Eccentric Training – The Best Bodybuilding Workout Ever – Physiotherapists Kerry

Physiotherapists Kerry – Overview of Eccentric Weight Training

When I was younger I used to concentrate on how much weight I could lift. I reached some decent levels with a 300kg squat, 180kg bench press and 320kg deadlift at a pretty young age. As I have grown older(and wiser), my goals have changed and I am more concerned Physiotherapists Kerrywith health, longevity, minimizing injury risk, holding a decent level of strength and muscle mass while keeping in shape. I have as a result totally changed my training. I still go close to failure but at a much higher rep range, no singles. I train less, warm up more and make sure to incorporate stretching and mobilization exercises , especially for my spine.

The biggest change I have made to my training in an attempt to keep the intensity but lower the risk of injury, is that I do exercises much slower, especially the eccentric part. This is where you lower the weight in free weights movements or on a pulley type machine where you release the weight. It is generally the easier part of the movement. The eccentric phase of a lift occurs when a muscle contracts while lengthening. This is the down motion of the bench press, biceps curl, or squat. The concentric phase of a lift occurs when a muscle contracts and shortens, as in the up motion of the bench press, biceps curl, or squat. Just to explain things even simpler.  Concentric is where you are lifting the weight. For example say on a bench press concentric is where you are pushing up a weight off your chest, eccentric is where you are lowering the weight to your chest. It is a great pity I didn’t discover the benefits of eccentric weight training when I was younger, because it is such an effective, underutilised method of building muscle and strength.

What I want you to think about first is why would you cheat on an exercise in the gym, concentric or eccentric….why swing or bounce through a range of motion where the muscle does not engage…Isn’t the idea of  training to stimulate the muscle. Do you really think doing a quarter rep with the leg press loaded up is working all your muscles. The only thing it is working is your ego. The idea is to build balance in your physique and this can only be done with full movements. Say you do a quarter squat, you are mainly just working vasti muscles (lower quad) to the detriment of hamstrings, glutes and upper quads etc. which all get worked in the full squat.

Below is a set of upper body exercises that will work almost the entire upper body in a single session. I have keep the list to a minimum because this workout is meant to be minimalist while working the muscles maximally. If you do too many exercises, you will spoil the intensity and slow recovery. I want you to concentrate more on the muscles you are working in each exercise than the amount of weight lifted. The weight does not matter. If you want to make the exercise harder, do it slower. After warming up for each exercise I want you to take a weight, about 70 % of what you can do comfortably for ten reps. I want you to slow everything down especially the eccentric part(lowering part) of the exercise. I want you to perform the eccentric part of each exercise at least three times as slow as the concentric part. Movements in both directions should be slow, controlled and deliberate focusing and isolating the muscles you are working. Do each exercise for one set of as many slow reps as you can. If you have done things properly the muscles you are working should be pumped to the max. You will also begin to understand the effectiveness of this type of training.

Each exercise below is done after warmup and all exercises are done to failure (probably 15 to 20 reps). I keep the rep range higher because it is easier to maintain strict control during each rep as you tire.

  1. Flat bench press with a 2 second pause on the chest at each rep.
  2. Straight barbell curls(no swinging at any stage).
  3. Flat dumbell  bench press – go deep.
  4. Barbell rows (low and slow – pull to below belly button/ touch lower stomach with bar and let the bar down fully – remember you are trying to work your lats and back, not the biceps as such).
  5. Incline dumbell bench press – again go deep.
  6. Wide lat pulldown to front – stay up as straight as you can and flare out lats keeping elbows and shoulders back.
  7. Press behind neck (right down to base of neck) – use a smith machine if you have no spotter.
  8. Narrow grip lat pulldown to front – as above letting the lats stretch out fully on top
  9. Straight arm dumbell pullovers lying sideways across a bench..get a good deep stretch. Keep hips low. Remember our priority here is to stretch that ribcage for a big chest.
  10. Reverse dumbell flies. Lie face down on a 30 % incline bench. These hit the rear deltoid as well as the middle and lower traps, rhomboids etc.

There should be a maximum of 2 minutes rest between each set. This entire program should be done in about 30 minutes. If you have done it properly, every muscle in your upper body should be pumped to the max. This program is more for a novice to intermediate trainer. More seasoned trainers could add a few extra exercises. I cannot over-emphasize that you must slow down and control the weight movement especially during the eccentric phase of each exercise, and focus on working the muscles to the maximum. This is paramount to the success of this program. The strength will always be there and most likely you will have more when you return to looser form.

Bottom line: Eccentric exercise puts muscles under tension for longer, stimulating more muscle growth.

 

Physiotherapists Kerry – phone 086-7700191

Meniscus injuries in the knee – Knee Pain

Knee Pain – Meniscal Tears

Cartilage within the knee joint provides cushioning between the bones at this joint to protect them from the stresses of walking, jumping, running etc. There is articular cartilage which is the smooth, white tissue that covers the ends of bones(Femur, tibia) where they come together to form the knee joint. Healthy cartilage in our joints makes it easier to move. It allows the bones to glide over each other with very little friction. Articular knee paincartilage can be damaged by injury or normal wear and tear. Within the knee you also have fibrocartilage in the form of the medial and lateral menisci. These are two thick wedge-shaped pads of cartilage attached to top of the tibia (tibial plateau) and under the femur bone,  allowing the femur to glide when the knee joint moves. Each meniscus is curved in a C-shape, with the front part of the cartilage called the anterior horn and the back part called the posterior horn. Meniscal tears are usually described by where they are located anatomically in the C shape and by their appearance (for example, “bucket handle” tear, longitudinal, parrot beak, and transverse).

Because the blood supply is different to each part of the meniscus, knowing where the tear is located may help decide how easily an injury might heal (with or without surgery). The better the blood supply, the better the potential for recovery. The outside rim of cartilage has better blood supply than the central part of the “C.” Blood supply to knee cartilage also decreases with age, with up to 20% of normal blood supply  lost by age 40.

What causes a meniscus to tear?

A forceful twist or sudden stop can cause the end of the femur to grind into the top of the tibia, pinching and potentially tearing the cartilage of the meniscus. This injury can also occur with deep squatting or kneeling, especially when lifting a heavy weight. Meniscus tear injuries often occur during athletic activities, especially in contact sports like football and hockey. Motions that require pivoting and sudden stops, in sports like tennis, basketball, and golf, can also cause meniscus damage.

The risk of developing a torn meniscus increases with age because cartilage begins to gradually wear out, losing its blood supply and its resilience. Increasing body weight also puts more stress on the meniscus meaning that routine daily activities like walking and climbing stairs increase the potential for wear, degeneration, and tearing. It is estimated that six out of 10 patients older than 65 years have a degenerative meniscus tear. Many of these tears may never cause problems.

Because some of the fibers of the cartilage are interconnected with those of the ligaments that surround the knee, meniscus injuries may be associated with tears of the collateral and cruciate ligaments, depending upon the mechanism of injury.

Symptoms of a meniscus injury can include some or all of the following:

  • Pain with running or walking longer distances
  • Intermittent swelling of the knee joint: Many times, the knee with a torn meniscus feels “tight.”
  • Popping, especially when climbing up or down stairs
  • Giving way or buckling (the sensation that the knee is unstable and the feeling that the knee will give way): Less commonly, the knee actually will give way and cause the patient to fall.
  • Locking (a mechanical block where the knee cannot be fully extended or straightened): This occurs when a piece of torn meniscus folds on itself and blocks full range of motion of the knee joint. The knee gets “stuck,” usually flexed between 15 and 30 degrees and cannot bend or straighten from that position.  

The diagnosis of a knee injury begins with a history of the injury etc. and physical examination. There have been many tests described to assess the internal structures of the knee. The McMurray test one long used orthopedic test . The health-care professional flexes the knee and rotates the tibia while feeling along the joint. The test is positive for a potential tear if a click is felt or noticeable pain is felt while circumducting the knee in full flexion.

(MRI) is the test of choice to confirm the diagnosis of a torn meniscus. It also allows a radiographer to visualize the inner structures of the knee, including the cartilage and ligaments, the surface of the bones, and the muscles and tendons that surround the knee joint. Plain X-rays cannot be used to identify meniscal tears but may be helpful in looking for bony changes, including fractures, arthritis, and loose bony fragments within the joint. In older patients, X-rays may be taken of both knees while the patient is standing. This allows the joint spaces to be compared to assess the degree of cartilage wear. Cartilage takes up space within the joint and if the joint space is narrowed, it may be an indicator that there is less cartilage present, likely from degenerative disease.

Treatment of Meniscal Tears

Sometimes conservative measures such as physical therapy, NSAIDs and rest can be enough to settle the condition, if it is not too serious. When conservative measures are ineffective the next step may be surgery to repair or remove the damaged cartilage.

Physical Therapists and Physiotherapists in Tralee. Phone 086-7700191

Levator Scapula Muscle Related Neck pain. Physiotherapists and Physical Therapists in Tralee.

Levator Scupula Muscle Related Neck Pain.

