Overtraining syndrome, a common cause of persistent tiredness in sportspeople, seen by physio’s, frequently occurs in athletes who are training for competition or a specific event and train beyond their bodies ability to recover. Athletes often exercise longer and harder so that they can improve. However without adequate rest, recovery and nutrition, these training regimens can backfire, actually decreasing performance. Proper training and conditioning requires a balance between overload and recovery. The terms overtraining, overreaching, overtraining syndrome, burnout, and staleness have all been associated with overtraining syndrome and need to be clarified. Overtraining is excessive training with inadequate recovery. Overtraining has also been linked to glycogen depletion(Costill et al. 1988) when inadequate refuelling of muscles glycogen occurs due to low carbohydrate intake. The sooner carbohydrate is consumed following a bout of exercise, the more effective the replenishment of glycogen stores. Adequate quality protein intake would also be important in the case of strength athletes to help protect against overtraining syndrome. Sufficient iron intake is important for endurance athletes especially women.
The term overreaching describes similar symptoms(fatigue, performance decrements, mood state
changes) but is generally of a more transitory nature and is often utilised by sportspeople/coaches
during a typical training cycle to enhance performance. Intense training, in the short term can result
in a decline in performance; however when incorporated with periods of recovery, a
super-compensation effect may occur, with the sportsperson exhibiting enhanced performance
when compared with baseline level (Halson and Jeukendrup, 2004). Overtraining syndrome
develops when there is failed adaptation to overload training due to inadequate regeneration.
Unfortunately , many sportspeople and coaches, especially at amateur level, react to impaired
performance by increasing the intensity of training. This leads to further impairment of
performance, which may , in turn, result in the sportsperson increasing training even further. A
vicious cycle develops which leads overtraining syndrome.
Changes within the central nervous system seem to play an important role in the development of
chronic fatigue and many of the other common signs and symptoms that are frequently seen in
overtraining syndrome, such as disrupted sleep, changes in appetite and weight, irritability, impaired
concentration, decreased motivation, and depressed mood. It has been suggested that alterations in
levels of brain neurotransmitters(e.g. a reduction in serotonin levels) and an increased release of
inflammatory mediators(e.g. cytokines) are important factors in the development of overtraining
syndrome(Anish, 2005). Many of the signs and symptoms that characterize overtraining syndrome are remarkably similar to those of clinical depression. Unfortunately, no single test can detect overtraining in the sportsperson. Probably the simplest and most effective means of monitoring overtraining is self analysis by sportspeople themselves. Daily documentation should include sources and ratings of stress, fatigue, muscle soreness, quality of sleep, irritability, and perceived exertion during training or standardized exercise.
Blood parameters such as red and white blood cell counts, haemoglobin, hematocrit, urea, and
ammonia are usually normal during overtraining. Changes in exercise blood lactate concentration
and blood lactate threshold however have been shown to be good indicators of overtraining but are
influenced by many other factors and are probably only useful if assessed repeatedly.
The initial symptom of the overtraining syndrome is usually fatigue but in time, other symptoms
develop.(Mackinnon and Hooper, 2000) Indicators of overtraining include; decreased performance
despite continued training, persistent fatigue, increased early morning heart rate or resting blood
pressure, frequent illnesses such as upper respiratory tract infections, persistent muscle soreness,
loss of body mass, mood changes, loss of appetite, sleep disturbance, high self-reported stress
levels, irritability, depression , decreased maximal heart rate. Overtraining syndrome can also leave
an athlete more susceptible to injury.
Deep tissue massage and injury prevention advice is where or physiotherapists come in. Feel free to set up an appointment at our Tralee clinic to discuss things. For more details click here.
Mackinnon, L.T., Hooper, S.L. Overtraining and overrreaching: causes, effects, and prevention. In :
Garret, W.E., Kirkendall, D.T., eds. Exercise and Sports Science. Philadelphia : Lippincott, William &
Acceleration/deceleration injury to the cervical spine(neck) and back, also known as whiplash, is a common injury due to traffic accidents regularly treated by our physiotherapists in Tralee. Whiplash as it is commonly known may result from rear-end or side impact motor collisions. It can also occur with activities such as diving or due to a direct blow from an opponent etc. The impact of any of these may result in injury to the cervical spine(bones of neck) or soft tissues such as the muscles or ligaments of the neck/back. This in turn leads to what is called ”whiplash associated disorders” or WAD for short(Spitzer, W.O., 1995).
