Patella Dislocation : Knee Injury


Patella DislocationThe patella, or kneecap lies in front of the knee joint. It is attached to the quadriceps muscle via the quadriceps tendon and acts to increase the leverage from this muscle group when straightening the knee. The patella glides up and down virtically within a groove called the patello-femoral groove at the front of the thigh bone(femur) during knee bending. Patella dislocation occurs when the patella moves outside of this groove. The patella may also sublux rather than fully dislocate, meaning it only moves partially out of position. These injuries  usually occurs as a result of an acute blow to or as a result of a twisting action on the knee. In most cases the patella will relocate into the patello-femoral groove on straightening of the knee. This, however is usually extremely painful. Risk factors which make a patella dislocation more likely are 1. insufficient quadriceps strength especially on the inside of the knee,   2. over pronation of the feet , and 3. an increased Q angle of the knee.

The vastus medialis obliqus muscle (VMO) is part of the quadriceps muscle group on the inside of the thigh, and is responsible for maintaining the stability of the patella towards the inside of the knee. If the VMO  isn’t strong enough, the patella is much more susceptible to dislocation.

Over pronation of the feet is where the feet roll in(collapse in slightly on the flattened arch  with the toes turning outwards) when running. This causes torsion at the knee, leaving the patella susceptible to moving outwards as the quadriceps contract.

The Q-angle of the knee is the angle formed by lines representing the pull of the quadriceps muscle and the axis of the patellar tendon. People with an increased Q ankle are often termed knock kneed. This angle when too large increases the risk of patellar dislocation.


 Treatment of patella dislocation

Apply  RICE(rest, ice, compression and elevation) principles to the injured knee . Ice can be applied for 10 to 15 minutes every hour initially reducing to 2 or 3 times a days as swelling and symptoms reduce.  Also medications like non steroidal anti-inflammatories (NSAIDs), analgesics, pain killers etc. would be beneficial, in order to manage both the inflammation and the pain .

Rest from any sporting activities and seek medical advice. An athlete who has had one episode of patella dislocation is often susceptible to another. The knee may need to be immobilized for 2-3 weeks initially. A knee support can provide protection for the joint initially during rehab. Patella stabilizing braces have been specifically designed to provide support for the knee cap.

Quadriceps strengthening is initiated during this phase. These should be in the form of static exercises. Quadriceps electrical stimulation is an option for muscle reeducation if the patient has difficulty activating the muscle secondary to pain. Electrical stimulation may also play a role in the management of knee joint effusion. When swelling, inflammation has subsided, the patient may progress to the recovery phase of rehabilitation.

When the acute symptoms settle down a full knee strengthening rehabilitation program is required to help avoid future recurrence. Specifically exercises for the VMO muscle on the inside of the quadriceps are important, but overall quadriceps strengthening is also beneficial . The VMO is an important medial stabilizer of the patella.  The prevailing theory has been that lateral patellar tracking is associated with VMO weakness. However, research has been inconclusive for VMO weakness as a direct causative mechanism of lateral patellar tracking(patellar subluxation/dislocation). Recent findings have shown that general quadriceps strengthening has demonstrated reductions in lateral tracking irrespective of the mechanism. Therapy should also include a protocol for hamstring muscle stretching. Tight hamstring muscles functionally counteract their agonist group, the quadriceps.


Any physical therapy program for patellofemoral problems must address any tightness or reduced flexibility in the quadriceps, hamstrings, hip abductors,  iliotibial band and calf muscles.

Medial patellar gliding exercises may loosen lateral retinacular tightness in this stage. Medial patellar gliding exercises are performed with the leg extended. The patient manually pushes the patella medially and holds for a count of 10 seconds.

An important concept in the rehabilitation of patellar dislocation and patellofemoral pain is knee flexion. Initially, any activity that requires greater than 40-45° of knee flexion causes symptoms. Initial rehabilitation programs start with the isometric open kinetic chain . Early rehabilitation programs should limit all activities that require quadriceps firing with the knee flexed greater than 45°.

Once isometric open kinetic chain exercises are tolerated without discomfort, the rehabilitation program advances to closed kinetic chain exercises (eg, mini squats, lunges, stair climbing). The rectus femoris, VMO, and VL are all strengthened by the mini squats (repetitions and sets modified to the tolerance of the patient).

Important goals are to restore ”range of movement” in the joint, mobilize soft tissues, and strengthen the surrounding musculature. Lunges and bike riding allow strengthening through a controlled ”range of movement”.  Once pain has resolved sufficiently to complete daily activity requirements without exacerbations, the patient can advance to the final phase of rehabilitation.

Advanced rehabilitation programs progress to jogging, running, plyometrics, and sport-specific exercises. Patients must be monitored and must always follow proper technique, as well as learn to properly fire the VMO.

Sometimes Surgery is needed. Most surgeons agree, if the kneecap dislocates multiple times, then surgery should be considered. When the kneecap dislocates, it is possible to damage the cartilage in the knee, leading to an increased risk of knee arthritis. When multiple dislocations occur, patellar stabilization surgery should be considered. While dislocations of the patella can occur after surgery, they are much less common.