The Levator Scapulae muscles are located on either side of the neck. They originate on the four upper vertebrae of the cervical spine (neck) and insert, or attach, to the scapula, also known as the shoulder blade at the superior, medial border. These two muscles are involved in elevation, downward rotation and abduction of the scapulae. They are also involved in flexion and extension of the cervical spine(neck), turning of the neck slightly left and right, along with side bending of the neck left and right.

When you wake up in the morning with a crick in your neck, feel a burning pain on the top inner corner of your shoulder blade, or have trouble turning your head to look behind you while driving etc., the culprit may be a Levator Scapula muscle in spasm. The pain can be described as a throbbing, ache, or tightness, and usually presents from the top inner corner of the shoulder blade up along the neck.

Physiotherapists in Tralee

 

 

 

 

 

 

 

 

Levator Scapula Muscle  Trigger points                 Levator Scapula Muscle

 

What Causes Levator Scapula Spasm / Trigger Points?

A trigger point is a tight area within muscle tissue that causes pain in that area and/or other parts of the body. The trigger points are shown above as two dark red circles, with the pain referral area also shaded in. Muscle spasm is a tightening of a muscle usually, due to overuse or overstress. It  can in itself cause pain and loss of mobility. The following events and activities are likely to activate, or reactivate, tension / pain and trigger points in the levator scapulae.

  • whiplash from an automobile accident
  • sleeping on the stomach with the head turned/or sleeping in an odd position
  • chilling of the muscle during sleep from an air conditioner or draft from an open window
  • working at a computer with the head turned for long periods
  • holding a phone between the shoulder and ear
  • carrying a heavy bag with a shoulder strap
  • use of crutches that are too tall and elevate the shoulder
  • emotional and mental stress
  • Working with your arms raised above your head for prolonged periods of time can also irritate the Levator Scapula. To help reduce neck pain, stabilize your shoulder blade when you raise your arm.
  • poor posture with a forward head position puts this muscle under continuous strain causing overuse.

 

Usually the condition settles after a few days if it is only a once off. Proper hands-on deep tissue massage and dry needling, when used together, can be great to settle the condition either in the short term, or if the condition has become more chronic. Also for the long term, correcting posture, stretching and strengthening of the upper back(particularly middle / lower traps, serratus posterior, rhomboids etc.) and the neck muscles(specifically the posterior neck muscles) can help prevent the condition from returning.

Posture is key to a healthy neck and spine. Try and sit up straight on a comfortable supportive chair, when at work or at home,  allowing the shoulders to relax by using the arm rests of the chair. When at a computer, pull the screen close and try to get it up to eye level (say using books underneath it), so your head doesn’t have to be coming forward. The same applies when driving a car. Pull the seat in close to the steering wheel(within reason),and try to position yourself so the shoulders are relaxed and the head isn’t jutting forward. Activities like reading in bed, playing computer games for hours etc. can really tighten up the levator muscles and are a disaster for thoracic and cervical posture in the long term.
 

Why the Levator Scupula muscle can be a pain in the neck. Physiotherapists and Physical Therapists in Tralee… Phone 086-7700191

Restless Leg Syndrome. Overview by Physical Therapists and Physiotherapists,Tralee

Restless Legs Syndrome 

Restless legs syndrome(RLS) is a nervous system resulting in an urge to move the legs. Because it usually interferes with sleep, it also is considered a sleep disorder. The condition causes an uncomfortable, “itchy,” “pins and needles,” or “creepy crawly” type feeling in the legs. The sensations are usually worse at rest, especially when lying or sitting. The symptoms are generally worse in the evening and at night. The severity of RLS symptoms varies from mild to intolerable. Symptoms can come and go and vary in severity. For some people, symptoms may lead to severe sleep disturbance at night, which can significantly impair their quality of life.

 

Who Gets Restless Legs Syndrome?

Restless legs syndrome (RLS) may affect up to 10% of the population. It affects both sexes, but is more common in women. It may begin at any age, but most people affected are middle-aged or older.  RLS is often unrecognized or misdiagnosed. This is especially true if the symptoms are intermittent or mild.

 

Causes of Restless Legs Syndrome

In most cases, doctors do not know the cause of restless legs syndrome; however, they suspect that genetics plays a role. Nearly half of people with RLS also have a family member with the condition. Factors other than genetic associated with the development of restless legs syndrome can include  certain chronic diseases and medical conditions. These include iron deficiency, Parkinson’s disease, kidney failure, diabetes, and peripheral neuropathy. Treating these conditions often gives some relief from RLS symptoms.

Some types of medications including anti-nausea drugs, antipsychotic drugs, some antidepressants, and cold and allergy medications containing sedating antihistamines , may exacerbate symptoms.  Some women experience RLS during pregnancy, especially in the last trimester. These symptoms usually go away within a month after delivery. Other factors, including alcohol use and sleep deprivation, may trigger symptoms or make them worse.

 

Diagnosis of Restless Legs Syndrome by Physiotherapists/ Doctor

There is no medical test to diagnose RLS; however, doctors may use blood tests or other diagnostic tests to rule out other conditions. The diagnosis of RLS by a doctor or physiotherapist in Tralee is mainly based on a patient’s symptoms and answers to questions concerning family history of the condition, the presence of other symptoms/  medical conditions, use of medications, sleeplessness.

 

Treatment for Restless Legs Syndrome

Treatment of RLS is targeted at easing the symptoms. In people with mild to moderate restless legs syndrome, lifestyle changes, such as beginning a regular exercise program , establishing regular sleep patterns, and eliminating or decreasing the use of caffeine , alcohol, and tobacco, may be helpful.

Non-drug RLS treatments may include:

Leg massages

Hot baths or heating pads or ice packs applied to the legs

Good sleep habits

A vibrating pad called Relaxis

Medications may sometimes be helpful in treatment of RLS but results vary among individuals. Drugs used to treat RLS include:

Dopaminergic drugs, which act on the neurotransmitter dopamine in the brain; Mirapex, Neupro, and Requip, levodopa.

Benzodiazepines, a class of sedative medications, may be used to help with sleep, but they can cause daytime drowsiness.

Narcotic pain relievers may be used for severe pain.

Anticonvulsant drugs  such as Tegretol, Lyrica, Neurontin,  and Horizant.

 

Although there is no cure for restless legs syndrome, current treatments can help control the condition, decrease symptoms, and improve sleep.

 

Physical Therapists and Physiotherapists in Tralee and Dingle, Co. Kerry. Phone Eddie on 086-7700191. Click for Website

Longterm Effects of Poor posture / physiotherapists Tralee

The Long Term Effects Of Poor Posture – Physiotherapists and Physical Therapists in Tralee

Kyphosis is curvature of the spine that causes the top of the back to appear more rounded than normal. Everyone has some degree of curvature in their spine. However, a curve of more than 45 degrees is considered excessive. Poor posture (postural kyphosis) can be caused by over an extended period of time by slouching, carrying heavy bags, reading in bed, hours of forward head posture at a computor, hours playing xbox etc. The resulting continuous stretching of the supporting muscles and ligaments of the spine can lead to an increase in spinal curvature.

Postural kyphosis mainly occurs in the thoracic region(upper spine). It is often accompanied by “hyperlordosis” of the lumbar (lower) spine. The lumbar spine has a natural “lordosis” ie. a backward “C”-shape. Hyperlordosis means the lumbar spine compensates for the excessive thoracic kyphosis with an excessive C-shaped lordosis.
 

Different types of posture

 

Effects of forward head posture

Increased weight of head on the neck with forward head posture

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Sometimes kyphosis causes no symptoms other than the back appearing abnormally curved or hunched. However it may cause:

• back pain and stiffness
• tenderness of the spine
• tiredness
• difficulty breathing

These issues usually become more likely as somebody with this condition(kyphosis) ages.
 

Postural neck pain / Physiotherapists Tralee

The most common condition that contributes to neck pain is forward head and shoulder posture. Forward head posture is when the neck juts forward placing the head in front of the shoulders. This head position leads to several problems. The forward pull from the weight of the head puts undue stress on the vertebrae of the lower neck, contributing to the chances of developing degenerative disc disease and other degenerative neck problems. Similarly, this posture causes the muscles of the upper back to be continually overworked counterbalancing the pull of gravity from the forward head position. Forward shoulder posture can also lead to impingement/injury of the supraspinatus muscle causing shoulder pain/disfunction. The more time spent with a forward head posture, the more likely it is that one will develop neck and shoulder problems.
The part of the neck most vulnerable to forward head posture is the lower part of the neck (C5 and C6 ), just above the shoulders. These cervical vertebrae may slide or shear slightly forward relative to one another as a result of the persistent pull of gravity from a forward head posture. This can sometimes be seen as a little step in these vertebrae at this area. Prolonged shearing of the vertebrae from forward head posture often irritates the small facet joints in the neck as well as the ligaments and soft tissues.
This irritation can result in neck pain that radiates down to the shoulder blades and upper back, due to the following conditions:
 
• Trigger points in the muscles. These are points of exquisite tenderness that are painful to touch, also leading to reduced range of motion in the neck.
• Disc degeneration problems, which may potentially lead to cervical degenerative disc disease, cervical osteoarthritis, cervical herniated disc etc.
• Neuropraxia ; Nerve pain due to nerve compression by tight muscles of the neck, locked cervical/thoracic facet joints, and/or compression of nerves due to discogenic disorders.
Muscular neck pain can be caused by the following neck/ shoulder muscles becoming tight due to being overworked:
• Scalene muscles (three pairs of muscles that help rotate the neck)
• Suboccipital muscles (four pairs of muscles used to rotate the head)
• Pectoralis minor muscles (a pair of thin triangular muscles at the upper part of the chest)
• Subscapularis muscles (a pair of large triangular muscles that attach from behind your scapulae up to the shoulders )
• Levator scapulae muscles (a pair of muscles located at the back and side of the neck).
• Trapezius
 

Physiotherapists Tralee

Physiotherapists Tralee / Correct Desk Posture

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Foot Pronation and Supination Explained

Foot Pronation and Supination Explained


Pronation SupinationPronation
and supination are  movements that occur at the subtalar joint of the foot. The normal biomechanics of the foot are designed to absorb and direct the forces occurring throughout the gait cycle. As the foot is loaded, eversion of the subtalar joint, dorsiflextion of the ankle, and abduction of the forefoot occur. This is the pronation part of the gait cycle. Pronation should not continue past the latter stages of midstance during the gait cycle. At this stage the foot should then supinate in preparation for toe-off. Approximately four degrees of pronation and supination are necessary to enable the foot to propel forward properly. Any increase on this four degrees brings a foot into over-supination or over-pronation.