To simplify the mechanism of this type of injury, think of a whip snapping. This is basically what is happening with your neck during these incidents, the head jolts swiftly forward first, then snaps backwards. It is being propelled swiftly with great force in one direction, then there is a recoil swiftly in the opposite direction. The back may also experience similar trauma.
The most common symptoms of whiplash include neck pain, headache, back and shoulder pain with decreased mobility. The condition can be graded into WAD 1 – 4 depending on the degree on injury. With Wad 1 the patient complaints of pain, stiffness or tenderness only but no physical signs are noted. With Wad 2 the patient complains of neck pain and there is decreased range of motion and point tenderness in the neck. Where there are hard neurological signs, for example tingling and/or numbness down one or both arms WAD 3 is the grade assigned. Where there is a resulting fracture of the cervical spine, the term WAD 4 is used(Balla and Iansek, 1988, Stovner, L.J., 1996).
With whiplash the patient may not feel any pain immediately after the accident, however symptoms can increase gradually in the 48 hours after injury. Muscles, joints, ligaments and neural tissue can all be affected depending on the level of injury. Once an x-ray or Mri is performed to rule out serious injury to the bones, ligaments etc. of the neck , red flag signs also being ruled out, it is important that physical therapy is started as soon as possible. A multimodality approach to treatment as early as possible has shown good results in best evidence practice. This includes very specific therapeutic exercises, manual therapy, postural education and the use of drugs most notably non steroidal anti-inflammatories and muscle relaxants(Childs et al. 2008, 2009). It is extremely important to try to return range of movement to the neck as soon as possible after the accident once adequate safety checks have been performed. The neck stiffens up quite quickly when immobilized for even short periods of time. This current thinking is very different to years ago when neck braces and immobilization for long periods after accidents was standard.
Some symptoms associated with whiplash that can indicate the condition may be a little more serious, needing immediate review by a doctor or specialist include bilateral parasthesia(numbness on both sides of body), dizziness, feeling sick, a lump in throat when swollowing, progressively worsening neurological symptoms, signs of neck instability, unrelenting pain, increase in any of these symptoms with rotation or flexion of head. For more information on whiplash click here.
Balla J., Iansek, R., Headaches arising from disorders of the cervical spine. In : Hopkins A, ed. Headache. Problems in diagnosis and management. London: Saunders, 1988:241-67.
Childs, J.D., Cleland, J.A., Elliott, J.M. et al. Neck pain: clinical practice guidelines linked to the International Classification of Functioning, Disability, and Health from the Orthopedic Section of the American Physical Therapy Association. Erratum appears in J. Orthop. Sports Phys. Ther. 2009 Apr;39(4):297, J. Orthop. Sports Phys. Ther. 2008;38(9):A1-34.
Spitzer, W.O., Skovron, M.L., Salami, L.R. et al. Scientific monograph of the Quebec Task Force on Whiplash Associated Disorders : redefining ”whiplash” and its management. Spine 1995;22(8suppl.):S1-73.
Stovner, L.J. The nosologic status of the whiplash syndrome: a critical review based on a methodological approach. Spine 1996; 21(23):2735-46.
A mobile thoracic spine allows you turn your back in many directions, enabling you to do everyday tasks with ease. Today’s sedentary lifestyle often contributes to reduced spinal mobility. Basically ”motion is lotion” and if you are inactive and also prone to poor posture, your thoracic spine can seize up. If it goes on long enough, say into old age portions of the spine may fuse and not move at all. A lack of thoracic spine mobility means that the lumbar spine, pelvis, shoulders and surrounding muscles have to compensate. Long term, these over-compensations can lead to overuse conditions and injuries, the lower back being particularly suceptable. This is because the lumbar spine is meant to keep us stable and is not very mobile, so when these joints are forced to overcompensate for the lack of movement in the thoracic area, it can place alot of pressure on the discs of the lower back. Possible consequences include inflammation, degeneration, herniation of the discs, generalized low back pain, compression fractures, muscles spasms, and spinal nerve injuries. Similar pressures and injuries can occur in the neck and shoulders. For example, if your thoracic spine isn’t mobile, anytime you have to do a movement overhead, your shoulders make up for that lack of mobility. If you have shoulder impingement or chronic shoulder and neck problems lack of mobility in the thoracic spine will make every thing worse.
