certain stomach strengthening exercises can do more harm than good, especially in people with lower back pain, neck pain and postpartum mums with a split in their abdominal wall.

The abdominal wall consists of four separate layers of muscles. Although all four layers have a role in spinal stability, the deepest layer is the most important when it comes to safety of the spine. This deep layer is a thin, endurance type muscle called the Transverse Abdominus. It is often the problematic muscle when we talk about the core. An effective contraction of this muscle co-ordinates with the pelvic floor muscles, diaphragm muscle and breathing to pre-tension the fascial system around the spine to keep the spinal segments safe when we move. 

Accurate activation and correct timing of this deep layer are very important. The core needs to be on before we load the spine. There are many reasons the timing of the deep layer is inhibited. Pain is the most common reason, but fear of movement and asymmetries in the abdominal wall that are caused by dysfunctional movement patterns in other parts of the body can also inhibit the core. All of our abdominal muscle attach to the thorax, so twists in this part of the body can have a huge effect on our abdominal function

We can see the layers of the abdominal wall with real-time ultrasound (RTUS) (click here for further information about RTUS). Being able to visualise them contracting on the screen, can help you learn and understand what you are really meant to be doing and how to co-ordinate this contraction with your breathing and your pelvic floor.

An effective core is important for spine health in every day function, but it is even more important during exercise and especially with heavy lifting in the gym. Men can also get an abdominal separation when they use an incorrect bracing strategy with heavy weight lifting. Heavy lifting in the female body with incorrect abdominal patterning is more likely to injure the pelvic floor.

You are welcome to make an appointment with us to have your core contraction assessed - you will be surprised how simple it is.

To Stand or Not to Stand?

Most progressive work places are beginning to recognise the perceived health benefits of standing and will offer their employees the option of a standing desk (or adjustable sit-to-stand desk that can be raised and lowered as desired) or at the very least be open to the option of investing in such changes in the office.

To Sit...

By now it is common knowledge that sitting all day at work is not only bad for your posture but sustaining such long periods of sitting can also adversely effect your health and lead to an increased risk of cardiovascular disease, obesity, poor blood sugar control, diabetes and even cancer. Not to mention the increased risk of eye strain and visual disturbances along with reductions in cognitive and neurological function. 

Then there are the postural and musculoskeletal problems relating to prolonged sitting. These are well known and will often see you and/or your staff members spending plenty of time and money visiting the local physiotherapist. Common problems will vary from person to person but can range from:

• Weak and/or poor activation of the gluteal and core muscles
• Tight hip flexor muscles
• Strained neck and shoulder muscles
• Damage and compression to spinal discs
• Headaches and neck pain

So the answer is to stand up at work instead, right?

To Stand...

Well not necessarily. There is still a lack of any concrete studies showing that standing all day at work has superior health benefits when compared to sitting. A systematic review by MacEwen et al (2015) revealed there is a lack of research in this area and that standing alone seems to show few physiological improvements when compared with sitting (treadmill desks on the other hand showed several benefits... but that is taking the topic a bit far here!). Often the use of a standing desk in a workplace will be short-lived. People try with little success, usually due to fatigue and soreness, which eventually leads them to return to the easier option of sitting. The benefits of standing have been documented but they are often anecdotal and nothing more than personal accounts and tributary blogs written about its benefits. They include:  

• Reduced lower back pain
• Increased productivity
• Improved leg strength and increased balance
• Increased calorie consumption
• Improved general body circulation (which is contrary to the increased risk of varicose veins)

But do the pro's out way the cons? There are several adverse side affects to having prolonged periods on your feet. Some research has shown that standing at work for longer that 6 hours a day can lead to:

• Increased circulatory stress resulting in varicose veins
• Increased risk of carpal tunnel syndrome with increased leaning while using a computer
• Fatigue
• Hip/knee/foot pain

The answer is, as with most things, about having the flexibility and the option to do both. There are many styles of desks now that can be adjusted to allow you the ability to both sit for a period and, with a slight adjustment, stand for a period. Standing at work is a new posture for many people, so it will take time for the body to build endurance for sustained standing.  Here are a few tips to reduce the chance of causing pain and to make the transition a bit easier: 