 

Pronation

Pronation of the foot is where the heel rotates away, and the little toe moves away, from the centre of the body. The foot also dorsiflexes up slightly, the ankle rolling inwards. Pronation is part of the natural movement of the human body, but certain injuries can occur with excessive pronation.  Runners with flat feet often overpronate. Over-pronation can contribute to injuries such as shin splints, anterior compartment syndrome, patello-femoral pain syndrome, plantar fasciitis. tarsal tunnel syndrome. bunions (hallux valgus), Achilles tendonopathies. The running shoes of over-pronators often show extra wear on the inside of the heel and the ball of the foot extending to the big toe.

 

 Supination

With supination the heel rotates towards the centre of the body, the big toe turns towards the centre of the body, the foot flexes down and the ankle rolls out. It is the opposite of pronation. A natural amount of supination occurs during the push-off phase of the running gait as the heel lifts off the ground and the forefoot and toes are used to propel the body forward. However, excessive supination  places a large strain on the muscles and tendons that stabilize the ankle, and this can make the oversupinator more prone to ankle sprain or ankle ligament rupture.

With over-supination the forces of impact on the foot are concentrated on a smaller area of the foot (the outside part), and are not distributed as efficiently. In the push-off phase, most of the work is done by the smaller toes on the outside of the foot, rather than the big toe, which is what should happen. This places extra stress on the foot, which can lead to conditions such as iliotibial band syndrome, Achilles tendinitis, or plantar fasciitis. Over-supination causes the outer edge of running shoes to wear sooner. In extreme cases, there will also be holes in the uppers where the runner’s foot has broken through. Runners with high arches and tight Achilles tendons/calves tend to be over-supinators.

 

 

Properly prescribed foot orthotics can be beneficial in the treatment of over-pronation or over-supination where these conditions are leading to injury during training etc. We supply both off the shelf and custom made orthotics. We only prescribe them when we really feel they are necessary. Often the much cheaper off the shelf orthotic does the trick once it is a quality and prescribed by an experienced practitioner. Sometimes you just have an injury that needs treatment. Just because you have a high arch or a flat foot does not mean in itself you need orthotics, especially if you are not in pain.

 

 

What causes a bone spur?

What causes  a bone spur?

A bone spur(also called an osteophyte) is an outgrowth of bone occurring along the edge of a bone. Bone spurs are most commonly found in joints, where two bones come together. They also occur close to where muscles, ligaments, or tendons attached to bone. Bone spursSome common parts of the body affected include the neck (cervical spine), shoulders, hips, hands and heel bone. Bone spurs typically occur because of continued stress or rubbing on a bone over a prolonged period of time. This can occur due to inflammatory conditions  such as osteoarthritis , tendinitis or tenosynovitis. Normally there is a smooth layer of cartilage on the edges of bones where they come together to form a joint. With osteoarthritis this cartilage layer becomes worn away, causing the exposed bones to rub against each other. New bone forms in response to this stress and the resulting inflammation. Bone spurs usually develop in areas near tendons and ligaments due to chronic inflammation in these areas, from friction between these tissues and bone, or from overuse. This is the bodies way of trying to protect itself.

Signs and Symptoms of a Bone Spur?

Bone spurs may or may not cause symptoms. Symptoms are location dependent. If bone spurs rub against other bones at joints they can cause pain and/or more limited movement in these joints. Bone spurs can also be associated with pain, numbness, tenderness, and /or weakness in areas where  they irritate adjacent tissue structures(muscles, ligaments, bones, nerves etc.). If the bone spur rubs against tendons or ligaments, they can sometimes cause a tear in these tissues over time. This is a common cause of tears in certain rotator cuff tendons .

If bone spurs occur in the spine  they can sometimes pinch the nerves (radiculopathy) or spinal cord(myelopathy). A radiculopathy can cause pain, numbness, tingling, or weakness in the arms or legs depending on the area affected. With a myelopathy there can be pain and problems with balance along with weakness.

How Do Health-Care Professionals Diagnose Bone Spurs?

Generally X-Rays, MRIs or CT scans are used to confirm suspected bone spurs. Sometimes an experienced practitioner can feel the spur with their finger depending on the area(i.e. heel spur).

When Is Surgery Appropriate for Bone Spurs?

In some cases, if symptoms cannot be controlled with more conservative treatment, surgery could be an option. The goal is to remove the bone spur, allowing a return to normal joint motion, or to remove the pressure on muscles, tendons, ligaments, or nerves.

Posterior Impingement Syndrome(Ankle). Review by Physical Therapist & Physiotherapist in Tralee

Posterior  Impingement  Syndrome(Ankle)

Physiotherapist in TraleePosterior ankle impingement is a condition characterised by tissue damage at the back of the ankle joint due to compression of these structures. This occurs when the foot and ankle are pointed maximally away from the body (plantarflexion ). It may occur when compressive forces are too repetitive and/or too forceful. This can occurs in the presence of ankle swelling or bony anomalies, such as additional bone, a condition known as an “os trigonum”. Posterior ankle impingement is most commonly found in gymnasts, ballet dancers, and footballers, because they regularly maximally plantarflex their ankles during their activities. The condition can also occur due to inadequate rehabilitation of an acute ankle injury (ie. ankle sprain).

 

Mechanism of Injury

Posterior ankle impingement may develop due to an acute traumatic plantar hyperflexion event, such as an ankle sprain. It may also occur as a result of repetitive low-grade trauma associated with plantar hyperflexion, say like in case of a female ballet dancer. It is important to differentiate between these two, because the latter, that is posterior impingement from overuse, has a better prognosis.

The anatomy of the posterior ankle is a key factor in the occurrence of posterior impingement syndrome . The more common causes of the condition are osseous in nature, such as the os trigonum, an elongated posterolateral tubercle of the talus (known as Stieda’s process), a downward sloping posterior lip of the tibia, an osteophyte from the posterior distal tibia , or a prominent posterior process of the calcaneus. However, posterior impingement can also be soft tissue related, as with a thickened posterior joint capsule , post-traumatic scar tissue, post-traumatic calcifications of the posterior joint capsule, or loose bodies in the posterior part of the ankle joint. Symptoms for all of these conditions relate to physical impingement of osseous or soft tissue structures, resulting in painful limitation of the full range of ankle movement.

The most common cause ”os trigonum” is an extra (accessory) bone that sometimes develops behind the ankle bone (talus). The mineralized os trigonum appears between the ages of 7 and 13 years and usually fuses with the talus within 1 year, forming the trigonal (Stieda) process. It may remain as a separate ossicle in 7-14% of patients, and is often bilateral(in both ankles). An os trigonum can be a focus of osseous abutment against other structures. Pain can also be caused by disruption of the cartilaginous synchondrosis between the os trigonum and the lateral talar tubercle as a result of repetitive microtrauma and chronic inflammation.

In the case of soft tissue impingement it usually results from scarring and fibrosis associated with synovial, capsular, or ligamentous injury ie. bad ankle sprain.  It is thought that this type of manifestation usually usually occurs when a significant soft-tissue component forms. The soft-tissue component can consist of synovial thickening throughout the posterior capsule or be more focal, involving the posterior intermalleolar or talofibular ligament. The flexor hallucis longus tendon runs in the groove between the lateral and medial processes of the talus and can also be injured in posterior impingement, resulting in tenosynovitis.

 

Signs and symptoms of posterior ankle impingement

Patients who have posterior impingement complain of chronic deep posterior ankle pain worsened by forced plantar flexion or push-off forces as occur during activities such as ballet dancing, jumping, or running downhill. In some patients, forced dorsiflexion(opposite to plantarflexion) is also painful.