Improving Thoracic Spine Mobility
Yoga, pre- and post-workout stretching, and mobility exercises are the best way of maintaining and improving thoracic spine mobility. These need to be done regularly and consistently, especially as you get older. Your physiotherapist will be able to guide you on the correct exercises and help correct your form and technique until you get used to them and can do them yourself. Here are a few exercises to get you started.
Chondromalacia patella, also known as ”Runners Knee” is one of the most common causes of knee pain in runners. The condition results from irritation of the cartilage on the under-surface of the kneecap. This cartilage is smooth and the kneecap normally glides effortlessly across it during bending of the knee joint. In some individuals however the kneecap does not track so smoothly due to poor alignment and the cartilage surface becomes irritated, resulting in inflammation and knee pain. In more severe cases there can be breakdown of the cartilage. Chondromalacia patella can affect athletes of any age but tends to be more common in women, most likely due to anatomical differences between the sexes ie. wider hips in females which results in a greater angulation between hip and knee, thus resulting in increased lateral forces on the patella.
Chondromalacia Patella – Causes
There are several causes both structural and dynamic which are linked to the condition. These include excessive foot pronation(feet turn out when running etc.), tight IT band, tight vastus lateralis(basically outer lower quad), weak or slow firing vastus medialis (basically lower inner quad), increased Q angle (simply put the angle between the outer hip and centre of the knee), a lateral femoral condyle that is not sufficiently prominent anteriorly (simply put the knee joint does not fit together properly),and a small or high riding patella(knee cap).(McConnell, 2002)
Chondromalacia Patella – Symptoms
The most common symptom is a dull, aching pain in the front of the knee, behind the kneecap. This pain is often worse when you go up or down stairs. It also can flare up after you have been sitting in one position for a long time. For example, your knee may be painful and stiff when you stand up after watching a movie or after a long trip in a car or plane. In some cases, the painful knee also can appear puffy or swollen. Chondromalacia can sometimes cause a creaky sound or grinding sensation known as ”crepitus” when you move your knee.
Chondromalacia Patella – Physio Treatment
Suitable treatment may involve 1. Soft tissue work to loosen tightened structures such as vastus lateralis muscle, IT band, lateral retinaculum etc., 2.Strengthening of weak structures such as vastus medialis, glutes , hip abductors etc., 3. Correction of overpronation using orthotics, 4. Non steroidal anti-inflammatories such as ibuprofen to reduce pain and inflammation, 5. Rest with gradual return to exercise, 6. Taping to correct tracking can be a short term solution.(Hertling and Kessler, 2006) while you strengthen the vastus medialis muscle. Also there are supports you can purchase to help correct patella tracking while exercising. These are a good short term solution while you correct the problems referred to above. Here is a good example.
If nonsurgical treatments fail, or if you have severe symptoms, your doctor may recommend arthroscopy to check the cartilage inside your knee. If the cartilage is softened or shredded, damaged layers can be removed during the surgery, leaving healthy cartilage in place .
Hertling, D., Kessler, R.M. ”Management of Common Musculoskeletal Disorders : Physical Therapy Principles and Methods.” Lippincott, Philidelphia 524-533, 2006.
Mc Connell, J. ”The physical therapist’s approach to patellofemoral disorders.” Clinical Sports Medicine 21:363-387, 2002.
For more information on chondromalacia patella see this video.
If you would like to get in touch to discuss your condition or make an appointment for physio in Tralee, please click
The term “back mice” is a rather cute description for a painful yet often overlooked condition, even by back pain specialists. The term “back mice” was first used to label the condition by Peter Curtis in 1993. Back mice present as small, firm, fleshy yet moveable nodules upon palpation over the sacral region. Firm pressure directly on the nodules usually produces pain and tenderness, which sometimes radiates into the sacrum and hip. Also, the back mouse seems to suddenly appear following trauma to the back as in a motor vehicle accident or perhaps following a lifting injury. The size of the nodules does not change and they remain the same regardless of the administered soft tissue treatment.