4 Tips for standing:

1. Stand differently - If you find yourself standing for longer periods where your body is stuck in extension (and often pain), try a few pelvic tilts using your anterior core and posterior gluteal muscles to set yourself in a slightly more neutral tilt. Here are some tips to correct poor pelvic position.
2. Breathe better - another way to get your pelvis to posterior tilt is to exhale fully, which lowers your rib cage and relaxes that increased lumbar lordosis. Try a table top stretch like this one but rest your hands higher than your hip height.
3. Rest postures - try to find time to sit, lie on your back on the floor or a half kneeling lunge position. While standing try to adopt a split stance position where is it harder to hang on one hip or arch your lower back into a fixed lordosis. Try some simple extension exercises like standing with your back to the wall and sliding your arms vertical up the wall.
4. Wear good footwear - obviously a no brainer if you are standing a lot. All feet are different so match the shoe you need with you foot you have. Feet with poor arch stability will need increased support and firmer feet might need more padding. Ladies, high heels + standing all day is never a good idea, so keep a change of shoes under your desk.

Whether you choose to sit or stand at work it is important that you do both well. Incorporating periods of standing into your nine to five working day is important to prevent extended periods of static, often poor postures and to help keep your body moving, healthy and hopefully injury free.

Headaches; A Pain in the Neck?

Most people will suffer from a headache at some point in their life. In fact, the WHO reports that up to 47% of people will have suffered from a headache within the past 12 months.

The cause of a headache is often multi-variate. It can be the result of a physical injury or illness, emotional or psychological stress, pharmacological overuse or genetics. They can have a huge impact on a persons quality of life and can often result in time off work. Neck pain and cervical muscle tenderness are commonly featured in primary headache disorders.

TYPES OF HEADACHE

According to the International Classification of Headache Disorders (ICHD) headaches can be classified into primary and secondary causes. Primary headache classification includes:

• Migraines
• Tension-Type headache 
• Cluster headache 
• Other primary headaches

Migraine headaches are uncommon and are generally attributed to a vascular inflammatory cause.  They can often begin early in life and be life long. Features of migraine are the sporadic 'attack' type nature, increasing intensity, short duration of a few hours, association with auras (such as light and sound) and nausea. Most effective management is medical with correct use of non-steroidal anti-inflammatory (NSAIDs) and analgesia (aspirin/panadol) medication. Acupuncture and relaxation techniques have also been shown to be effective in prevention of recurrence. New evidence with the work of Dean Watson however is showing that Migraine type headache can result from a sensitisation of the nerves of the upper 3 cervical vertebrae... more on that below.

Tension-Type headaches (TTH) are by far the most common type. They account for nearly 90% of headaches. The pressure-like pain from TTH is often felt from the base of the skull and can radiate to the forehead, eyes and neck. It usually effects both sides. Causes can include stress, sleep deprivation, posture, eyestrain and even hunger.

Cluster headaches are very rare and are identified by frequently recurring but brief, extremely severe headaches. These are usually felt one sided and with pain around the eye. There may be some associated autonomic symptoms such as tears, redness, nasal congestion, swelling and eyelid droop. There are limited effective treatments available. Most treatment options involve medication which are best discussed with your doctor.

In treating headaches, it is useful to understand the difference between a primary headache (such as TTH) and and secondary headache (such as cervicogenic). Management of these headache types vary though their symptoms may be similar. There is a vast list of secondary causes of headache, most needing further investigations and management with your medical doctor. Any severe headache that is new or different to your normal headache pattern should be investigated medically first.

Cervicogenic headache

Physiotherapy can successfully treat TTH, migraine and cervicogenic headaches that arise from the neck and surrounding soft tissue structures and help to prevent their recurrence. The symptoms experienced in relation to a headache that is referred from the upper 3 vertebra (C1/2/3) in the cervical spine (neck), can mimic a migraine, including the associated aura and nausea.

The upper 3 vertebra can refer pain to the face and head through the links between the nerves in the neck and the trigeminocervical complex (TCC) found in the upper cervical spinal cord. This linkage of nerve pathways allows pain from the neck to be referred to the face. Muscle spasm, joint stiffness, neural hypersensitisation and vascular changes can all be a source of pain in headaches referred from the neck. It is not uncommon for people who suffer from headaches to have identified certain triggers for their headaches. Certain foods, hormone cycles, dehydration and posture are all possible triggers which can sensitise the structures in the upper neck and result in a headache. 