Physical examination reveals pain on palpation over the posterolateral  talar process, which is located along the posterolateral aspect of the ankle between the Achilles and peroneal tendons (Fig. 3. ankle). Passive forced plantar flexion results in pain and often a grinding sensation as the posterolateral talar process is entrapped between the posterior tibia and calcaneus.(Fig. 4. ankle)

 

Diagnosis of posterior ankle impingement

A thorough examination by an experienced practitioner  may be all that is necessary to diagnose posterior ankle impingement. Further investigations such as an X-ray, MRI, CT scan or Ultrasound may help confirm diagnosis.

 

Treatment

Initial treatment of posterior impingement consists of rest, ice, and non-steroidal anti-inflammatory medications. Injection of steroids, perhaps under ultrasound guidance, is also effective for symptom relief and for reduction of swelling. If conservative measures fail, operative treatment may be recommended. Areas of soft-tissue impingement are debrided. Bone spurs or an os trigonum are removed, typically in an open procedure in light of the proximity of the sural nerve, tibial nerve, and flexor hallucis longus tendon. In general, operative results are excellent, as the offending structures that caused the mechanical impingement have been removed. Many athletes are able to resume running four to six weeks after surgery.

Shin Splints – Which Type Have You?

”Shin Splints” – Which Type Have You ?

shin splints”Shin splints” is a catch-all term for shin pain either on the front outside part of the lower leg (anterior shin splints) or on the inside of the lower leg (medial shin splints). It is the curse of many athletes including runners, tennis players, dancers etc. Frequently the condition plagues novice runners who do not build their mileage gradually enough. It also affects seasoned runners who abruptly change their workout regimen, suddenly adding too much mileage, or switching from running on the flat to hills. The term mainly refers mainly to the following three conditions 1. mini stress fractures within the tibia bone, 2. chronic exertional compartment syndrome, 3. medial tibial stress syndrome.  It is important to differentiate between the three for treatment.

1. Real ”shin splints” are mini stress fractures (splint-ers) within the tibia bone. With this condition pain is gradual in onset, getting worse with activity, and there is usually a history of an increase in training intensity. Pain may occur with walking, at rest, or even at night in bed. Treatment for this condition involves rest for about eight weeks from running to allow the little stress fractures to heal. You should be able to keep up fitness levels by cycling, swimming etc., as these exercises are low impact. You may need to look at lower limb biomechanics, running style, training practices etc. to prevent recurrence of the shin splints .

2. Chronic exertional compartment syndrome is defined as increased pressure within a closed fibro-osseous space(like the space the tibia and fibula), causing reduced blood flow and tissue perfusion(perfusion is the process of a body delivering blood to a capillary bed in its biological tissue), which subsequently leads to ischemic pain(pain due to restriction of blood supply, and thus oxygen and nutrients to tissue) and possible permanent damage to tissues of the compartment. The syndrome is frequently bilateral (both legs). Typical features of the condition are absence of pain at rest, with increasingly achy pain and a sensation of tightness in the shins upon exertion. Symptoms usually resolve or significantly dissipate within several minutes of resting. Anyone can develop the condition, but it is more common in athletes who participate in activities that involve repetitive impact, such as running. Sometimes Chronic exertional compartment syndrome may respond to deep tissue work and myofascial release of the structures involved. Changing your chosen activity to one involving less impact may also help. Surgery may be used as a last resort to relieve the pressure. It involves operating on the inelastic tissue encasing each muscle compartment (fascia). Methods include either cutting open the fascia of each affected compartment (fasciotomy) or actually removing part of the fascia (fasciectomy).

3. Medial tibial stress syndrome is an inflammation of the muscles, tendons, and bone tissue around your tibia. A common cause of Medial Tibial Stress Syndrome is pes planus (flat feet) or over-pronation of the foot during running. This puts increased strain on the Tibialis Posterior and soleus muscles leading to chronic traction at their insertions onto the periosteum on the posterior inner border of the tibia, producing pain in this area. Mild swelling in the area may also occur. The pain may be sharp and razor-like or dull and throbbing, occurring both during and after exercise, and aggravated by touching the sore spot. Initial treatment involves rest, ice, analgesics. Again switching to low impact activities such as swimming or cycling can keep a sports person active during recovery. For treatment, the entire calf should be assessed. The use of myofascial release techniques along with proper hands-on deep tissue work concentrating on thickened muscle fibres of the soleus, flexor digitorum longus and tibialis posterior adjacent to their bony attachments can prove effective. Dry needling and electro-acupuncture can also benefit recovery. Arch supporting orthotic insoles designed to reduce impact forces, correct flat-footedness and overpronation during running can help prevent recurrence and facilitate recovery by offloading affected structures. For some more information click here.

Dead leg injury ; Diagnosis, treatment and management.

Dead leg

A ”dead leg”, also known as ”charley horse” or ”quadriceps contusion”, is essentially an injury due to a traumatic blow, crushing the quadriceps muscle against the femur bone. The quadriceps is the muscle at the front of your thigh. The injury can be either intermuscular or intramuscular. Treatment depends on the type of contusion and grade in Dead legseverity of the injury. An Intramuscular contusion occurs when the muscle gets torn within the sheath surrounding it. This causes the initial bleeding to cease within hours due to increased pressure within the muscle. However, the fluid and blood is not able to escape from the muscle sheath surrounding it resulting in considerable loss of function and a lot of pain. This can take days or weeks for a full  recovery. You are unlikely to see any bruising with this type of contusion, especially in the early stages. In the case of intermuscular contusions, the muscle as well as part of the sheath surrounding it gets torn. This results in a longer bleeding time initially, especially if there is no use of ice therapy. The patient usually recovers faster from this type of dead leg, as the blood and fluids can easily flow away from the injury site. Bruising is often present in this type of contusion.

Grading

  • Grade 1: Quadriceps pain, tightness in the thigh and a limp while walking. The swelling is very mild and so is the pain. The patient has almost complete range of motion upon stretching.
  • Grade 2: The patient is not able to walk properly and limps when walking. There is some swelling present and the patient will experience bouts of pain upon activity. There is pain upon extending the leg against resistance. Pressure on the site also produces pain and the patient is unable to completely flex the knee.
  • Grade 3:The patient has severe pain with obvious swelling, and is unable to walk without the help of crutches. Muscle contraction produces an obvious gap or bulge. This type of dead leg needs at least a month or two to completely heal.

Treatment for dead leg

  • I.C.E (Rest, Ice, Compression, Elevation).
  • Rest is very important and the limb should be kept elevated as much as possible.
  • Compression and ice therapy should be applied for 15 to 20 minutes every hour for the first 24 to 48 hours. Ice should be wrapped in a wet towel to prevent ice burns. A compression bandage should be worn 24/7 to reduce swelling and to give support until the pain has subsided.
  • Crutches should be used if required.
  • Never apply heat therapy(that includes having a hot bath…Do not) or perform deep tissue massage in the initial acute stage (24 to 48 hours) of a dead leg injury. This can aggravate the injury or lead to myositis ossificans later. Sports massage to help recovery should be started once the acute phase (24 to 48 hours) of the injury has passed, provided it’s not an intramuscular contusion(This may need more time to settle and sometimes requires medical intervention).
  • Gentle stretching of the area should be done after the acute stage (24 to 48 hours) has passed, but not before, provided it does not cause too much pain. The stretch should be held for 30 seconds and should be repeated 4 to 5 times in a day. With severe (grade 3) intermuscular contusion there should be no overpressure with passive stretching for 7-10 days.

 

When Can Exercises Be Started For Dead Leg?

  • For dead leg of grade 1 contusion of quadriceps, strengthening exercises can be started as soon as the pain has subsided. Patient should start with mild exercises and should move on to difficult ones as the dead leg pain.
  • For dead leg of grade 2 contusions of quadriceps, strengthening exercises should be started after a week or so. Patient should start with gentle warm up exercises and finish with good stretching exercises. Strengthening exercises should be continued for several weeks. Strengthening exercises should be started more than a week later and for grade 3 contusions of the quadriceps.
  • Gentle exercises such as cycling or swimming are nice gentle strengthening exercises to start with.

 

Myositis Ossificans

The more severe a contusion, the greater the risk of development of Myositis Ossificans, especially with poor treatment and management. In this condition calcification occurs within the healing hematoma(swelling of clotted blood within the muscle). The healing hematoma forms bone within the layers of affected muscle. Symptoms include overnight and morning pain, as well as pain on muscle contraction. It may be possible to feel a hard bump or ‘woody’ lump within the affected muscle tissue.  Stiffness and loss of knee range of movement are also common.  Sometimes surgery is required to remove the calcified tissue.

Physio – Why early referral is important

Physio and the importance of early referral

PhysioYou have been getting treatment for back pain twice a week for the past four weeks. Each time you lie there for the first fifteen minutes with a hot pack while somebody else is being treated at the same time. The therapist pops in, has a brief chat, does a quick manipulation, reassures you of your improvement, then books you in for your next appointment. You leave wondering if you are really getting any better, but console yourself with the fact that the practitioner told you that you are.
Recently a client told me a story of where they endured a situation like the above for six months. Finally they decided to go to a doctor, who referred them for an MRI. The results showed a stress fracture to one of the lumbar vertebrae of the spine. In this case the treatments had been exacerbating the condition, and what was needed was rest and immobilisation. Also manipulations, generally speaking, need to be done only once. They are used mainly to open a locked joint. A decent amount of soft tissue and myofascial work should be done by a physio beforehand to open up and relax the area. Otherwise the joint may revert to its locked position again shortly after the physio has manipulated it. Also as a general rule there should be a noticeable improvement in a clients condition from physio treatment to physio treatment.
To illustrate the importance of early recognition and referral by your physio, let us look at a few more sinister conditions that present as back pain, requiring referral to a doctor or specialist.
 