Physiotherapist in Tralee

Morton's Foot
Morton’s Foot

Morton’s foot and pyridoxal 5′-phosphate deficiency: genetically linked traits.

I came across an extremely interesting article lately regarding Morton’s foot and vitamin B6 deficiency. A lot of what I say in the article comes from scientifically published research referenced at the end of the article. Apologies if some of it is a bit technical. I have tried to simplify it while keeping the content intact.

What is Morton’s foot?

A Morton’s foot  also  called Morton’s toe, is a condition characterized by a longer second toe.


Morton’s Toe will cause an individual to have abnormal or over pronation.  It is this pronation that is the ultimate cause or contributing factor to most of the problems not only of the foot but also of the whole body.

Normal Pronation is a series of motions the foot must have, so that it can absorb the shock of meeting the ground. It must be able to do this, in order to adapt and adjust to the new walking surfaces it has just met. This adjustment should only last a fraction of a second to allow the foot to slow down; absorb the shock of your body weight in order to adjust and adapt to the walking surface. If this adjustments last longer, the foot will then begin to abnormally pronate and to correct itself. This is the start of a “chain reaction” that puts the foot under a lot of abnormal stress and strain, causing  Bunions, Heel Spurs, plantar fasciitis, Corns, Callouses, ingrown toenails and numerous other foot problems.


Vitamin B6 deficiency

Vitamin B6 is an essential vitamin needed for many chemical reactions in the human body. It exists as several active forms but pyridoxal 5′-phosphate (PLP) is the phosphorylated form needed for transamination, deamination, and decarboxylation. PLP is important in the production of neurotransmitters, acts as a Schiff base and is essential in the metabolism of homocysteine, a toxic amino acid involved in cardiovascular disease, stroke, thrombotic and Alzheimer’s disease. Nichols and Gaiteri(2014) showed the connection between a deficit of pyridoxal 5′-phosphate and the physical foot deformity known as the Morton’s foot. Morton’s foot has been associated with fibromyalgia/myofascial pain syndrome. PLP deficiency also plays a role in impaired glucose tolerance and may play a much bigger role in the obesity, diabetes, fatty liver and metabolic syndrome. Without the Schiff-base of PLP acting as an electron sink, storing electrons and dispensing them in the mitochondria, free radical damage occurs.



To put this all very simply : Vitamin B6 is an essential vitamin needed for many chemical reactions that take place within the human body. This vitamin is obtained from your diet. The genetically linked condition of ”Morton’s toe” has been linked to the inability to convert Vitamin B6 into the active form pyridoxal 5′-phosphate needed for cetain chemical processes in the human body. This in turn can lead to conditions seen with vitamin B6 deficiency. Some of these conditions include:

  • Anemia
  • Skin/Hair/Nail problems
  • Depression/Anxiety
  • Nerve damage
  • Pain syndrome development
  • Systemic Inflammation
  • Circulation problems, including oxygen transport
  • Hormone Issues
  • Seizures

Do not take a B6 supplement, or “b-vitamin complex” and expect it to help. It won’t.
You need the activated form of B6 called P5P. This is the only form that your body can use.



Supplementation with PLP, L5-MTHF, B12 and trimethylglycine should be used in those patients with hyperhomocysteinemia and/or MTHFR gene mutation.(Trent W. Nichols, Christopher Gaiteri ,Published in Medical hypotheses 2014, DOI:10.1016/j.mehy.2014.09.003).


Physiotherapists in Tralee.  Open early until late. Phone 086-7700191

When Back Pain Is A Symptom Rather Than A Condition

Back pain may sometimes be a symptom rather than a condition as such. A practitioner needs to always keep this at the back of their mind when treating or assessing somebody. Sometimes things need more investigation. A good physio will spot this early and refer you on quickly to your G.P. for further examination. It is always better to play it safe if in doubt.  I always believe you should be seeing improvement in your condition from treatment to treatment. If there is no improvement after several treatments you need to be asking yourself a few questions i.e. Do I need to try a different physio or do I need to consult my doctor for a second opinion. Sometimes the proper treatment protocol for a condition is all that is needed for a swift recovery. The list below is not meant to be alarmist. It is more to emphasize the fact that continuous unrelenting back pain can be a symptom of something else going on within your body.


Below are examples of conditions/medications etc. that may have back pain as a side effect/symptom.


kidney stones – A kidney stone may not cause symptoms until it moves around within your kidney or passes into your ureter (the tube connecting the kidney and bladder). At that point, you may experience symptoms such as severe pain in your side and back below the ribs, or pain that radiates into the lower abdomen and groin.

Lupus is a long-term autoimmune disease in which the body’s immune system becomes hyperactive and attacks normal, healthy tissue. Symptoms include inflammation, swelling, and damage to the joints, skin, kidneys, blood, heart, and lungs. Lupus can cause neck and back pain, because muscles in these areas can become inflamed due to the lupus. Furthermore, the muscle pain syndrome  ”fibromyalgia”  can cause pain in these areas and is commonly associated with lupus.