Poor loading patterns of the neck and head can result in postural causes (relating to muscles and joints of the neck) that are associated with headaches, the term cervicogenic headache is often used. This term relates to headache symptoms that include:

• neck and/or jaw pain (such as following a whiplash injury)
• pain felt in the forehead or back of head
• feelings of dizziness or light-headedness

The symptoms often worsened with prolonged/sustained neck positions or repetitive neck movements (such as when using computers/phones/tablets). They are often eased by manual pressure to the base of the skull.

PHYSIOTHERAPY MANAGEMENT OF HEADACHE

Hands on treatment (manual therapy) of these types of headaches has been shown to be effective in reducing the severity of symptoms and frequency of occurrence. Your physiotherapist can use various manual techniques such as massage, joint mobilisations, dry needling and taping to correct any imbalances around the neck and to restore normal movement and mechanics to the joints in the upper cervical vertebrae. Your physiotherapist can help you recognise your triggers associated with the headaches and use these as a re-assessment tool to monitor the progress of your treatments.

Postural re-education is an important component of managing these headaches as stress on the lumbar and thoracic spines can create sub-optimal patterns of loading in the head and neck. Re-training of the deep stabiliser muscles around your neck and mid back (thorax) with a biofeedback tool and correcting the imbalances of the larger muscle groups has been shown to be effective in long term headache management. 

Your physiotherapist can show you how to alleviate your symptoms through self-massage and specific self-mobilising techniques to maintain the mobility of the upper cervical joints. It is important to identify the patterns of movement and the structures in the body that are responsible for your symptoms. Your physio will identify which static postures or dysfunctional movement patterns that you have adopted in your daily movement tasks or sports are contributing to your headache. Restoring normal movement patterns in your thorax and neck can help prevent further occurrences. 

An ergonomic assessment of your work station will often be recommended by your physiotherapist. Correct setup of your computer at work (or home) can help manage symptoms. This may require changes to chair/desk height, monitor position and height, foot placement and sitting postures. Using a standing desk may be an appropriate alternative, read more here to learn about this. Your physio will help you understand how your posture at the computer is related to your headache.

Finally, management of a headache is multifaceted and will often require attention to other factors such as:

• Diet  
• Sleep patterns
• Medication (prevent overuse)
• Lifestyle choices and stress management strategies

Discuss these and other treatment options with your physiotherapist.

Patellofemoral Pain

Patellofemoral pain (PFP) represents about 25-40% of all knee injuries. It presents as anterior knee pain that is worse with stairs, squatting, jumping, running and after long periods of sitting. It is an injury that is often poorly rehabilitated and it is not uncommon for symptoms to persist for years after the initial onset. 

Unfortunately, persistent symptoms often result in reduced levels of activity and in some cases  physical activity is stopped all together, which has long term consequences for our general health.

The key to managing PFP pain is to address it early (anterior knee pain is common in adolescents) and rehabilitate it thoroughly. Most rehabilitation programs fail because they are not specific enough and are not continued for long enough to build the strength and endurance necessary for the knee to cope with the loading demands of everyday life.

So what causes PFP?

There is ongoing debate as to the cause of PFP, but a widely recognised theory is that mal-alignment or mal-tracking of the knee-cap (patella) alters the stress on the tissues of the joint between the patella and the femur. 

Symptoms most commonly start with an overload situation. Too much, too fast, too hard is a common story in PFP.

Some of the risk factors for PFP are:

• Weak quadriceps muscles especially when there is an imbalance between the medial and lateral quadriceps muscles
• Weak gluteal muscles which effects the alignment of the thigh bone under the patella
• Weak core and trunk muscles
• Weak calf muscles
• Foot pronation and poor dynamic function of the foot
• Tight hamstrings and calves

Pain is a big factor in perpetuating the patterns of weakness seen in PFP. Once the knee is symptomatic, the body alters its movement patterns and reduces the loading demands on the knee to avoid and reduce pain. This results in further de-conditioning of the relevant muscles and perpetuates a vicious cycle of chronic pain and weakness.

An accurate diagnosis is important as there are many causes of anterior knee pain and the rehabilitation of these other injuries differ slightly from PFP rehabilitation. Taping of the patella during the initial phases of rehabilitation is important to manage pain and allow the rehabilitation program to progress. Exercises that target all the relevant muscles in the lower limb and pelvic area need to be progressed as the symptoms improve and need to be continued until the strength of these muscles match the demands of your lifestyle.