Spondylitis; Ankylosing spondylitis is a condition where there is chronic inflammation of the spine and sacroiliac joints. This causes pain and stiffness in and around the spine, including the neck and back. Over time this condition can lead to a complete cementing together (fusion) of the vertebrae, a process referred to as ankylosis . Ankylosis causes loss of mobility of the spine.
Spondylolysis; A common cause of low back pain in adolescent athletes. It can be seen on X-ray and is a stress fracture in one of the bones (vertebrae) that make up the spinal column. It usually affects the fifth lumbar vertebra in the lower back, and less commonly the fourth. If the stress fracture weakens the bone too much the vertebra can start to shift out of place. This condition is called spondylolisthesis.
Spondylolysthesis; Spondylolisthesis is a condition whereby one of the vertebra of the spine slips forward or backward on the next vertebra. Spondylolisthesis can lead to deformity of the spine as well as a narrowing of the spinal canal (central spinal stenosis) and compression of the exiting nerve roots (foraminal stenosis). Spondylolisthesis is more common in the lower back but can also occur in thoracic and cervical spine.

Arthritis ; various types including spondylitis, reactive arthritis, osteoarthritis, juvenile onset spondyloarthritis, enteropathic arthritis, rheumatoid arthritis, polymyalgia rheumatica etc. can all present as back pain.
kidney stones ; can cause back pain.
Osteoporosis ; Osteoporosis means porous bones. It is a silent disease that usually goes undiagnosed until a bone fracture occurs. Bone is a living tissue that is constantly being turned over. Bones need normal sex hormones, calcium, vitamin D, adequate calories, proteins and weight bearing/strengthening exercise to keep them healthy. As we get older, more bone is lost than is replaced, but people with Osteoporosis lose more bone than people who do not have the disease. This causes bones to become more fragile and break or fracture more easily.
Various cancers ; pancreatic, liver cancers etc. can cause back pain.
ovarian cysts ; Ovarian cysts are fluid-filled sacs or pockets within or on the surface the female ovary. A large ovarian cyst can cause abdominal discomfort and a dull ache that radiates into the lower back and thighs.
Spinal stenosis ; This is a narrowing of spaces in the spine causing pressure on the spinal cord and nerves. About 75% of cases of spinal stenosis occur in the low back. In most cases, the narrowing of the spine associated with stenosis compresses a nerve root, which can cause pain down the leg.

physio in Tralee
 
Basically what I am saying in this article is that if your condition is not improving from physio session to physio session you may need to go back to your doctor for further investigation. Just keep it in mind. A good physio will probably have already referred you.
 

Foot Orthotics – A few things to think about

Foot Orthotics – The Truth

Foot OrthoticsThe science behind foot orthotics is relatively new and continually evolving. To date some of the evidence regarding the benefits foot orthotics for athletes etc. has been a little conflicting. Reasons for this may include 1. differences in the experience and training of prescribing practitioners; 2. differences between foot orthotics suppliers and materials used 3. the temptation of monetary gain from prescribing foot orthotics unnecessarily.

From my experience foot orthotics do work for certain conditions the majority of the time but I feel they are way overprescribed for monetary gain. They mainly seem to benefit conditions from the knee down to and including the foot.  I cannot  really see how they would prevent hip or back pain(unless maybe there is a leg length discrepancy),neck pain etc. as some suppliers suggest. A lot of people are under the illusion that foot orthotics are some kind of amazing item especially the more expensive ones. If you have a pair, take a good look at them. They are basically a very fancy supportive insole, not much more.
 

Foot Orthotics – How they work

Let’s look at how they work, i.e. in the case of a lower limb tendinopathy. This condition usually occurs when the tendon has been under strain for long periods. The idea is that you put in a strategically located lift in the orthotic to take the pressure off the tendon and thus give it a chance to heal. For example with an achilles tendinopathy, you put in a little heel lift thus taking the pressure off the tightened achilles tendon. You are trying to reduce the tension on the tendon or give it slack, hoping as a result it gets a chance to heal. Looking at it from a different angle though, maybe you just had tightened calves from wearing high heels or from overdoing it in training. By loosening out the calves with massage and stretching you can reduce the pull and strain on the achilles tendon to which they are attached….maybe there is no need for orthotics? However other tendinopathies like tibialis posterior or peroneal can be more difficult to treat and may benefit from foot orthotic.

Say you have medial knee pain from running, it may be due to flat feet causing an inward force on the knee. You put in a foot orthotic with an arch support, it corrects the fallen arch, lessening the inward stress on the knee and  taking the pressure of the medial knee. As you can see there is nothing amazing going on here and the theory is pretty good. You can even use different types of materials when manufacturing foot orthotics, some which give more spring in your step reducing the load on shins (shin splints) etc.

In the case of plantar fasciitis which can be due to torsion on the plantar fascia as a result of rotational movement between the heel and forefoot. Here a heel lock in the foot orthotic coupled with an arch support can stabilise the heel and forefoot, reducing torsion on the plantar fascia and allowing it to heal.

However, here are a few things I want you to consider. 1. If you have been running for several years injury free, why would you suddenly need orthotics, could you not just have an injury that needs rest or treatment. 2. You have a young child and somebody says they need foot orthotics because they have flat feet even though they are not in any discomfort. The child is growing and developing, do you want to alter and interfere with that natural process. sometimes even if there is mild pain, maybe it is just ”growing pains” . 3. if you have flat feet or high arches and are in no pain or discomfort, why let somebody convince you that you need foot orthotics. I know plenty of runners and athletes with one of those conditions(high arches or flat feet) that never wear foot orthotics and have no problems.  4. The ”one leg an inch shorter than the other trick” to sell you foot orthotics. I can easily make it appear like one of your legs is shorter than the other when measuring you. A tiny percentage of the population 1/1000, have leg length differences of greater than 20mm or 3/4 inch(Guichet et al.; Clin Orthop. Rel. Res. 1991, 272:235). It is at this level that leg length discrepancy becomes significant. Wearing orthotics to correct a difference when there is no difference could quiet possibly cause you problems down the line. However if there is a definite actual leg length discrepancy a little heel lift in an orthotic can correct this and provide considerable relief. I regularly see people told they have a one inch discrepancy in leg length and sold foot orthotics for several hundred euro. Upon testing them I frequently see little or no difference whatsoever in their leg lengths. Here is an interesting article on leg length discrepancies http://runnersconnect.net/running-injury-prevention/leg-length-discrepancy-running/. Also the only way to reliably determine anatomical leg length discrepancies is to take x-rays of the lower extremities and actually measure the length of the femur, tibia, talus and calcaneus, since these are the primary weight bearing bones.   5. Lower back pain is often either disc or muscular related. I cannot in any way see how orthotics could benefit these conditions. As for neck pain, not a hope.

As for gait analysis in running stores, this is my advice; If you have been using a specific runner and having no problems, stick with it, brand and all. So often I have seen people measured up for runners and told for example they are over-pronating.  Then they are  given a runner to correct for this. Next thing two months later they have a tendon injury because they have been used to running a certain way in specific running shoes and now this altered runner is changing that suddenly, with no chance for the body to adapt.  Stick with the footwear you are used to. Make sure it is comfortable, supportive and laced up well. Replace worn out foot wear.

Also for people new to running, give your body time to adapt. Take it slowly, this is the best way to prevent injury. In terms of price, you should be able to get a quality off the shelf foot orthotic for around 60 euro. These often do the trick for many conditions. They usually include little stick on attachments to correct for various conditions so your practitioner can customise them to the injury. Custom foot orthotics shouldn’t really set you back more than 300 euro. Paying more does not mean you have a better product. Many are way overpriced for what you are getting. What seems to be major factor in whether orthotics will work or not is how comfortable the feel when worn. If you have been overtraining resulting in a lower limb tendinopathy, don’t think you can just stick on a pair of foot orthotics and keep going. Often it is rest along with eccentric rehabilitation exercises that is needed, not foot orthotics as such. I hope the above article gives you a few things to think on.