Spinal arthritis/facet joint arthritis causes stiffness and back pain.

Cancers – A primary bone cancer tumor in the spine can cause back pain, as can a number of other cancers when they have metastasized(spread to other sites in the body), such as breast cancer, testicular cancer, colon cancer, and lung cancer. In fact, back pain is often the one of first symptoms that people with lung cancer notice before they are diagnosed. A tumor in the lungs can put pressure on the spine, or can affect the nerves around the chest wall and spine.

Spondylosis a painful condition of the spine resulting from the degeneration of the intervertebral discs.

Spondylitis is a condition resulting in inflammation within the joints of the spine. As the inflammation goes and healing takes place, bone grows out from both sides of the vertebrae and may join the two together, causing a stiffening known as ankylosis. The progressed condition is called ankylosing spondylitis. The cause is not yet known.

back pain


Spondylolisthesis is a slipping of vertebra that occurs, in most cases, at the base of the spine.

Spondylolysis is a defect or fracture of one or both wing-shaped parts of a vertebra, can result in vertebrae slipping backward, forward, or over a bone below.


Spondylosis, Spondylitis, Spondylolisthesis, Spondylolysis all have back pain as a symptom.


Fractures – Even a minor fracture along the spine  can cause considerable back pain.

StatinsStatins are drugs that can help lower your cholesterol. One of the more severe side effect of statins is myotoxicity(having a toxic effect on muscle), in the form of myopathy(a disease of the muscle in which the muscle fibers do not function properly. This results in muscular weakness), myalgia(muscle pain), myositis(inflammation and degeneration of muscle tissue) or rhabdomyolysis(a condition in which damaged skeletal muscle breaks down). Currently, the only effective treatment of statin-induced myopathy is the discontinuation of statin use in patients affected by muscle aches, pains and elevated creatine kinase levels. Creatine kinase are the clinical measure of muscle damage (rhabdomyolysis).

Anticonvulsant drugs such those used in the treatment of conditions like epilepsy can cause changes in calcium and bone metabolism. This may in time lead to decreased bone mass and a risk of osteoporotic fractures in the spine which may also result in severe back pain. Two widely used antiepileptic drugs phenytoin and carbamazepine are recognized to have direct effects on bone cells.

Corticosteroids – Longterm use of corticosteroids increase the risk of compression fractures in the spine(back).



Neurological Compromise — A Red Flag

Neural compromise can result from spinal cord or cauda equina compression . Cauda equina compression usually results from a fracture, tumor, epidural hematoma, or abscess, and occasionally from a massive disk herniation. Paraplegia(impairment in motor or sensory function of the lower extremities), quadriplegia(paralysis caused by illness or injury that results in the partial or total loss of use of all four limbs and torso), or cauda equina deficit should trigger an aggressive search for the cause.

Cauda equina compression classically presents with back pain, bilateral sciatica(pain down the back of both legs), saddle anesthesia, and lower extremity weakness progressing to paraplegia, but in practice these symptoms are variably present and diagnosing the condition often requires a high degree of suspicion. Hyporeflexia(no reflexes) is typically a sign of cauda equina compression, while hyperreflexia(overresponsive reflexes), clonus(series of involuntary, rhythmic, muscular contractions and relaxations), and the Babinski sign(see below *)  suggest spinal cord compression, requiring an evaluation of the cervical and thoracic spine. Cauda equina compression typically involves urinary retention; in contrast, cord compression typically causes incontinence. If either cauda equina or spinal cord compression is detected during an initial examination, an immediate more extensive evaluation is warranted. MRI is the study of choice.

*(The Babinski reflex occurs after the sole of the foot has been firmly stroked. The big toe then moves upward or toward the top surface of the foot. The other toes fan out. This reflex is normal in children up to 2 years old. It disappears as the child gets older. It may disappear as early as 12 months. When the Babinski reflex is present in a child older than 2 years or in an adult, it is often a sign of a central nervous system disorder. The central nervous system includes the brain and spinal cord.)

Spinal epidural hematoma

Spinal epidural hematoma is a rare but dramatic cause of paralysis in elderly patients. In most cases, there is no antecedent trauma. Lawton et al. (1995), in a series of 30 patients treated surgically for spinal epidural hematoma, found that 73% resulted from spine surgery, epidural catheterization, or anticoagulation therapy. Other possible causes of epidural hematoma include vascular malformations, angiomas, aneurysms, hypertension, and aspirin therapy. The same study found that the time from the first symptom to maximal neurologic deficit ranged from a few minutes to 4 days, with the average interval being nearly 13 hours.

Although painless onset has been reported, spinal epidural hematoma typically presents with acute pain at the level of the lesion, which is often rapidly followed by paraplegia(impairment in motor or sensory function of the lower extremities) or quadriplegia(is paralysis caused by illness or injury that results in the partial or total loss of use of all four limbs and torso), depending on the location of the hemorrhage. Sometimes the onset of pain is preceded by a sudden increase of venous pressure from coughing, sneezing, or straining at stool. Urinary retention often develops at an early stage.