Once again, rehabilitation of PFP often fails because the program is not specific enough and it is often stopped before the necessary strength gains are achieved.

A good physiotherapy rehab program for PFP should:

• Educate you as to what factors are contributing to your problem
• Advise you about appropriate activity modification during rehabilitation
• Set realistic expectations for how long the rehabilitation process will take - regaining the necessary strength in the appropriate muscles takes time!
• Motivate you to stay on board with the rehabilitation 
• Manage your pain with hands on treatment and strapping
• Use foot orthotics where appropriate
• Address any biomechanics issues or technique issues in sport that are contributing to the problem
• Especially in Adolescents - manage pain early and rehab well! Remember studies have shown that symptoms can persist for years after initial onset and can predispose the joint to arthritic change in later years

In summary, a good physiotherapy program will:

• Unload
• Settle
• Improve movement patterns
• Reload. 

This process takes time and patience and often requires an element of continued self-management to prevent re-occurrence of the symptoms.

Take home message for PFP:

Manage early, diagnose thoroughly, rehabilitate well and to full function.

Managing a Hamstring Tear

One of the most common muscle tears an athlete will have, is a tear of the hamstring muscles. It can put an athlete out for the season if it is not managed correctly. Hamstring tears can originate in various parts of the muscle (the origin or insertion, muscle tendon or muscle belly) and differ in severity of grade. 

It is usually the result of over exerting the muscle during a sprinting style activity, although a fall, slip or sudden movement may also result in the injury occurring. An early, accurate, diagnosis by a physiotherapist and appropriate treatment will provide the best chance of returning safely to sport in a timely manner.

Anatomy 

The hamstrings are a group of 3 muscles found in the posterior (rear) region of the thigh, extending from the buttocks to either side of the knee. They are some of the longest muscles in the body and are diarthoidial in nature, which means they extend across two joints (the hip and the knee). This last point is important when examining the action of the muscles, as both joints are implicated when an injury occurs. 

The hamstrings can be divided into 2 groups; the medial (inside) and lateral (outside) groups. The medial group is made up of the semimembranosus and semitendinosis. The lateral group consists of the biceps femoris (long and short head). The primary function of the hamstrings is to flex (bend) the knee. It also has lesser functions to extend the hip and control rotary forces at the knee at end of range. They are primarily innervated by the tibial nerve. 

The attachments of the hamstrings all originate at the ischial tuberosity (the short head of the biceps femoris originates at the posterolateral femur). The semitendinosisinsertion fans out in the shape of a ducks foot (pes anserine) and joins with the tendons of Sartorius and Gracilis as it attaches just above the tibial insertion of the medical collateral ligament of the knee. The semimembranosus is attached to the posteromedial tibia. The lateral insertion is less complicated although it incorporates its attachment at the head of the fibula with the arcuate complex at the posterolateral corner of the knee.  

(NB: These variations in attachments are important as often an injury to the hamstring can implicate the medical collateral ligament or the posterolateral corner of the knee) 

Causes 

There are many different factors that can predispose an athlete to a tear:

• Poor flexibility of the muscles  
• Reduced or side-to-side differences in strength of hamstrings   
• Increased neural tightness, often arising from the lower back 
• Inadequate warm up 
• Fatigue 
• Poor biomechanics or running pattern
• Return to activity prematurely following previous injury 

Grade of Tear

Grade 1

• Usually a mild strain where cramping or tightness may be felt. Often there is some pain when the muscle is stretched or palpated. 

• Recovery: 5 days-4 weeks (depending on recurrence and ability to perform a sports specific program pain free). 

Grade 2 

• This grade usually is associated with more marked, instant, pain causing immediate cessation of activity. Athletes often describe a “ping” feeling, like a rubber band has snapped. This is confirmed again with palpation and stretch/contraction pain. There may be signs of swelling and often delayed bruising in and around the area. 

• Recovery: 4-6 weeks

Grade 3 

• This is a complete rupture and is quite rare. Usually associated with a slip or fall into a splits position or jerking movement (often with water skiing). There will be immediate loss of strength. Pain is usually present, but not always. There will be a palpable area of swelling and a depression where there is a tear.  