 

Thoracic Outlet Syndrome

 

Thoracic Outlet Syndrome

thoracic outlet syndromeThoracic outlet syndrome is a disorder that occurs when the blood vessels or nerves in the space between the collarbone and first rib (thoracic outlet) become compressed. This can result in any of the following symptoms ; 1. pain in your shoulders and/or neck , 2. numbness / pain / tingling down the arm and / or in a finger / fingers. Common causes of thoracic outlet syndrome include physical trauma, i.e. car crash ; repetitive injuries from job or sports related activities; anatomical defects (such as having an extra rib); poor posture( protruding neck / rounded shoulders); and pregnancy.
You may notice symptoms of thoracic outlet syndrome if your job requires you to do a repetitive movement continuously for long periods, i.e. typing on a computer; working on an assembly line; or lifting things above your head. These repetitive activities tend to tighten up neck and shoulder muscles. Athletes, such as baseball pitchers and swimmers can also develop thoracic outlet syndrome from the years of repetitive movements.
Obesity can put an undue amount of stress on your body structures and joints leading to the development of thoracic outlet syndrome.
Carrying around an over sized bag or backpack or having somebody sitting on your shoulders for long periods, say at a concert can compress nerve structures etc. and lead to the condition.
You may suffer symptoms of thoracic outlet syndrome during pregnancy as muscles, ligaments, tendons and joints come under strain. This is as a result of the release of the hormone relaxin around week twelve of pregnancy, and also due to the increase in bodyweight.

The two most common types of thoracic outlet syndrome are:

1. Neurogenic (neurological) thoracic outlet syndrome: This form of thoracic outlet syndrome is characterized by compression of the brachial plexus ( nerves coming from the spinal cord (neck). This network of nerves controls muscle movements and sensations in the shoulder, arm and hand. This is the most common cause of thoracic outlet syndrome.

Signs and symptoms include:
• Numbness or tingling in your arm or fingers.
• Wasting of muscles through which the compressed nerve travels; either in the arm or fingers or both.
• Pain in the neck , shoulder or hand.
• Weakened grip in hand / loss of strength in the arm.

Treatment : Often if neurogenic thoracic outlet syndrome is caught early, deep tissue work on neck, shoulders and arm to loosen out tightened muscles; joint mobilisations / manipulation of the cervical and thoracic spine; electro acupuncture along the affected nerve pathway; postural correction exercises, can usually bring great relief within one or two treatment sessions. If the condition is chronic ( i.e. there a month or months), it may take more time for the irritated nerve to settle. You may need to lose weight if obesity is the cause of your thoracic outlet syndrome.

2.Vascular (venous or arterial) thoracic outlet syndrome : This type of thoracic outlet syndrome occurs when one or more of the veins or arteries are compressed in the area between the collarbone and first rib.
Signs and symptoms include:
• Discoloration of the hand (bluish colour).
• Arm pain and swelling, possibly due to blood clots.
• Blood clots in veins or arteries in the upper area of your body.
• Lack of colour in one or more of your fingers or your entire hand.
• Weakened or no pulse in the affected arm.
• Cold fingers, hands or arms.
• Arm fatigue after activity.
• Numbness or tingling in your fingers.
• Throbbing lump near your collar bone.
• Weakness of arm or neck.

Treatment : For vascular (venous or arterial) thoracic outlet syndrome…you need to consult with your doctor. This condition may require thrombolytic medications, anticoagulant medications or surgery.

For more information click here

 

Back Pain And Treatment Options Made Simple – Physiotherapist Kerry

Back Pain And Treatment 0ptions Made Simple – Physiotherapist Kerry

Three very common causes of back pain presenting in clinic are 1. muscular, 2. discogenic (from a disc), 3. locked facet joint.

Muscular back pain – Physiotherapist Kerry

–  For the low back a common muscle to cause trouble is the piriformis muscle (see diagram). It is involved in hip rotation movements so if it tightens you lose rotation putting pressure on the lower back during activities. When the piriformis muscle tightens it may also squeeze on the sciatic nerve which travels from the lumbar spine  down the back of the leg causing pain anywhere along the nerve path(low back, hamstring, calf, sole of foot). Tightened hamstrings may also contribute to low back pain(often resulting from being seated for long periods) making the spine do more work due to resulting poor posture in lifting etc.

Treatment – The piriformis muscle can usually be worked out and loosened in one to two treatment sessions. That means proper hands-on deep tissue work though. The hamstrings can also be worked. Electro-acupuncture also helps loosen the muscles/trigger points and settle nerve irritation in affected areas. There should be a substantial improvement even after just one treatment session with a competent practitioner.

Back pain treatment Tralee

 

 

 

 

 

 

 

 

 

 

 

 

Locked Facet joint back pain – Physiotherapist Kerry

– This is a common cause of back pain in the upper thoracic region(along back of the rib cage)…Often the person feels like somebody is sticking a finger into their back when they inhale deeply. Also with this condition a person may find that they can turn completely in one direction but not the other. In more serious cases pain may shoot down the arm due to nerve entrapment/irritation. A locked facet joint may also occur in the lower back sending nerve pain down the leg. The crack you hear when the back is manipulated is locked facet joints opening, it is not a ”slipped disc” being put back into place.

Treatment – One simple manipulation done correctly on the spine, with a little soft tissue work done thereafter. With the manipulation you get a little crack if the facet joint was locked, as it opens, giving immediate relief. One treatment session usually sorts this condition.

Bback pain treatment Tralee

 

 

 

 

 

 

 

 

 

 

Discogenic (Disc) related back pain – Physiotherapist Kerry

– This is a more tricky one. Probably most common in the lower back (lumbar region). The patient will sometimes present with their spine all twisted off to one side in a sort of ”S” shape. This is usually because the disc bulge or protrusion is touching a nerve. The body compensates for this by trying to get the disc away from the nerve, hence the ”S” shape. Also there will be muscle spasm as the body tries to protect itself. A patient with this condition is usually in a lot of pain and even simple tasks like walking can be excruciatingly painful. Disc pain is less common in the thoracic region but again here it presents with deep unrelenting pain.

Treatment – Do not let somebody tell you they are putting back in your ”slipped disc” with some manipulation or other. This is a blatant lie. There is no such thing as a ”slipped disc”, it is just a misnomer. Discs basically bulge, degenerate(collapse) or herniate(a little fluid filled sack can protrude or leak out of them)(see diagram below). It is when this bulge or protrusion touches a nerve, the trouble starts. Do not let somebody tell you they can feel your disc out when they touch your back. The disc is at the front of the spine behind the stomach etc. with the facet joints (bone)behind it. You couldn’t possibly feel the disc. Repeating above(The crack you hear when the back is manipulated is locked facet joints opening, it is not a ”slipped disc” being put back into place). Do not get roped into loads of treatments especially where you are going in twice a week for a ten minute session with the same manipulation done over and over again and probably no tissue work. A manipulation only needs to be done once if it is going to work. Good physiotherapists spends time with you.

Basically a muscle relaxant (valium) from your doctor along with an anti-inflammatory (NSAIDS) for a couple of days usually helps a lot.  Usually two treatment sessions along with the medication to loosen out the muscles will also reduce pain and improve recovery time. A manipulation to open any locked facet joints may help as the condition settles.

When a disc touches a nerve it initiates a series of reactions including muscle spasm and inflammation. The medication is very important in this condition and the combination of the both muscle relaxant and anti-inflammatory seem to complement each other along with treatment. Things such as ”Mckenzie technique” and ”nerve glides” can also help when introduced at the right time during treatment but require too much detail to go into here.

Once the condition settles it is important to 1. Train your body to engage its core. 2. Strengthen your core muscles with pilates type exercises, along with developing your core fitness. 3. Lose weight if you are overweight. 4. Try and improve your flexibity.

Once you get somebody moving, loosened out, give them a proper rehab routine and they are taking the medication, it is more about giving the body time to heal itself than anything else. Basically what you are trying to do with initial treatment is to relax any muscle spasm, reduce inflammation, reduce pressure on the disc with the more long-term goal of strengthening the body in the hope of bringing back in the disc bulge/ protusion enough from the nerve it is touching, so that symptoms subside. If there is little improvement in your condition after a week, an mri may be required to get more accurate information on the injury.  In some cases an epidural or surgery  may be required.

Back pain treatment Tralee

 

 

 

 
Some more information on different treatment and study outcomes can be found at Back pain treatment in Kerry

 

Please note the above article only lists some common causes of back pain.

Physiotherapist Kerry –  phone 086-7700191

 

 

Severs Disease – Kid’s Heel Pain

Severs disease

Severs Disease – Kid’s Heel Pain

Severs disease (also known as calcaneal apophysitis) is a type of bone injury in kids whre the growth plate on the lower back part of the heel, where the Achilles tendon (the heel cord that attaches to the growth plate) attaches, becomes inflamed and painful. The reason for this is that the heel bone grows faster than the ligaments in the leg. As a result, muscles and tendons can become very tight and overstretched in children who are going through growth spurts. Sever’s disease occurs as a result of repetitive stress on the Achilles tendon. Over time, constant pressure on the already tight achilles tendon can damage the growth plate, causing children. Symptoms of Severs disease include pain and inflammation. This is why it is more common in physically active. Symptoms of Sever’s pain, inflammation or tenderness at the back of one or both heels which sometimes also extends in to the sides and bottom of the heel ; swelling and redness in the heel ; heel pain with limping, especially after running ; difficulty walking.Although it is painful and the name sounds a little scary, severs disease is only a temporary condition with no long-term problems. It is more common in physically active kids and occurs during the growth spurt at adolescence. This can begin any time between the ages of 8 and 13 for girls and 10 and 15 for boys. To be brief Severs disease is not a disease, it is in fact just growing pains.