Most lesions occur in the thoracic region(rib area of back) and extend into the cervicothoracic(upper back and neck) or the thoracolumbar(ribs to lower back area) area. The pain distribution may be radicular(affecting or relating to the root of a spinal nerve), mimicking a ruptured intervertebral disk.

Evaluation should be with MRI. Early recognition, MRI confirmation, and treatment should be accomplished as soon as possible. Recovery depends on the severity of the neurologic deficit and the duration of symptoms before treatment. Lawton et al.(1995), found that patients taken to surgery within 12 hours had better neurologic outcomes than patients with identical preoperative neurologic status whose surgery was delayed beyond 12 hours. Surgery should not be withheld because of advanced age or poor health: in 10 reported cases in which surgery was delayed, all patients died.


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Everyone’s spine has curves, from your neck down to your lower back. These curves, which create the spine’s ”S” shape, are  lordotic in shape in the neck and lower back, and  kyphotic in shape for the upper back. They help your body 1. absorb shock,  2. support the weight of the head, 3. align your head over your pelvis, 4. stabilize and maintain its structure, 5. move and bend flexibly. When these curves are exaggerated through poor posture or hereditary conditions like scoliosis, spinal pain and problems can develop over time.



KyphosisKyphosis is an exaggerated, forward rounding of the back. It can occur at any age but is more common in older people. Age-related kyphosis is often due to weakness in the spinal bones that causes them to compress or crack. Other types of kyphosis can appear in infants or teens due to malformation of the spine or wedging of the spinal bones over time. Mild kyphosis causes few problems. Severe kyphosis can cause pain and be disfigurment. Treatment for kyphosis depends on your age, and both the cause and the effects of the curvature.



LordosisSome curvature in the lower back is normal. However, if your curve arches too far inward, it’s called lordosis, or swayback. Lordosis can affect your lower back and/or neck. The condition can lead to excess pressure on the spine, causing pain and discomfort. It can affect your ability to move if it’s severe and left untreated. Treatment of lordosis depends on how serious the curve is and how you got lordosis. There’s little medical concern if your lower back curve reverses itself when you bend forward. You can probably manage your condition with physical therapy and daily exercises.





scoliosisScoliosis is a medical condition in which a person’s spine curves sideways, usually in an  “S” or “C” shape. In some, the degree of curvature  remains stable, while in others, it increases over time. Mild scoliosis does not typically cause problems, however severe cases can interfere with breathing. The cause of most cases is unknown, but is believed to involve a combination of genetic and environmental factors. Diagnosis is confirmed by Xray. Treatment depends on the degree of curve, location, and cause.

Minor curves may simply be watched periodically. Treatments may include bracing or surgery in more severe cases. The brace must be fitted to the person and used daily until growing stops. Evidence that chiropractic manipulation dietary supplements, or exercises can prevent the condition from worsening is non existent. However, exercise is still recommended due to its other health benefits. Scoliosis occurs in about 3% of people. It most commonly occurs between the ages of 10 and 20. Girls typically are more severely affected than boys.




Physiotherapists in Tralee Phone 086-7700191

bicipital-tendonitisBicipital tendonitis is a common cause of shoulder pain, often developing in people who perform repetitive, overhead movements. Biceps tendinitis develops over time, the pain being located at the front of the shoulder. The biceps muscle has two parts referred to as the long head and the short head. The tendon of the long head of the biceps is most commonly implicated with tendonitis. When this tendon is subjected to repetitive stresses, it can become irritated, swollen, and painful.This occurs where the tendon sits within the bicipital groove at the top of the humerus under the transverse ligament before it becomes part of the shoulder joint capsule.

Pain at this exact spot when pressed with a finger as the arm is rotated in and out while standing, is usually a fairly reliable test to confirm this condition. Imaging techniques such as MRI are typically not needed to diagnose biceps tendonitis.

Symptoms – Bicipital Tendonitis

Pain or tenderness in the front of the shoulder, which worsens with overhead lifting or activity.

Pain that moves down along the upper arm

An occasional snapping sound or sensation in the shoulder

Treatment – Bicipital Tendonitis

The initial goals of treatment for bicipital tendonitis are to reduce inflammation and swelling. Patients should restrict above shoulder height movements, reaching out with the affected arm and lifting. They should apply ice to the affected area for 10-15 minutes, 2-3 times daily for several days. Non-steroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, may help recovery. Probably the biggest aid to recovery is rest from the aggravating activity for several weeks. I often come across this condition in weight trainers who front press or incline bench press, the bar being too far out from their neck during pressing. It is also common in swimmers with poor technique or who ramp up their training distance/pace too quickly.


Physiotherapist Tralee : Phone 086-7700191 for an appointment, second opinion or to discuss your injury.

Lumbosacral Plexopathy

Lumbosacral Plexopathy : Recently I had a patient present with footdrop (foot drops and drags as you walk due to weakness in dorsiflexor muscles), also severe pain down the leg, along with lumbar-sacral pain(lower back area). Initially this might appear to be signs of disc herniation with nerve root compression, even though the footdrop would be fairly uncommon with that condition. An MRI showed the spine to be normal. We also looked at anything that might have injured the peroneal nerve which is quiet close to the skin on the lower leg, which in itself could cause the footdrop, but there was no sign of injury. We were also able to rule out diabetes which can lead to nerve damage.

