Nearly 60% of patients who present with hip pain are due to a condition called trochanteric bursitis. This form of bursitis is more common in women and the middle-aged or elderly, than in men or younger athletes.
Low back pain (LBP) is an extremely common symptom in the general population, with up to 80% of people suffering from various levels of discomfort and limitation in their daily lives.
LBP is a mystery, even to the experts, with it often not caused by trauma, such as lifting a heavy couch or a bruising tackle in a contact sport. It is often due to an ‘insidious onset’, such as bending forward to put your shoes on or picking up a pen awkwardly from the floor.
In managing back injuries, the physiotherapist will perform a thorough assessment to exclude obvious diagnoses, such as fractures and the more serious (rare) conditions such as malignancy or osteoporosis. Following this, it is often not possible to make a precise diagnosis. However physiotherapy management involves an identification and correction of any abnormalities in movement patterns, as well as strengthening the muscles around the spine, to minimize the risk of back pain returning.
The more common clinical causes of low back pain include Non-Specific Low Back Pain (NSLBP), Intervertebral Disc Degeneration / Sciatica and Lumbar Stress Fractures (and its associated conditions).
1. Non-specific Low Back Pain (NSLBP)
Low back pain can be caused by structures being too tight (hypo-mobility) or too loose (hyper-mobility). The pain producing structures in the lumbar spine include the vertebra, the facet joints (links two vertebra together in your spinal column), intervertebral disc, ligaments, nerves and their protective coverings, muscles and their attachments.
With our activities of daily living (whether this is by being inactive or participating in sport) these structures may become overloaded and fatigued over time. This ‘wear and tear’ cause’s micro-trauma within the facet joint or intervertebral disc, causing it to ‘lock’, preventing the joint from moving smoothly throughout its normal range. This can result in pain, movement dysfunction and degeneration.
2. Intervertebral Disc Degeneration / Sciatica
The intervertebral discs are composed of a soft, inner nucleus pulposus surrounded by a tough fibrous outer ring, the annulus fibrosus. With trauma and / or ageing, the annulus fibrosus can weaken and thin (disc degeneration or herniation), particularly with the repetitive combination of bending forwards while rotating the trunk i.e. lifting. This may result in the disc bulging outwards and exerting pressure on one or more of the closely associated spinal nerves. This disc degeneration process is often incorrectly termed as the ‘disc slipping out and in’, and it’s important to realise that this does not occur. In some serious cases, the disc may leak some fluid into the spine from the internal nucleus pulposus, known as a disc prolapse.
Compression of a spinal nerve by a disc fragment causes radiculopathy, which may include weakness of muscles controlled by that spinal nerve, pain in the distribution of the nerve root, or sensory changes such as numbness, tingling, or hypersensitivity in the same area. Back pain is often experienced in conjunction with these symptoms. Sciatica is a term used to describe pain which occurs in the distribution of the sciatic nerve, a major nerve in the leg made up of several spinal nerves from the lower spinal cord.
3. Lumbar Stress Fractures
LBP may also be caused by spondylolysis, or a stress fracture of the pars interarticularis, a region of the vertebra. This is often seen in sports involving repeated back extension and rotation, such as gymnastics, cricket fast bowling or tennis. While it was thought to be congenital, it is probably an acquired overuse injury. The fracture usually occurs on the opposite side to the one performing the task i.e. a left sided fracture occurs in a right handed tennis player.
Spondylolisthesis, which is defined as a slippage of one vertebral body forwards in relation to the one below, can also cause LBP. This usually occurs where the lumbar and sacral spines meet at the bottom of the back. This slippage may be caused by stress fractures of the pars regions (as above), degenerative changes in the spine, congenital defects of the spine, or trauma. The result is pain caused by spinal nerve compression, with symptoms similar to those seen in spinal canal stenosis, or irritation of nerve endings at the joints, which results in back pain. It is most commonly seen in children between the ages of 9 and 14 years of age.
4. Spinal Canal Stenosis
Another commonly encountered cause of LBP is spinal canal stenosis. It is a condition that is rare in young and middle-aged athlete’s, but may be seen occasionally in older athletes. The condition is caused by arthritic degeneration of the spine, resulting in the vertebra, facet joints, and ligaments which surround the spinal nerves of the spinal cord to become enlarged. In this manner, these structures may compress one or several spinal nerves, causing LBP, leg pain, and leg numbness while walking. These symptoms maybe relieved by rest.
In the management of most cases of LBP, investigations are not required. However, there are certain clinical indications that require further investigations. This may include:
- X-ray: to exclude fractures and to ‘screen’ those patients whose LBP is not responding to treatment.
- CT scan: is commonly performed in patients suspected of nerve root compression, spinal cord stenosis or facet joint pathology.
- MRI: is used to investigate the structural status of the intervertebral disc i.e. degeneration (‘bulging’) or a tear in the outer annular wall.