Severs Disease – Treatment

The primary method of treating Severs disease is by taking time off or at least reducing participation in sports and other physical activities. This is in order to alleviate the pressure on the growth plate referred to above. Your physical therapist may prescribe stretching exercises for the calf muscles to help reduce pressure on the achille’s tendon attachment. Icing the area by placing an ice pack in a wet towel and applying it to the area of pain for 10 to 15 minutes at a time may help to alleviate pain and swelling, as may the use of NSAIDs(non steroidal anti-inflammatories). For more information on Severs disease click here

Tendinosis – Overview of Treatments


tendinosis treatmentsTendinosis – A brief overview

Tendinosis is damage to a tendon at a cellular level (the suffix “osis” implies a pathology of chronic degeneration without inflammation). It is thought to be caused by microtears in the connective tissue in and around the tendon, leading to an increase in tendon repair cells. This may lead to reduced tensile strength, thus increasing the chance of tendon rupture. Tendinosis is often misdiagnosed as tendinitis due to the limited understanding of tendinopathies by the medical community.
 

Tendinosis – Treatment

Eccentric exercise – Strengthening and repairing the tendon should be the ultimate goal of any rehabilitation program. At present eccentric exercise programs are the gold standard for treating most cases tendinosis.

Concentric contractions occur when the joint moves in the same direction as the muscle contracts. When curling a barbell up towards the shoulders the biceps contract concentrically. Lowering the barbell back down again is an eccentric contraction, the biceps contracting eccentrically. Another example would include lowering the weight during a bench press(pectorals and triceps contract eccentrically). An example of the treatment protocol for achilles tendinosis involving eccentric exercises would be straight and bent knee heel drops performed for three sets of 15 reps twice a day, every day for twelve weeks, done slowly and increasing the weight used over time, performed into mild or moderate pain levels only(Alfredson et al, 1998).

Though Alfredson ‘s eccentric program (for achilles tendinopathy) achieves good results in terms of recovery from the injury, twelve weeks out is an awfully long time for a runner in training for competition. About ten to thirty percent of athletes who complete the eccentric heel drop program still aren’t able to return to their previous levels of activity. Recovery levels of over seventy per cent is still a pretty good success rate for such a tricky condition with few viable treatment alternatives. Because of the prevalence of tendinopathies other treatments are constantly being investigated. It is important to keep in mind the general principles of recovery for tendinopathies: encouraging the tendon to heal by taking the stress off the tendon, and correcting any contributing biomechanical faults. Rest is also a great way to encourage healing and take stress off the tendon but athletes are always anxious to return to their sport as soon as possible.
 
NSAIDs(non steroidal anti-inflammatories) – these are not an effective way to manage tendinosis because tendinosis is not an inflammatory condition, it is a failed healing response(Stovitz and Johnson, 2003).
 
Cortico steroids – no benefit and possibly increase the damage to tendons leading to a greater risk of tendon rupture in the future(Coombes et al. 2010).
 
Orthotics – limited and conflicting evidence of benefits – in theory orthotics should help to offload the stress on the injured tendons of the lower limbs by correcting faulty foot biomechanics. However the benefits have still to be proven with proper scientific studies. Orthotics may help in combination with eccentric training treatment programs(Kulig et al. 2009).
 
Minimalist shoes or running barefoot (tendinopathies of foot and lower limb) – No proper supporting scientific evidence to support this despite a lot of media coverage etc.
 
Kinesiology tapes like Kinesiotape or KT tape – Little evidence of benefit
Soft-tissue techniques like ”Active Release Techniques” and ”Graston Technique” are completely untested. No proper research trials have been completed supporting these treatments for tendinopathies.
 
Ultrasound, low-level lasers, and platelet-rich plasma injections all show little evidence supporting their use in tendinosis treatment.
 
Extracorporeal shockwave therapy (ESWT) – Very conflicting evidence and many different treatment protocols. Not showing as much promise as initially thought.
 
Topical nitroglycerin patches. Nitroglycerin patches have shown promise in a few high-quality studies(Murrell, 2007).
 
Sclerosing injections are designed to destroy blood vessels and nerve endings in the tendon with the intention of reducing pain in the injured tendon. For some reason there is usuallya proliferation of nerves within a tendon during tendinosis. Prolotherapy also attempts to damage the tendon, with the aim of restarting the healing process. Both these techniques have limited research backing them at present. Considering the risks involved with injecting untested medication or chemicals into important body structures like tendons, it is not possible to recommend these injection-based therapies for tendinopathies barring further research.
 

For more information on tendinopathies  see click here
 
 

References
 
Alfredson, H.; Pietilä, T.; Jonsson, P.; Lorentzon, R. Heavy-load eccentric calf muscle training for the treatment of chronic achilles tendonitis. American Journal of Sports Medicine 1998, 26 (3), 360-365.
Coombes , B.K., Bisset, L., Vicenzino, B. Efficacy and safety of corticosteroid injection and other injections for management of tendinopathy: a systematic review of randomised controlled trials. Lancet 2010, 376,1751–67.
Kulig, K., Reischl, S.F., Pomrantz, A.B., Burnfield, J.M., Mais-Requejo, S., Thordarson, D.B., Smith, R.W. Nonsurgical Management of Posterior Tibial Tendon Dysfunction With Orthoses and Resistive Exercise: A Randomized Controlled Trial. Physical Therapy 2009, 89 (1) 26-37.
Murrell, George A.C . Using nitric oxide to treat tendinopathy. Br J Sports Med 2007, 41, 227-231.

Stovitz, S. D., Johnson, R. J. NSAIDs and musculoskeletal treatment: what is the clinical evidence? Physician and Sportsmedicine 2003, 31 (1), 35-52.
 
 

Statins – Muscle pain and other side effects

statins

Statins and Muscle Pain

Elevated low-density lipoprotein-cholesterol (LDL-C) has long been established as a major cause of coronary heart disease(CHD). The group of cholesterol-lowering drugs known as statins are widely used in the management of atherosclerotic disease processes that include CHD, myocardial infarction, stroke, and peripheral vascular disease(Pastemak et al. 2002). Although these drugs have been very successful in managing the cardiovascular health of many patients, they also can have some potential adverse side effects . These include muscle pain, inflammation, cramps and/ or weakness in areas such as the shoulder, neck, back, abdomen, hip, lower limbs, biceps brachii and masseter muscles etc.(Bennet et al. 2003). If left unchecked these symptoms may progress on to more serious conditions (Thompson et al. 2003). When detected early however, statin-related symptoms are reversible after withdrawal of the statin(Sinzinger et al. 2002). It is thus important for both physical therapists and physiotherapists to be aware of these associated symptoms linked to statin usage, because they frequently screen patients with musculoskeletal complaints. It becomes even more relevant when a patient presents with muscle pain, tenderness, weakness or inflammation that cannot be explained (for example, pain that is not due to physical work or injury).

Your doctor can carry out a blood test to measure a substance in your blood called creatine kinase (CK), which is released into the blood when your muscles are inflamed or damaged. If the level of CK in your blood is more than five times the normal level, your doctor may advise you to stop taking the statin. Regular exercise can also sometimes lead to a rise in CK, so tell your doctor if you have been exercising a lot. Once your CK levels have returned to normal, your doctor may suggest you start taking the statin again, but at a lower dose. It is important to note that a healthy diet and exercise can often reduce your LDL cholesterol to within the normal range without the need for medication. This is best done with the aid of a qualified dietician, backed up by follow up blood testing and advice from your doctor.

Statins and the problems found with grapefruit consumption

Grapefruit contains a chemical that interferes with your body’s ability to break down or metabolize certain statin medications. When statin takers ingest large amounts of grapefruit, the level of statins in their blood can increase, raising the possibility of side effects. Problems can occur for those who are sensitive to statin medications or those who have kidney disease or other illnesses. Side effects from grapefruit-statin interaction can be mild, such as muscle and joint pain. Severe side effects include muscle fiber breakdown and kidney failure.

See more at Statins and muscle pain

References

Bennett W.E., Drake A.J., Shakir K.M. Reversible myopathy after statin therapy in patients with normal creatine kinase levels. Ann Intern Med.2003;138:436–437.

Pasternak R.C., Smith S.C., Bairey-Merz C.N., et al. ACC/AHA/NHLBI clinical advisory on the use and safety of statins. Circulation, 2002 ;106:1024–1028.

Sinzinger H., Wolfram R., Peskar B.A. Muscular side effects of statins. J Cardiovasc Pharmacol. 2002 ; 40:163–171.

Thompson P.D., Clarkson P., Karas R.H. Statin-associated myopathy. JAMA,2003 ;289:1681–1690.

 

 

Temporomandibular Joint Disorders – Treatment in Tralee

Temporomandibular Joint disorders

Temporomandibular Joint DisordersThe temporomandibular joint (TMJ) is the hinge joint that connects the lower jaw (mandible) to the temporal bone of the skull, which is immediately in front of the ear on each side of your head. The joints are flexible, allowing the jaw to move smoothly up and down and side to side and enabling you to talk, chew, and yawn. Muscles attached to and surrounding the jaw joint control the position and movement of the jaw.  Temporomandibular Joint Disorders (TMJD) occur as a result of problems with the joint and surrounding facial muscles that control chewing and moving the jaw.
 