• Recovery: Complete tears require surgical reattachment followed by a 3-6 month specific rehabilitation program 

Physiotherapy and Rehabilitation 

Optimal recovery from an injury to the hamstrings requires accurate diagnosis and grading. The length of time from injury is important in determining a suitable program. An individualised rehabilitation program should follow a basic timeline of:

• acute/subacute phase
• repair/remodelling phase
• functional/return to activity phase  

Timelines for the use of Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) has been debated with some professionals opting for immediate use (to prevent adverse effects from the injury that may interfere with tissue remodelling) and others suggesting a delay of 2-4 days post injury (to prevent interference with the inflammatory response and the laying down of new muscle fibers). It is best to discuss this with your treating physio or doctor. 

Acute/subacute Phase (1-14 days) 

The goals of this phase include reduction of pain and swelling and restoration of normal range of motion (ROM). This initial treatment follows the general principles of RICE (rest, ice, compression, elevation) and may involve the use of aides with more severe injuries. Once pain is reduced, gentle soft tissue massage and ROM exercises can begin, progressing from passive to active-assisted to active movements.  

Eventually flexibility and strengthening exercises can be started, commencing with closed chain. Cardiovascular exercise can commence, such as cycling, swimming and light jogging. A graduated running program can be commenced once pain free and is progressed accordingly (see running program). 

It is important to perform adequate strengthening, flexibility and balance exercises as advised by your physiotherapist. Returning to activity too early can pre-dispose to re-injury. 

Repair/remodeling Phase (1-6 weeks) 

During this phase strengthening can be progress to open chain concentric exercises, initially with low weight and reps and slowly increased. This can then be progressed to eccentric exercises but should be done carefully at first so as to avoid over exertion and lumbo-pelvic compensations. Strength should be progressed to reflect similarity with the unaffected leg. At the same time flexibility and balance (proprioception) should be worked on and progressions through the running program. 

Other modalities such as ice/heat, dry needling, taping and joint mobilisation may also be used throughout this phase. 

Functional/return to activity Phase (2 weeks-4 months) 

By this phase there should be no pain, normal gait pattern, good strength and ROM. Functional, sport specific exercises can gradually be incorporated into the program after careful discussion with your physiotherapist.

This is where the graduated running program is very useful as is provides a suitable progression of intensity and volume of activity. Plyometric and dynamic exercises can also be added to improve speed and power. Extrinsic variables such as use of equipment and balls can also be introduced in this phase. The patient should be reminded of the importance of a warm up and should continue doing flexibility exercises. 

Surgical Repair 

The need for surgical intervention is rare but generally required for grade 3 complete ruptures when the tendon has come off the bone. The time frame from injury to surgery is variable with good results in both acute and chronic cases (although acute intervention is preferred).

References

Warren P, Gabbe BJ, Schneider-Kolsky M, et al. Clinical predictors of time to return to competition and of recurrence following hamstring strain in elite Australian footballers. Br J Sports Med. Aug 14 2008;[Medline]. 

Agre JC. Hamstring injuries. Proposed aetiological factors, prevention, and treatment. Sports Med. Jan-Feb 1985;2(1):21-33. [Medline]. 

Clanton TO, Coupe KJ. Hamstring strains in athletes: diagnosis and treatment. J Am Acad Orthop Surg. Jul-Aug 1998;6(4):237-48. [Medline]. 

Sallay PI, Ballard G, Hamersly S, et al. Subjective and functional outcomes following surgical repair of complete ruptures of the proximal hamstring complex. Orthopedics. Nov 2008;31(11):[Medline]. 

THE THORAX IN GOLF

It is an all too common story in golf. An acute or overuse injury to the lumbar spine will result in a change in swing mechanics, poor shot selection and a few lost balls. This is due to pain it causes or physical impingement that results, or both.  So after repeated treatments with your local physiotherapist to manage the low back pain only give temporary relief at best. Then some x-ray or MRI images are sort after which pain the picture of a degenerative back with possible disc damage. Next stop is the orthopaedic surgeon for surgery to fix the picture. The problem is the problem never really goes away. What if the lumbar spine is not the problem in the first case?

How many of you have walked into a clinic expecting to be treated for your lower back only to find yourself having some manual therapy done on your thorax (mid back)? This combined with some exercises that address the mobility and control of your mid back are what you then work on. Don’t be too surprised to find the lower back pain will often then lessen or, better still, disappear.

Does a pain-free thorax then equate to ideal mechanics in your spine?