So where did we go next? Answer : An electromyography (EMG)(nerve conduction study). Electromyography is a diagnostic procedure used to assess the health of muscles and the nerve cells that control them (motor neurons). EMG results can reveal nerve dysfunction, muscle dysfunction or problems with nerve-to-muscle signal transmission. As a result of this testing by a specialist, the client was diagnosed as having a Lumbosacral plexopathy. In this case it seemed that the nerve had been damaged by a viral or bacterial infection. More tests need to be done to confirm and treat this infection.

The lumbosacral plexus represents the nerve supply to the lower back, pelvis and legs. Lumbosacral plexopathy is characterized as inflammation and or damage to the nerve bundles in the area of the lumbar and sacral vertebrae regions. Symptoms may include shooting or burning pain, numbness, and decreased movement in the thigh, buttock and/or leg area. It is an uncommon idiopathic disorder(relates to or denotes any disease or condition which arises spontaneously or for which the cause is unknown). It is characterized by the acute onset of severe lower extremity pain followed by wasting and weakness of leg muscles along with variable sensory loss.

To Summarise : Lower Lumbosacral Plexopathy

It predominantly affect the L4–S3 nerve fibers.

There patient complains of a deep boring pain in the pelvis that can radiate posteriorly into the thigh and down into the posterior and lateral calf.

The ankle reflex may be depressed or absent.

Sensory symptoms and signs may be severely deminished over the posterior thigh and posterior-lateral calf and in the foot.

Other Causes of Lumbosacral Plexopathy

Retroperitoneal hemorrhage (anticoagulation, hemophilia)
Pelvic or abdominal tumor
Aneurysm (common or internal iliac artery)
Inflammatory (plexitis)
Postpartum [during childbirth]
Diabetes (diabetic amyotrophy – most common non-structural cause)
Postsurgical (retractor injury)

Please note that the presentation of Lumbosacral Plexopathy has subtle differences to sciatica and discogenic pain, the later conditions being much more common than Lumbosacral Plexopathy.



Physiotherapists in Tralee  Phone 086-7700191 to discuss your condition or to make an appointment.

ROTATOR CUFFRotator Cuff Tears

Your arm is kept in your shoulder socket by your rotator cuff. The rotator cuff consists of four muscles, the supraspinatus muscle, the infraspinatus muscle, the terres minor muscle, and the subscapularis muscle. These muscles attach the humerus to the shoulder blade and help lift and rotate your arm.

Your shoulder is made up of three bones: your upper arm bone (humerus), your shoulder blade (scapula), and your collarbone (clavicle). The shoulder is a ball-and-socket joint: the ball, or head, of your upper arm bone fits into a shallow socket in your shoulder blade.

There is also a lubricating sac called a bursa between the rotator cuff muscles and the bone on top of your shoulder (acromion). The bursa allows the rotator cuff tendons to glide freely when you move your arm. Sometimes it may become inflamed and painful due to overuse.


Rotator Cuff Tears – Causes

There are two main causes of rotator cuff  injury and degeneration.


1. Acute Tears

If you fall down on your outstretched arm or lift something too heavy with a jerking motion, you can tear your rotator cuff at that moment.

2. Degenerative Tears

Many rotator cuff tears are the result of a wearing down of the tendon occurring slowly over time. They are more common in the dominant arm.

Several factors contribute to degenerative, or chronic, rotator cuff tears.

  • Repetitive stress : Repeating the same shoulder motions again and again can stress your rotator cuff muscles and tendons. Baseball, tennis, rowing, and weightlifting are examples of sports activities that can put you at risk for overuse tears. Many jobs and routine chores can cause overuse tears, as well.
  • Lack of blood supply : As we get older, the blood supply to our rotator cuff tendons reduces. Without a good blood supply, the body’s natural ability to repair tendon damage is impaired. This can ultimately lead to a tendon tear.
  • Bone spurs : As we age, bone spurs (bone overgrowths) often develop on the underside of the acromion bone. When we lift our arms, the spurs rub on the rotator cuff tendon. This is part of a condition which comes under the general term of ”shoulder impingement”.  Over time this can damage the tendon, making a tear more likely. The supraspinatus muscle is probably the more common of the rotator cuff muscles to get injured as we age. This is because the supraspinatus passes under the acromion process before attaching to the greater tubercle of the humerus.
  • Poor posture : With poor posture over time the shoulders start to protrude forward making the subacromion space smaller and causing shoulder impingement, sometimes leading to rotator cuff muscle/tendon damage, especially the supraspinatus muscle/tendon.