Causes of Temporomandibular Joint disorders

The cause of Temporomandibular Joint Disorders though not clear may incude injury to the jaw, temporomandibular joint, or muscles of the head and neck as a result of say whiplash / a blow to the jaw / grinding or clenching the teeth, which puts a lot of pressure on the TMJ / dislocation of the soft cushion or disc between the ball and socket which can result if say the mouth is kept open too wide for an extended period of time during dental work /  presence of osteoarthritis or rheumatoid arthritis in the TMJ / stress which may cause a person to tighten facial and jaw muscles or clench the teeth.

TMD is more  common women than men experience and is seen most commonly in people between the ages of 20 and 40. The condition can be temporary or may last for many years.
 

Symptoms of Temporomandibular Joint Disorders

Symptoms include pain or tenderness in the face, jaw joint area, neck, shoulders, and in or around the ear when you chew, speak, or open your mouth wide / limited ability to open the mouth very wide  / jaws that get “stuck” or “lock” in the open- or closed-mouth position / clicking, popping, or grating sounds in the jaw joint when opening or closing the mouth (which may or may not be accompanied by pain) or chewing / a tired feeling in the face / difficulty chewing or a sudden uncomfortable bite – as if the upper and lower teeth are not fitting together properly / swelling on the side or sides of the face. Other common symptoms of TMD include toothaches, headaches, neck aches, dizziness, earaches, hearing problems, upper shoulder pain, and ringing in the ears (tinnitis).
 

Treatments for Temporomandibular Joint Disorders

Conservative treatment by physical therapists can often be quiet effective especially if the condition is identified and addressed early on. This includes massage and trigger point release of tight facial, neck and shoulder muscles, gentle joint mobilisation with movement along with muscle energy techniques to help realign the temperomandibular joints and relax tight muscles affecting the temperomandibular joint. Tension habits of a patient may also need to be addressed. Home exercises are also given to help rehabilitate the condition. The use of NSAIDs and  muscle relaxants in conjunction with treatment may also prove beneficial. It is also advisable to stick to eating soft foods until the condition improves.  The use of night splints in the treatment of TMD have shown very inconsistent results( Manfredini, D. et al., 2012) and are usually very expensive so don’t go rushing off buying them . Surgery for TMD should only be considered after all other treatment options have been unsuccessful. Because surgery is irreversible, it is wise to get a second or even third opinion from other dentists. For more information on temperomandibular joint disorders click on http://www.tmj.org/

 
References

Manfredini, D., Dental occlusion, body posture and temperomandibular disorders: where we are now and where we are heading for, Journal of Oral Rehabilitation, 4:19, 2012.

 

 

Gilmores Groin

Gilmores Groin Overview

gilmores groinGilmores groin is common in sports such as soccer, hurling, football, rugby etc. games which place considerable strain on the groin due to the  running, turning, twisting and kicking involved. It  is a condition that was not fully understood until relatively recently,
many cases being  misdiagnosed as a groin strain or inguinal hernia. This injury occurs at the junction between the leg and the torso. It involves the area (called an aponeurosis) where the abdominal muscles (Internal obliques, External obliques and Transversus abdominus) converge to form the inguinal ligament. The external oblique muscle has an archway through which several nerves and vessels pass. In Gilmores groin, a tear  in the external oblique muscle causes this archway to open up much wider. Further tears in the obliques cause them to lift up and away from the inguinal ligament, leaving the transversus abdominus muscle unsupported.

Patients with Gilmores groin have one-sided, persistent groin pain that is increased by running, sprinting, twisting and turning. Coughing and sneezing may also cause an increase in the groin pain. Male athletes are more commonly affected by the condition than females. Typically, patients experience pain and stiffness in the evening after a sporting event and during the following morning. In two thirds of cases, the pain of Gilmore’s groin develops gradually , while a third of patients notice it beginning suddenly after a specific event i.e. ball kick out, twisting while running etc.

Gilmores groin can often be diagnosed during a physical examination by a trained professional, but Mri  etc. would be needed to confirm the diagnosis. Usually, a structure known as the superficial inguinal ring is dilated. The superficial inguinal ring is an opening in the external oblique muscle in the lower abdomen, and the doctor is able to feel this opening through the skin. It enlarges when tears develop in both the external oblique muscle and the tissue band to which it joins, known as the conjoint tendon.
 
 

Gilmores Groin Treatment Options

Surgery is really the only long term effective treatment. Following surgery a 4 to 6 week intensive rehabilitation period is usually required before returning to play. The rehabilitation program will be aimed at gradually improving the strength and flexibility of the pelvic muscles in order to allow full recovery and return to play. For more information click  on Gilmores Groin.
 
 

Physical Therapists   & Physiotherapists in Killarney, DingleTralee , Co. Kerry .Please ring 086-7700191 anytime to make an appointment. We also specialise in proper deep tissue massage.

 

 

Tennis Elbow

Tennis Elbow
Tennis Elbow

Tennis Elbow

Tennis elbow is a tendinopathy of the common flexor tendon close to its origin on the lateral elbow. Although the pathology is in the elbow region, patients often present with pain on extension  movement of wrist (lifting back of hand in upwards direction) and fingers(especially middle finger) and also supination of the forearm(motion of turning palm of hand upward ). This is because of the way the common flexor tendon acts as the origin(in part at least) for a number of superficial muscles of the forearm and fingers.

”Tennis elbow” occurs in association with many tasks that involve loaded and repeated gripping and/or  wrist extension actions/activities. These tasks include sports such as tennis, squash and badminton, as well as occupational and leisure pursuits such as carpentry, bricklaying, sewing, knitting, barbering etc. Computer use has also been shown to be associated with the development of this condition(Waugh et al., 2004), but this is often  neural in nature.

There are two distinct clinical presentations of true lateral elbow tendinopathy (tennis elbow). The most common is lateral elbow pain occurring 24-72 hours after unaccustomed activity involving repeated wrist extension. The typical onset here is after a person spends a weekend engaged in manual activity, such as laying bricks, using a screwdriver, or after prolonged sewing or knitting. In the tennis player, it may occur following the use of a new racquet, playing with wet heavy balls, or over-hitting, especially into the wind. It may also occur due to poor playing technique.

The second clinical presentation is the sudden onset of lateral elbow pain associated with a single instance of exertion involving the wrist extensors, for example lifting a heavy object, or a tennis player attempting a hard backhand with too much reliance on the forearm and not enough on the trunk and legs. The insidious onset  is thought to correspond to microscopic tears within the tendon, whereas the acute(sudden) onset may correspond to larger macroscopic tears.

 

Tennis Elbow Treatment

No single treatment has proven to be totally effective for tennis elbow. The best results can be obtained through a combination of treatments selected on the basis of the patient’s clinical presentation(Coombes et al., 2009) and informed by current evidence. What is very important is early proper diagnosis and treatment. It is important that the practitioner checks the following. Is there neural involvement from neck/shoulder impingement? How long has the condition been present? Is it tendinosis rather than tendinitis etc.?

First treatments of choice can include NSAIDs to reduce pain and inflammation, manual therapy which may include mobilisations, deep tissue work, stretching, muscle energy techniques, electro-accupuncture etc. It is important to rule out neural involvement , often common in occupations susceptible to postural issues, such as computer/office workers etc. Here rounding of the shoulders and protrusion of the neck can lead to neural impingement. Treatment of any spinal or neural dysfunction can rapidly progress healing and should never be overlooked. The use of eccentric exercises in treatment/rehab if tendinosis is present has proved highly effective with progression to concentric exercises and gradual return to normal activity over time(Shalabi et al 2004). The use of cortisone injections while often providing immediate relief are harmful in the longer term and no longer recommended in most cases.( Orchard and Kountouris, 2011). Further research is needed on newer(minimally invasive) treatments, such as platelet-rich plasma injections, hyaluronan gel injections, and nitrate patches. Many cases of tennis elbow can sometimes resolve naturally within 6 to 12 months. Surgery may be considered in extreme cases. For some more information on tennis elbow click here
 

Tennis Elbow Differential Diagnosis

It is important that this condition is differentiated from lateral elbow pain resulting from nerve impingement at neck and shoulders. This is treated very differently. Usually the patient will feel some neck discomfort with this condition and main feel an increase in pain and discomfort in the arm at night in bed.

 

References

Coombes, B.K., Bisset, L., Vicenzino, B. A new integrative model of lateral epicondylalgia. Br. Journal of Sports Medicine, 2009;43(4):252-8.

Orchard J., Kountouris, A. The Management of Tennis Elbow. The British Medical Journal 2011;342;d2687.

Waugh, E.J., Jaglal, S.B., Davis, A.M. Computer use associated with poor long-term prognosis of conservatively managed lateral epicondylalgia. Journal of Orthopaedic  Sports Physical Therapy, 2004;34(12):770-80.

Shalabi, A., Kristofferson-Wilberg, M., Svenson, L., Aspelin, P. and Movin, T.,(2004),” Eccentric training of the gastrocnemius-soleus complex in chronic achilles tendinopathyresults in decreased tendon volume and intratendinous signal as evaluated by MRI.” The American Journal of Sports Medicine, 32 : 5 : 1286-1296.

 

 


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