Symptoms of LBP May Include:
- Pain in the back and occasionally in the legs
- Difficulty in moving i.e. can’t straighten up or uncomfortable sitting
- Muscle spasms in the back
- Referred pain and / or altered sensation into the groin, thigh, leg or foot
- Sleep can be disturbed with pain on rolling over
- Slumped positions such as that in a car seat or on the couch at home, cause pain
- Pain sometimes on coughing and sneezing
- Pain on weight bearing
What can Physiotherapists Do To Help?
The physiotherapy management varies depending on the specific back diagnosis of the individual athlete, but will possibly include:
- Massage of the muscles to relieve pain, muscle spasm and promote healing.
- Gentle joint mobilization techniques to relieve the spinal segment and ‘free it’ to move without pain, throughout its full range.
- Strapping techniques in the acute stages to protect the vulnerable joints.
- Commence a progressive muscle strengthening program to improve both your core stability and general back strength, so as to protect your intervertebral disc, their associated ligaments and joints, from ‘general wear and tear’. The major muscle groups that work in synergy to protect the back and the spine are: (1) the multifidus, a deep back muscle and (2) the transversus abdominis, which joins the back bone with the rib cage. Recent scientific evidence has shown in a variety of different populations with LBP, whether you are an athlete or not, that these deep back muscles, in particular the multifidus, have shrunk in size and strength.
- Maximise your muscle flexibility, in particular your hamstrings, buttock and hip muscles.
- Improve your physical fitness and advise you on ongoing activity as maintenance.
- Provide postural education on reducing the load on the joints and muscles, so as to minimize the recurrence of back pain. This includes modifying your daily work tasks, sporting and personal activities.
Published by Balmain Sports Medicine
Aching at the front of the knee is one of the most common presenting symptoms in athletes. It is typical in children and more common in girls than boys.
The two most common causes of anterior knee pain are
- Patello-Femoral Syndrome
- Patellar Tendinopathy
Diagnosing these conditions can often be difficult as they often have similar symptoms, and can even present together. The patello-femoral joint is formed by the knee cap (patella) sitting on the front of the thigh bone (femur).
As the knee bends, the patella moves in a groove found at the end of the femur. The patella is a floating bone. Therefore, the patella’s position and function depend intimately on the structures that attach to the patella. This is important to remember when we discuss treatment and management.
Patellofemoral Pain What is it?
Patello-femoral pain occurs when the under surface of the patella (knee cap) is pain sensitive, due to damage and irritation to any of the pain sensitive structures between the patella and femur. This can be caused by incorrect tracking, or movement of the patella, as the knee bends and straightens. The patella rubs against the femur, instead of gliding correctly in the groove.
What causes it?
Remember the patella is a floating bone. Therefore, structures that are too tight will pull the patella into the wrong position. Usually the tightness occurs in the lateral thigh structures (tensor fascia latae, gluteals, quadriceps, hamstrings, calf) and a loss of muscular control (and strength) of the inner quadriceps muscle, the vastus medialis oblique (VMO). Typically, the ‘tug-of-war’ between the outside and inside structures is won by the outside, pulling the patella laterally. Eventually, too much incorrect rubbing leads to inflammation, pain, swelling and dysfunction (ie difficulty walking down stairs and hills). What are the symptoms?
- Pain that gradually worsens with activity i.e. running
- Pain going up or down stairs
- Pain with squatting
- Pain with prolonged sitting (movie-goers knee)
- Pain deep in the front of the knee
- Giving way or a feeling of instability
- Recurrent clicking What can be done? A thorough physical and biomechanical assessment, including functional testing to reproduce the patient's pain and locate the nature of the symptoms is required.
Physiotherapy management is based on scientific research led by physiotherapists. Treatment concentrates on improving the control of the patella, leading to a successful recovery and return to sport.
This will include:
- Relative Rest: inflammation must settle for motor control to improve • Minimise inflammation: regular application of ice will provide pain relief. Anti-inflammatories prescribed from your doctor may also assist at this time.
- Taping: of the patella to correct abnormal patellar position, will minimize pain and facilitate the contraction of the VMO / quadriceps muscle.
- Massage: plays an important role in allowing the lateral structures to stretch by ironing out any tight knots.
- Foam Roller and Self Trigger Point Management: self massage at home will help improve the effects of stretching and restore muscle function and alleviate tightness
- Increase Strength: of the VMO, to improve the control of the patella, and pelvic stabilisers (i.e. gluteal muscles of the buttock), to minimise the load on the patellofemoral joint.
- Correction of Pre-Disposing Factors: this ensures that the problem doesn't re-occur and can include advice on training principles (overload and recovery) and biomechanical issues such as lower limb mechanics including foot posture and function:
Patella Tendinopathy In the past this injury was labelled ‘patella tendonitis'.