The Thorax

The thorax is inclusive of the thoracic spine, the ribcage, chest plate and internal organs, forming 20% of our total body length. Contrary to popular belief, the thoracic spine works in combination with the ribs attaching to each vertebrae, forming a ring. It is the function of these rings in relation to each other (translation and rotation) that gives the thorax its mobility. For further information about how these thoracic rings work click here.

The thorax often gets under or misreported as lower back pain in a lot of clinical data. It is in the thorax predominantly that most of the rotation of the spine occurs. Compensatory rotation of the lumbar spine, especially when combined with flexion (bending) such as during a golf swing, can make the lumbar discs increasingly vulnerable to injury. The lack of thoracic rotation is seldom due to stiffness but instead a lack of adequate neuromuscular control of the joints in the thorax.

Now consider the number of muscles that attach from your thorax to your pelvis, head/neck and shoulders, all of which are pivotal in transitioning force generation from the pelvis to the upper limb in the golf swing. Lower thorax issues will most often impair and alter the functional movements of the pelvis resulting in loss of stability, strength and movement. Similarly, a poor upper thorax will alter the ability to lift and rotate the shoulders, arms and head/neck.
 

The Body-Swing Connection 

The sequence of body segments during the downswing (in a right hander) follows first the pelvis translating and rotating to the left, then rotation of the thorax, then arms and club back toward the ball. Dysfunction in the thorax will prevent the optimal transition of segmental movement from your lower body into your upper body and club. This can result in any number of the compensatory swing faults commonly seen. This impaired swing is also less effective (resulting in shorter and less accurate shots) and may also lead to further injury and overuse of other body segments.

A simple test to determine whether or not your thorax is affected and contributing to the dysfunction is to:

1. Sit on the edge of a chair, fold your arms across your chest

2. Turn as far as you can with your upper body, without moving your backside off the chair

3. Compare this from left to right, can you turn 90 degrees to both sides?

Questions to ask:

• Is there one side tighter than the other?

• Is there pain? Where is the pain?

• Are you actually moving your thorax versus turning your neck, side bending your trunk or pulling your shoulders around?

Treating a Dysfunctional Thorax

Treating the thorax may involve manual therapy by a physiotherapist to release fixated joints or normalise over/under active muscles that are preventing optimal movement. The body is an incredibly interconnected unit and more than just the sum of all its parts. Often there may only be one or two primary areas creating this suboptimal movement, which is generally referred to as a 'driver' as it is the lead cause of the problem (or primary and secondary drivers where there is more than one).

Once the driver has been identified (this may not necessarily be the thorax but can be elsewhere in the body) and normal motion is restored to that area, it is important to then retrain the brain to make effective use of the increased range of movement and to regain neuromuscular control of that area. Knowing where and what your driver is can help you address the problem with greater efficiency. This is where communication between your golf coach, physiotherapist and fitness trainer is important.

"Knowing where and what your driver is can help you address the problem with greater efficiency"

Motor control exercises to correct the primary driver and facilitate new muscle patterns are important to prevent unwanted muscle tone and postures from returning following treatment. Ever walked out of the therapist treatment room feeling great only for this to disappear 2 days later? Exercises to retrain and strengthen the area of treatment play a vital role and can include simple movements where specific segmental muscles are cued with appropriate feedback (often with tape, biofeedback or use of mirrors).

Gaining better activation awareness and strengthening of the serratus anterior muscle can obtained with exercises such are wall slides (as seen below) and with the use of resistance bands. Devices such as the TPro (from Gravity Fit) can aide and improve in feedback of the thoracic control muscles during various rotational movements that mimic the golf swing. It can also then be taken on range to incorporate this training into sport specific practice once the correct skill is obtained.

Appropriate thoracic strength and power exercises, and subsequent golf specific drills, can be added to increase performance measures. It is important to maintain the correct cueing pattern throughout, until such a time that the correct movement becomes automatic. Understanding where your driver can simplify this process and is key to effective long term management of such musculoskeletal conditions.

Treating the thorax may not fix your golf swing but it will enhance your movement pattern and ability to sequence body parts. This then decreases the chance of acutely injuring your back on the course or creating an overuse condition. Once you can optimise the fundamental movement components of a swing progress with your teaching professionals can help lead to improvements on the course.

For further information about a back pain in golf, or to have a golf screen, click here. For a physiotherapy appointment click here to book online.