The most common symptoms include:

  • Pain at rest and at night, particularly if lying on the affected shoulder
  • Pain when lifting and lowering your arm or with specific movements
  • Weakness when lifting or rotating your arm

Tears that happen suddenly, such as from a fall, usually cause intense pain immediately. There may be a snapping sensation or feeling of something giving way, followed by immediate weakness/severe pain in moving your upper arm.Tears that develop slowly due to overuse also cause pain and arm weakness but the increase in pain intensity occurs over time. You may have pain in the shoulder when you lift your arm, or pain that moves down your arm. At first, the pain may be mild and only present when lifting your arm over your head, such as reaching into a cupboard. Over time, the pain may become more noticeable at rest, and no longer goes away with medications. You may have pain when you lie on the injured side at night. The pain and weakness in the shoulder may make routine activities such as combing your hair or reaching behind your back more difficult.

There are different types of tears.

  • Partial tear : This type of tear is also called an incomplete tear. It damages the tendon, but does not completely sever it.
  • Full-thickness tear : This type of tear is also called a complete tear. It separates all of the tendon from the bone.


Rotator Cuff Tears – Imaging Tests

Magnetic resonance imaging (MRI) or ultrasound are probably the best way to confirm tears, bursitis, tendinopathies or bone spurs in the rotator cuff area.

 Rotator Cuff Tears -Treatment

If you have a partial rotator cuff tear and you keep using it despite increasing pain, you may cause further damage.  A rotator cuff tear can get larger over time.

Chronic shoulder and arm pain are good reasons to see your doctor. Early treatment can prevent your symptoms from getting worse. It will also get you back to your normal routine that much quicker.

The goal of any treatment is to reduce pain and restore function. There are several treatment options, and the best option is different for every person. In planning your treatment, your doctor will consider your age, activity level, general health, and the type of tear you have.

Nonsurgical Treatment

Nonsurgical treatment options may include:

  • Rest. Your doctor may suggest rest and limiting overhead activities. He or she may also prescribe a sling to help protect your shoulder and keep it still.
  • Activity modification. Avoid activities that cause shoulder pain.
  • Nonsteroidal anti-inflammatory medication. Drugs like ibuprofen and naproxen reduce pain and swelling.
  • Strengthening exercises and physical therapy. Specific exercises will restore movement and strengthen your shoulder. Your exercise program will include stretches to improve flexibility and range of motion. Strengthening the muscles that support your shoulder can relieve pain and prevent further injury.
  • Cortisone steroid injection. This is not recommended with a muscle or tendon tear and can actually lead to more damage in the long-term. One exception would be in the case of a subacromial bursitis where it can be very effective in shrinking the bursa back to normal size and reducing the inflammation.

Surgical Treatment

Your doctor may recommend surgery if your pain does not improve with nonsurgical methods. Continued pain is the main indication for surgery. If you are very active and use your arms for overhead work or sports, your doctor may also suggest surgery.

Other signs that surgery may be a good option for you include:

  • Your symptoms have lasted 6 to 12 months
  • You have a large tear
  • You have significant weakness and loss of function in your shoulder
  • Your tear was caused by a recent, acute injury

Surgery to repair a torn rotator cuff most often involves re-attaching the tendon to the head of humerus (upper arm bone).

Home rehab exercises for the rotator cuff muscles click here


Physiotherapist in Tralee : Phone 086-7700191

Common Knee Injuries

1. Chondromalacia Patella

knee injuriesKnee injuries like Chondromalacia patella result from degeneration of cartilage on the underside the kneecap (patella)due to poor alignment of the kneecap (patella) as it slides over the lower end of the thighbone (femur). This condition can also be referred to as patellofemoral syndrome.  It usually presents as pain in the front of the knee aggravated by activities such as running, jumping, climbing or descending stairs etc., or by prolonged sitting with knees in a moderately bent position. Patients with chondromalacia patella frequently have abnormal patellar “tracking” toward the lateral (outer) side of the femur. Some patients may also have a vague sense of “tightness” or “fullness” in the knee area with the condition. Mild swelling of the knee area may also occur.

2. Meniscus TearKnee injuries

knee injuriesAny activity that causes you to forcefully twist or rotate your knee, especially when putting your full weight on it, can lead to a torn meniscus. Each of your knees has two menisci — C-shaped pieces of cartilage that act like a cushion between your shinbone and your thighbone. A torn meniscus causes pain, swelling and stiffness. You might also feel your knee lock and have trouble extending it fully. Conservative treatment — such as rest, ice and medication — is sometimes enough to relieve the pain of a torn meniscus and allow the injury time to settle down on its own. In other cases, however, a torn meniscus requires surgical repair.

The meniscus weakens with age. Tears are more common in people over the age of 30. If you have osteoarthritis, you’re at higher risk of injuring your knee or tearing your meniscus. When an older person experiences a meniscus tear, it’s more likely to be related to degeneration. This is when the cartilage in the knee becomes weaker and thinner.


3. Cruciate ligament rupture

knee injuriesThese ligaments are found inside your knee joint. They cross each other to form an “X” with the anterior cruciate ligament in front and the posterior cruciate ligament in back. The cruciate ligaments stabilize the knee. About half of all injuries to the anterior cruciate ligament occur along with damage to other structures of the knee, such as articular cartilage, meniscus, or other ligaments. Partial tears of the anterior cruciate ligament are rare; most ACL injuries are complete or near complete tears.