Tendonitis suggests inflammation of the patella tendon, however recent clinical research has more accurately termed it ‘patella tendinopathy'. Histochemical examination indicates that there are few if any inflammatory chemicals in the patella tendon when it has pain and dysfunction. Hence the name change to tendinopathy. What is it? Patella tendinopathy, or ‘Jumper's knee', refers to a painful overuse injury of the patella tendon, which connects the kneecap (patella) to the shin (tibia). This occurs as a result of degeneration (either acute or chronic) and a 'weakening' within the patella tendon itself, without the presence of inflammation. Many cases of patella tendinopathy also co-exist with patellofemoral syndrome.
What causes it?
It is caused by excessive loads on the patella tendon, particularly if there are insufficient rest periods. It is most commonly seen in athletes that engage in running and jumping type sports, such as netball or basketball. What are the symptoms? • pain is well localised (from a dull ache to severe and sharp) at the front of the knee
- anterior knee pain is usually of a gradual onset
- jumping and landing activities will increase the pain • the bottom of the patella will be tender to touch
- pain will occur with squats and stairs, particularly descending • below the patella can be swollen, or ‘puffy', but this is rare
- unlikely to be episodes of giving way or instability What can be done? Rehabilitation is a lengthy process and the athlete may take from 3 - 6 months to return to sport. This may include:
- Rest / Ice: Reducing your activity levels and regular periods of applying ice is essential to prevent the patella tendon becoming more sensitive and painful.
- Taping: of the patellofemoral joint should be used if it is contributing to the symptoms. Taping the patella tendon itself can also assist in reducing the load on the tendon.
- Massage: is performed on the patella tendon to improve local blood flow and release adhesions between the collagen fibres that compose the patella tendon. Often other thigh structures (quadriceps, iliotibial bands) will also need to have any trigger points resolved.
- Stretching: poor hamstring and quadriceps muscle flexibility can overload the patella tendon. Hence, a regular stretching program, particularly in ‘growing' children, is essential.
- Increase Strength: a quadriceps strengthening program is needed to increase the tensile strength of the patella tendon. This involves a graduated series of exercises, that start slowly, and then progress by increasing the speed and weight involved during exercise.
- Correction of Pre-Disposing Factors: as already outlined in ‘patellofemoral pain' above, these changes ensure that the problem doesn't re-occur in the future.
- Surgery: if conservative management fails, then surgery can be a possibility with long-standing patella tendinopathy. Further investigations (ultrasound, MRI) can assist in determining whether surgery is required. The rehabilitation process is slow and lengthy, following the principles outlined above. A return to sport is approximately 6 - 12 months, with only 60-75% of patients returning to their previous levels of sport.
Published by Balmain Sports Medicine
RUNNING SCIENCE, an associated specialist running shoe store, provided some invaluable information on the ‘life' of your running shoe.
If you consider that your feet strike the ground between 600 - 1,000 times per kilometre (depending on your pace) at 2.5 - 3.5 times your body weight while running, it follows that footwear plays a critical role in running enjoyment, performance and injury prevention.
Running shoes that are improperly sized, unsuitable for your biomechanics or training needs and/or have gone past their use-by date can cause injury. Researchers have shown a significant correlation between infrequent changes of running shoes and injuries.
What can you expect from your running shoe?
Essentially it is very dependant on how much time you spend in your running shoes. As a general rule a good shoe will allow you to enjoy approximately 900 - 1,100km of running.
Why do running shoes where out?
Research has demonstrated that the midsole material of a running shoe will last for approximately 700-1,000 kilometres or 6-12 months, depending on the mileage and intensity of training. The midsole provides the important cushioning and stability to a shoe, so once it has worn out the shoe loses its functional stability and increases your injury risk.
The outsole of a running shoe is made of durable compounds and is a poor indicator of remaining shoe life. In most cases, the midsole will wear out long before the outsole - especially for heavier runners.
Signs of Wear and Tear?
You need to examine the major areas of decomposition - the heel counter, the midsole and the outsole - any extrinsic abnormality causes an imbalance of impact forces and may increase the risk of injury to your lower limbs.
- Look at the heel counter - is there any wearing on the inside or outside? Wearing on the inside can actually promote over-pronation and its associated overuse injuries, while wearing on the outside can occur even with a normal running gait pattern.
- Look at the midsole - is there any excessive compression, wrinkling or tilting? Monitor the torsional (twisting) stability of the shoe. Hold either ends of the shoe and twist in opposite directions - is there too much flexibility?
- Look at the outsole - have you worn through the rubber to the midsole? Can you start to feel the irregularities of the ground under your feet?
Tips to Get the Most Out of your Shoes
- Reserve your running shoes for running only! Not gardening, bush-walking, cycling etc.
- Rotate your shoes: alternate between 2 pairs of running shoes so as to extend the life of the midsole beyond that of wearing each pair consecutively. Thus:
- Use one pair for longer runs and any ‘events' and the second pair only for shorter runs, inclement weather and any off-road runs.
- The first pair to reach 1000 km run, should be given a new job description, (i.e. gardening, fishing etc) and a new pair should be brought into the rotation.
- Asplund. C, Brown (2005), The Running Shoe Prescription. The Physician and Sports Medicine, 31(1)
Published by Balmain Sports Medicine