Perhaps a more descriptive term for the back mouse is “lumbar fascial fat herniation” . This occurs when the lumbar subfascial fat layer herniates through the overlying thoraco-dorsal fascia and gets trapped and inflamed. The mechanism appears to be due to an anatomical defect or weakened area in the fascia, which, when there is increased internal pressure, allows the fat lobules to push through the fascia. Once herniated, the fat becomes trapped and as an expanded, inflamed, herniation in an otherwise unyielding fibrous capsule. This creates a focus of pain. Pressure on the fat mouse does not push it back through the fascia but only inflames the torn fascia more. These herniations occur at predictable sites along the iliac crest and sacrum very close to the natural dimple area. They also are approximately three times more prevalent in women, particularly in moderately obese women.
A client usually presents with an episode of low back pain. There may be a history of pain with lifting or prolonged sitting and the pain is usually greater on one side more than the other. The pain may radiate into the buttocks and sacrum and perhaps to the lateral thigh and into the lower extremity. Medications usually do nothing. Many will have gone through the pain pill merry-go-round, taking a cocktail of pain and anti-inflammatory medications even though the pain never truly goes away. The client has often tried everything, been everywhere and you are their last hope. They may have had radiographs, MRI studies or nerve conduction studies, all with negative or minimal findings. They may even have a minor disc bulge without nerve compression, yet the pain exactly mimics a discogenic disorder. When asked to point to the area of the greatest pain, they will invariably point just above and lateral to the natural “dimple” where the back and buttocks come together, near the multifidis triangle. When the area is palpated, the most marked finding is one or several firm, mobile 1.3 cm nodules. When pressed, these nodules reproduce the client’s complaints of back pain as well as the “sciatic” pain.
Subcutaneous lipomas in the back region differ from back mice in that they present as moveable non-tender “speed bumps” that cause pain only when they compress the underlying soft tissue. Subcutaneous lipomas can be found anywhere in the body. They grow slowly over time and are only cosmetically important.
Fig 2. Overlying thoraco-dorsal fascia.
Fig 3. Iliac crest and sacrum.
There always seems to be a focus by back pain specialists upon the disc and nerves issues even though the fat mice are readily palpable. Many sufferer’s have had epidural injections without success. I have had clients who have had surgery for disc herniations yet who still point to the back mouse post surgery as the focal point of pain. It could perhaps be considered diagnostic for the presence of a lumbar fascial fat herniation if a local infiltration of anesthetic takes away the pain.
Treatment of Back Mice
A medical doctor can inject the back mouse with a local anesthetic. This usually only helps temporarily. Dry needling techniques by acupuncturists may help reduce the tension in the fibrous capsule. Good results may sometimes be obtained with local electrical stimulation techniques such as electro-acupuncture. Do not apply deep pressure to back mice during manual physiotherapy treatment. Doing so may only serve to aggravate the herniation. Release of muscular tissue tension around the back mouse may provide some relief by easing pressure on the area.
Perhaps the only permanent cure for the back mouse is its excision and removal. This could be performed by a hernia repair specialist. Once the fat herniation is excised and the fascial tear repaired, the client usually enjoys a more enduring and sometimes dramatic relief. One of the biggest problems is that so many medical doctors fail to recognize this condition; they tend to discount its existence, thereby limiting the treatment options. Icing the area may also provide temporary relief.
Plantar plate injuries are easily missed, probably because a lot of people don’t know what the plantar plate is. Quite they are diagnosed under the general term metatarsalgia. The plantar plate is a deep fibrocartilaginous structure that originates from the metatarsal head and attaches to the proximal phalanx through the joint capsule within the forefoot. Its role is to help stabilize the metatarsophalangeal joints (MTPJ), along with a couple of other structures. The plantar plate also acts as an attachment site for the plantar fascia, so if you load the foot, the medial arch lengthens, the plantar fascia tightens, this engages the plantar plate to plantarflex the proximal phalanx until the toe reaches the ground. This is a simplification of a complex process and is commonly known as the The ‘reversed’ windlass mechanism (with weight-bearing the longitudinal arch flattens, the foot lengthens, the plantar fascia tightens, the proximal phalanx becomes plantarflexed and the mechanism comes to a stop when the proximal phalanx presses against the ground).
What causes a plantar plate injury and how common are they?