The  cruciate ligaments can be injured in several ways such as : changing direction rapidly ; Stopping suddenly ; Slowing down while running ; Landing from a jump incorrectly ; Direct contact or collision to the knee.

When you tear a  cruciate ligament, you might hear a “popping” noise and you may feel your knee give way under you. Other typical symptoms include:

  • Pain with swelling. Within 24 hours, your knee will swell. If ignored, the swelling and pain may resolve on its own. However, if you attempt to return to sports, your knee will probably be unstable and you risk causing further damage to the cushioning cartilage (meniscus) of your knee.
  • Loss of full range of motion
  • Tenderness along the joint line
  • Discomfort while walking

Treatment for a cruciate ligament tear varies depending on the patient’s individual needs. For example, the young athlete involved in agility sports will need surgery to return safely to sports. Less active, older individuals may be able to return to a quieter lifestyle without surgery.


4. Collateral ligament strain/ruptureKnee injuries

physiotherapists in DingleThe collateral ligaments of the knee are located one on either side of your knee joint. They help connect the bones of your upper and lower leg, inside your knee joint. The collateral ligaments help keep your knee stable. They keep your leg bones in place and keep your knee from moving too far sideways. A collateral ligament injury occurs when the ligaments are stretched or torn. A partial tear occurs when only part of the ligament is torn. A complete tear occurs when the entire ligament is torn into two pieces. A collateral ligament injury can occur if you get hit very hard on the inside or outside of your knee, or when you have a twisting injury. Sometimes the ligaments just sprain and this is easier to recover from and requires no surgery.

With a collateral ligament injury, you may notice:

  • Your knee is unstable and can shift side to side as if it “gives way”
  • Locking or catching of the knee with movement
  • Knee swelling
  • Knee pain along the inside or outside of your knee

Various orthopedic tests can help diagnose  collateral ligament damage. More detailed knowledge of the injury can be obtained by MRI. Injured ligaments are considered “sprains” and are graded on a severity scale.


If you have a collateral ligament injury, you may need:

  • Crutches to walk until the swelling and pain get better
  • A brace to support and stabilize your knee
  • Physical therapy to help improve joint motion and leg strength

A lot of the time people don’t need surgery for collateral ligament damage  but more serious cases may.


5. Baker’s Cyst – Knee injuries

 knee injuries

Baker’s cyst is a fluid-filled swelling that causes a lump at the back of the knee, leading to tightness and restricted movement. Usually, this condition is due to an underlying problem affecting the knee joint, such as arthritis or a cartilage injury.


6. Patella Tendinopathy

knee injuriesPatellar tendinopathy(also known as Jumper’s knee) is an overuse injury affecting this knee tendon. There are a number of factors which can contribute to the development of patellar tendinopathies. These include:

  • Rapid increase in amount of training
  • Sudden increase in training intensity
  • Playing/training on rigid surfaces
  • Tight quadriceps and hamstring muscles
  • Poor foot posture, knee or hip control.

Tendinopathies usually causes pain, stiffness, and loss of strength in the affected area. The pain may get worse when you use the tendon. An experienced practitioner will be able to diagnose a tendinopathy from both palpation and history of the condition.   Tendinopathies can be confirmed by MRI which will give a clearer picture of the level of damage. Treatment for patellar tendinopathies varies depending on the level of injury and can vary from conservative treatment combining rest / eccentric training  to surgical intervention in more serious cases.

7. Osgood Schlatter’s Disease(Kids)

 physiotherapists in DingleOsgood-Schlatter disease is a common cause of knee pain in growing adolescents. It is an inflammation of the area just below the knee where the tendon from the kneecap (patellar tendon) attaches to the shinbone (tibia) called the tibial tuberosity. The condition gets worse with activity and better with rest. Osgood-Schlatter disease most often occurs during growth spurts, when bones, muscles, tendons, and other structures are changing rapidly. Because physical activity puts additional stress on bones and muscles, children who participate in athletics — especially running and jumping sports – are at an increased risk for this condition. However, less active adolescents may also experience this problem. The condition normally resolves over time but can be anything from a few weeks/months to two years. It is nothing to worry about. A child can remain active but pain from the condition itself will limit that activity. Icing the area of pain and stretching leg muscles especially quads can help. NSAIDs can be used to relief the pain and inflammation but should be used sparingly and under doctors supervision.


Article by Eddie O Grady Physiotherapist.

Stem cell treatmentRecently in Ireland, people are paying thousands of euro for procedures advertised as ” stem cell treatment ”, for conditions such as osteoarthritis. These treatments are not covered by health insurance companies etc. They often use the term ”stem cell treatment”, for a process that bears little if any resemblance to what stem cell therapy actually is. Below is a summary of an article written by an orthopedic surgeon outlining the limitations of stem cell therapy as it presently stands. Before you part with your money for one of these treatments, have a read of it, discuss it with your doctor and do your research.