There are many contributing factors. The first is any activity that exposes the MTPJ to repetitive and excessive dorsiflexion, so think about jumping and running especially in forefoot runners. There are a few biomechanical conditions that increase the load through the plantar plate such as hallux valgus (bunions). As the function through the 1st MTPJ(big toe) is reduced, then we get what is known as low gear propulsion and increased loading through lesser MTPJs, typically the 2nd, 1st, then 3rd and so on. Another condition like having say an irregular metatarsal length, for example, if you have a long 3rd metatarsal, can expose the plantar plate to increased load, as can external factors like high heels. Basically anything that will result in excessive dorsiflexion or ground reaction forces at the MTPJs may increase plantar plate loading.
How does a plantar plate injury present?..
The patient will complain of pain on the dorsal and plantar aspects of the MTPJ, usually described as an ache or bruising.
Mild oedema may be present along with an episode of trauma, however, trauma is not essential as plantar plate injuries are typically a chronic overuse injury
Reduced plantarflexion strength – The ‘Digital Purchase’ test
A quick way to do this, put a piece of paper under the apex of the affected toe and ask the patient to try and stop you pulling the paper away, in a plantar plate injury you will notice the paper is pulled away much more easily.
Pain, oedema and positive Digital Lachmans (Anterior Draw) / Vertical Stress.
Floating toe, if late-stage hammertoe, or Churchill sign may be present.
Diagnosis of plantar plate injuries
Digital Lachmans / Vertical Stress Test (Fig 1)
Same style of test to assess ACL tears, helps to assess the integrity of the plantar plate, it is quick, easy and a simple test to perform. Stabilise the head of the metatarsal with one hand, using the other hand stabilise the base of the proximal phalanx, apply a vertical force, we are looking for pain and any translocation, it is important to remember this is different from dorsiflexion of the digit.
There are 2 scoring systems one by Thompson and Hamilton and the other Yu and Judge
Thompson and Hamilton
Stage 0, there is no dorsal translocation present of the proximal phalanx.
Stage 1 the base of the phalanx, will not dislocate, however, may sublux
Stage 2 the base of the phalanx can be dislocated.
Stage 3 the phalanx base is in a fixed dislocated position
Yu and Judge
Stage 1 mild odema on the plantar MTPJ with dorsal odema often present as well. Tenderness is present on palpation, however no anatomical malalignment.
Stage 2 moderate odema is present with a noticeable deviation.
Stage 3 odema present around the entire MTPJ with deviation and possible dislocation/subluxation, the odema will reduce however the deformities will remain.
I think the best way to describe the 2 different methods of testing, would be that the Thompson and Hamilton test best describes the integrity of the plantar plate at any given time, whereas the Yu and Judge test describes different stages based on clinical findings on the time of examination.
MRIs, X-rays and Ultrasound
There is still some debate as to whether an MRI scan or ultrasound scan is best for detecting plantar plate injuries. As we know ultrasound is cheaper, however, it is user-dependent, whereas MRI scan is more expensive but we can also get an overall picture of the structures within that area as well. X-ray in weight-bearing (lateral or oblique views) will show subluxation dorsally of the proximal phalanx on the metatarsal head, an anterior-posterior view will show a transverse deformity as well. An x-ray will also rule out other bony pathologies.12
Treatment of plantar plate injuries
The aim of treatments, like most musculoskeletal pathologies, is about managing the load. Essentially we want to try and reduce the ground reaction forces under the affected metatarsal head and reduce the plantarflexion moment of the metatarsal and the dorsiflexion of the phalanx.
Treatment protocols include
No barefoot walking/activity modification
Footwear advice / Air cast boot – we want to look at using a stiff-soled shoe, or reducing the heel height of a shoe, so footwear like high heels and the flexible minimalist type shoes tend to aggravate a plantar plate injury, the same goes for open-toe shoes and flip-flops, as you must claw your toes to keep these on which again increases the ground reaction force underneath the metatarsal.
Stretching / Strengthening – thinking about the mechanics of the foot, if there is tightness within the calf muscles, in turn, could result in early and increased loading through the forefoot, and if you are unable to get adequate dorsiflexion due to calf tightness, then the foot may pronate to compensate for this, which in turn could increase the loading through the lesser MTPJ’s. It is important also to work on strengthening the muscles within the foot.
Strapping can be very helpful in reducing pain, using a rigid zinc oxide tape and pulling the toe into a plantarflexed position to help offload a plantar plate (Fig 2).
Orthotics can be a useful way to help offload the affected plantar plate. One of the best ways to treat Plantar Plate Injures with or without surgery is using an orthotic device that places the pressure into the archway and off of the ball of the foot. If manufactured and molded correctly, they can keep the tension off the injury and pressure when standing and walking. Combining the orthoses with taping and footwear advice can be quite an effective way of offloading the affected plantar plate, whilst the patient reduces sporting activities.
Steroid injections can be tried , however repeated intra-articular injections has been shown to result in dislocation of the MTPJ. It has also been suggested that injections into a ligament resulted in destruction of fibrocytes and reduction in tensile strength for up to 1 year which in turn may result in further damage a possible rupture.
A recent case study showing a patient with a plantar plate tear was managed using conservative measures, consisting of taping, activity modification and the use of a Darco boot over a 6 month period, and progressing to stiffed shoe and orthoses and stopped taping. At the 1 year mark, the patient was pain-free with no toe deformity, and on MRI the plantar plate has healed.
So what’s my treatment plan?
No barefoot walking for 6 weeks (minimum)
To wear stiff-soled shoes
Strapping of digit changing every 72 hours
Orthoses as described as above, plus any other modifications required
Stretching and Strength work – Distal and proximal
If conservative measures fail, then it may require referral to a surgeon.
Physiotherapist in Tralee. Ring to discuss your condition, to get a second opinion or to make an appointment. Click here for website.
Herniated Disc vs Bulging Disc
Your spine is made up of lots of bones called vertebrae and discs stacked on top of one another, forming the spinal canal. The nerves of the spinal cord run down the length of the spinal canal. The discs in act like shock absorbers between the vertebrae. These discs are made of two components: a softer center (called nucleus pulposus) surrounded by a tough elastic-like band (called annulus fibrosus). A bulging disc is like a squashed jam doughnut before the jam bursts out. The disc sags and looks like it is bulging outward. With a herniated disc, the outer covering of the disc has a hole or tear. This causes the nucleus pulposus (jelly-like center of the disc) to leak into the spinal canal. It is like the jam leaking out from the inside of a squashed jam doughnut.
Bulging discs are usually caused by age-related degeneration. There is usually a progressive, gradual onset of symptoms. Bulging discs and herniated discs can occur anywhere along the spine. Pain from a herniated disc usually comes on abruptly often affecting one individual nerve root. Herniated discs are often caused by an acute injury. In some cases, you may know the cause of the injury, such as twisting incorrectly.
Herniated and bulging discs are the most common causes of lower back pain, as well as leg pain or ”sciatica.” Between 60% and 80% of people will experience low back pain at some point their lives. Although a herniated disk can be very painful, most people feel much better with just a few weeks or months of nonsurgical treatment, such as using muscle relaxants and anti-inflammatory medications, along with physiotherapy. Long term management of these conditions needs to including properly prescribed strengthening and flexibility exercises in order to avoid surgery. Surgery is the final option.
For more on herniated and bulging discs, see video.
Physio in Tralee. Phone 0867700191 to discuss your condition or make an appointment.
Peroneal tendonitis occurs when the peroneal tendons become inflamed. This happens when there is an increased load on and/or overuse of the tendons. This causes the tendons to thicken over time. If the injury becomes chronic, the tendinitis can progress to tendinosis. This is more serious and takes longer to treat.
Peroneal tendonitis is particularly common in athletes especially runners , more so if their feet roll outwards during gait(over supination).
There are two peroneal tendons in each leg peroneus brevis and peroneus longus. They run side by side down the outside of the lower leg bone (fibula) and behind the bony lump on the outside of the ankle, the lateral malleolus. One peroneal tendon attaches to the outside of the foot at the base of the little toe (fifth metatarsal). The other tendon goes underneath the foot and attaches to the inside of the arch.The peroneal tendons provide stability to the ankle when it is bearing weight and protects it from sprains. They also help turn the foot out and stabilize the arch when walking.