Below is a summary of an article written by Mark Miller, Professor of Orthopedic Surgery, University of Virginia, ”Stem cell treatment for arthritic knees is unproven, expensive and potentially dangerous”

Stem cells are “uncommitted” cells that are, at least theoretically, capable of becoming any type of cell – skin, heart, kidney or even knee cartilage cells. Stem cells can come from fetal tissue, including products of in-vitro fertilization as well as placenta and umbilical cord tissue. They can also come from a patient’s own “hidden” adult stem cells, which are most often harvested from bone marrow and fat. The potential for using these cells in medicine is tremendous.

The truth

Unfortunately, the excitement about stem cells has outpaced the science. In addition, due to the ethical issues associated with the use of fetal tissue, the U.S. Food and Drug Administration has severely restricted its use and obtaining an abundant source of concentrated stem cells can be difficult.

In orthopedics, researchers have proposed using stem cells for the treatment of joint/cartilage damage. This includes osteoarthritis. Osteoarthritis often results in the need for joint replacement surgery. Stem cell injections are now being  promoted as a potential way of avoiding the need joint replacement, by ”regenerating” the cartilage. Unfortunately, current technology and regulatory issues make obtaining and concentrating true stem cells a challenge, and encouraging them to become and remain cartilage cells and nothing else is even more difficult.

The problem with stem cells is that these cells can continue to evolve; they may not stop development at the cartilage cell phase. They may continue to differentiate into bone cells. This would make the joint even worse because bone creates a rough surface adjacent to the smooth articular cartilage. Bone is actually the end result of arthritis.

According to the American Association of Hip and Knee Surgeons, there are no proven medications or therapies that can delay or reverse the progressive joint destruction that occurs with osteoarthritis.

Many patients have paid out thousands of dollars for ”so-called stem cell treatment” only to later discover that they were scammed. Any positive effects of current stem cell treatment are likely not the result of the actual cells themselves but something else.

Alternatives to stem cell treatment

Depending on the cause and severity of their joint pain, patients have treatment options that range from physical therapy, to injections of various medications, to surgery. All have pros and cons; steroid injections can provide quick but short-lived pain relief, while a knee replacement can provide a permanent solution but also requires months of rehabilitation. Doctors need to help patients make the choice that best fits their particular needs.


Physiotherapists Tralee phone 086-7700191



Gout ?

GoutGout is a form of arthritis which starts as a result of excess uric acid build-up in the blood, also called hyperuricemia. It is an extremely painful condition. Uric acid is produced in the body during the breakdown of purines – chemical compounds that are found in certain foods such as meat, poultry, and seafood. Normally, uric acid is dissolved in the blood and is excreted from the body in the urine via the kidneys. If too much uric acid is produced, it can build up and form needle-like crystals that trigger inflammation and pain in the joints and surrounding tissue. The condition often starts by affecting the joint at the base of the big toe. Attacks often occur without warning and in the middle of the night. They can come on quickly and keep returning over time, slowly damaging tissues in the region of the inflammation.

Tests and diagnosis

Gout can be tricky to diagnose, as it’s symptoms can be similar to those of other conditions, i.e. bunion on the big toe. While hyperuricemia occurs in the majority of people that develop gout, it may not be present during a flare. There is one very subtle, important difference between gout and other foot conditions, that helps the health practitioner differentiate between them. When you very gently stroke the skin of a gout affected area, it will cause a lot of pain in the sufferer. This does not occur with other conditions. The gout makes the skin super sensitive. This test is not 100% accurate, but I have found it to be a reasonably good indicator that one should look in the direction of gout, and refer the patient onto a doctor. This is especially true, if during examination and history take, the patient meets other criteria that would make them more prone to gout, and there has been no specific injury to the area affected. Often with tests you are more trying to rule out other conditions and narrow your possibilities down to that of gout..

One diagnostic test that doctors can carry out is the joint fluid test, where fluid is extracted from the affected joint with a needle. The fluid is then examined to see if any urate crystals are present. As joint infections can also cause similar symptoms to gout, a doctor can also look for bacteria when carrying out a joint fluid test in order to rule out a bacterial cause. Doctors can also do a blood test to measure the levels of uric acid in the blood. However, people with high uric acid levels do not always experience gout. Equally, some people can develop the symptoms without having increased levels of uric acid in the blood. Finally, doctors can search for urate crystals around joints or within a tophus(deposit of uric acid crystals) using ultrasound or CT scans.  X-rays cannot detect gout, but may be used to rule out other causes.


Treatment and control of the condition requires certain dietary modifications such as reducing the intake of foods high in purines ie. red meat, shellfish, and beer to name but a few. Other factors that contribute to gout include being overweight, certain medications, high blood pressure, drinking too many sugary sodas, and being regularly dehydrated. These all need to be monitored and corrected.

Treatments for acute attacks include:

  1. NSAIDs – Non-Steroidal Anti-Inflammatory Drugs
  2. Colchicine
  3. Steroids
  4. Urate-Lowering Therapy (ULT)


For more see video


Overview by physiotherapists in Tralee, Co. Kerry