Causes of Peroneal tendonitis
People who take part in a sport that involves repetitive ankle motion are most prone to peroneal tendonitis Factors that can contribute to peroneal tendonitis include:
a sudden increase in training, particularly weight-bearing activities, such as walking, running, and jumping
improper training techniques
inadequate or un-supportive footwear
There are also some other issues that can increase a person’s risk of developing peroneal tendonitis:
higher foot arches
lower limb muscles and joints not working well together
imbalanced muscles in the lower limbs
If someone fails to complete a rehabilitation program following an ankle injury, such as a sprain, they are also more likely to develop peroneal tendonitis. Over time, the damaged peroneal tendons will thicken as scar tissue tries to repair the damaged area. This makes the tendons weaker and more prone to tearing. Treatment can include orthotics to support the foot and take pressure off the tendon, wearing well laced up supportive footwear, very specific rehab program. Also instrument assisted soft tissue work seems to be beneficial, stripping out the tendon and promoting healing.
Meniscus injuries are a relatively common knee injury. Cartilage within the knee joint provides cushioning between the bones at this joint. This protects 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 cartilage 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 meniscii. These are two thick wedge-shaped pads of cartilage attached to top of the tibia (tibial plateau) and under the femur bone. They allow 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. These meniscus injuries 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.
Meniscus injuries – Increasing risk with age
The risk of developing a torn meniscus increases with age. This is because cartilage begins to gradually wear out, losing its blood supply and its resilience. Being overweight also puts more stress on the meniscii. This means 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.
Some of the fibers of the cartilage are interconnected with those of the ligaments that surround the knee. Thus, meniscus injuries may also be associated with tears of the collateral and cruciate ligaments, depending upon the mechanism of injury.
Symptoms of meniscus injuries 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 is 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.
Physiotherapy in Tralee – referral for MRI
(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. These structure include; 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. When conservative measures are ineffective the next step may be surgery to repair or remove the damaged cartilage.
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Trigger-point dry needling is a procedure where a fine acupuncture needle is inserted into the skin and muscle. It is aimed at myofascial trigger points, which are points of exquisite pain in skeletal muscle, that are associated with a hypersensitive palpable nodule or a taut band.
Active trigger points can spontaneously trigger local or referred pain. They cause muscle weakness, restricted range of movement and autonomic phenomena. Latent trigger points do not cause pain unless they are stimulated. They may alter muscle activation patterns and contribute to restricted range of movement . Therefore both active and latent trigger points cause allodynia(nerve pain) at the trigger point site and hyperalgesia away from the trigger point following applied pressure.
The formation of trigger points is caused by the creation of a taut band or knot within the muscle. This band is caused by excessive acetylcholine release from the motor endplate combined with inhibition of acetylcholine esterase and upregulation of nicotinic acetylcholine receptors. Motor end plates, also called neuromuscular junctions, are specialised chemical synapses formed at the sites where the terminal branches of the axon of a motor neuron contact a target muscle cell. Motor neurons are nerve cells that send electrical output signals to the muscles.
Initially the taut bands are produced as a normal protective, physiological measure in the presence of actual or potential muscle damage. They are thought to occur in response to unaccustomed eccentric or concentric loading, sustained postures and repetitive low load stress. However when sustained they contribute to sustained pain. The pain caused by trigger points is due to hypoxia and decreased blood flow within the trigger point. This leads to a decreased pH which activates the muscle nociceptors to restore homeostasis. This causes peripheral sensitization. Trigger points are also involved in central sensitization. The mechanism remains unclear but trigger points maintain nocioceptive input into the dorsal horn and therefore contribute to central sensitization.
Stimulation of a local twitch response (LTR)
Dry-needling of these myofascial trigger points via mechanical stimulation causes an analgesic effect. This mechanical stimulation causes a local twitch response (LTR). A LTR is an involuntary spinal cord reflex contraction of the muscle fibers in a taut band. Triggering an LTR has been shown to reduce the concentration of nociceptive substances in the chemical environment near myofascial trigger points.
The needle may also cause a small focal lesion which triggers satellite cell migration to the area which then repair or replace damaged myofibers. This occurs 7-10 days after dry needling. It is unclear whether continued dry needling within this period may disrupt this process.
Dry needling may also cause a localized stretch to the cytoskeletal structures. This stretch may allow sarcomeres to resume their resting length. The mechanical pressure causes collagen fibers to intrinsically electrically polarize which also triggers tissue remodeling.
The effectiveness of this treatment depends greatly on the skill of the therapist to accurately palpate mysofascial trigger points.