Understanding Achilles Tendinitis: A Guide for Recreational Runners

Running is a fantastic way to stay fit, clear your mind, and enjoy the great outdoors. However, it can also come with its fair share of injuries, especially for those who are just starting out or ramping up their training intensity. One common issue among runners is Achilles tendinitis. In this blog post, we'll delve into what Achilles tendinitis is, why it happens, and how you can recover and get back to enjoying your runs.

What is Achilles Tendinitis?

Achilles tendinitis is an overuse injury of the Achilles tendon, the large band of tissue that connects your calf muscles to your heel bone. This tendon plays a crucial role in running, walking, and jumping, as it allows you to push off with your foot. When the tendon is subjected to excessive stress without adequate recovery, it can become irritated and inflamed, leading to pain and stiffness.

Types of Achilles Tendinitis: Insertional vs. Mid-Portion

Achilles tendinitis can be categorised into two main types based on the location of the injury: insertional and mid-portion.

Insertional Achilles Tendinitis

Insertional Achilles tendinitis affects the lower part of the tendon, where it attaches to the heel bone. This type of tendinitis is often associated with:

• Pain and Swelling: Pain at the back of the heel, especially when running uphill or on hard surfaces.

• Bone Spurs: In some cases, bone spurs can develop at the insertion point, exacerbating the condition.

Treatment Considerations for Insertional Achilles Tendinitis:

• Avoid Heel Drops: Unlike mid-portion tendinitis, eccentric exercises like heel drops can worsen symptoms in insertional tendinitis due to the added stress on the heel bone attachment.

• Heel Lifts: Using heel lifts in shoes can reduce the strain on the tendon insertion.

• Gentle Stretching: Focus on gentle calf stretches to avoid overstressing the insertion point.

Mid-Portion Achilles Tendinitis

Mid-portion Achilles tendinitis affects the middle section of the tendon, typically 2-6 centimeters above the heel bone. This is the more common type among runners and is characterized by:

• Pain and Swelling: Pain in the middle of the tendon, often during and after running.

• Thickening of the Tendon: The tendon may appear thickened in the affected area due to chronic inflammation and degeneration.

Treatment Considerations for Mid-Portion Achilles Tendinitis:

• Eccentric Exercises: Heel drops and raises on a step are effective for strengthening the tendon and promoting collagen alignment.

• Flexibility and Strength Training: Incorporate exercises to improve calf and tendon flexibility and strength.

• Cross-Training: Engage in low-impact activities like swimming or cycling to maintain fitness without stressing the tendon.

The Pathology of Tendinopathy

To understand Achilles tendinitis, it's essential to know a bit about tendinopathy, which refers to tendon disorders in general. Tendons are composed of tightly packed collagen fibers that are aligned to withstand tensile forces. However, when these fibers are repeatedly overloaded, micro-tears can occur. In the case of Achilles tendinitis, the following pathological changes can happen:

1. Collagen Degeneration: The repeated stress can cause the collagen fibers to break down faster than they can be repaired. Instead of the neat, parallel arrangement, the fibers become disorganized, resembling a frayed rope.

2. Inflammation: Initially, the body's response to injury includes inflammation. This is part of the healing process, but if the tendon continues to be stressed, inflammation can become chronic.

3. Neovascularization: As the body attempts to heal the damaged tendon, new blood vessels may grow into the area. While this sounds beneficial, these new vessels often bring nerve fibers with them, contributing to increased pain sensitivity.

Why Does It Hurt?

The pain associated with Achilles tendinitis is due to several factors:

• Mechanical Stress: The damaged tendon fibers are less capable of handling stress, leading to pain during activities that load the tendon, like running or even walking.

• Inflammation: Chronic inflammation can cause persistent pain and swelling.

• Nerve Sensitivity: The new nerve growth associated with neovascularization can make the area more sensitive to pain.

Chronic Tendinopathy: Managing Long-Term Damage

In more chronic cases of tendinopathy, where there is a significant amount of dysfunctional reorganisation of collagen, it can be very challenging, and perhaps even impossible, to fully restore the tendon structure. Instead of aiming to completely regenerate the damaged areas, rehabilitation focuses on enhancing the health of the unaffected tendon cells and increasing the capability of the remaining functional collagen fibers to compensate for the degenerated regions. Here’s how this works:

1. Healthy Tendon Cells: Rehab exercises and treatments aim to improve the overall environment of the tendon, boosting the health of the unaffected tendon cells. These cells can produce new collagen and other components necessary for tendon repair and maintenance.

2. Strengthening Intact Fibres: By increasing the strength and functionality of the remaining healthy collagen fibres, rehab helps these fibers to better support the tendon as a whole. This compensatory mechanism can help to improve the tendon's overall load-bearing capacity, reducing pain and improving function.

3. Enhanced Blood Flow and Healing: Therapies that enhance blood flow to the tendon can help to deliver essential nutrients and oxygen to the area, supporting the healing process and promoting the production of new, healthy tendon tissue.

How to Recover

Recovering from Achilles tendinitis requires a multifaceted approach focusing on reducing inflammation, promoting healing, and gradually restoring tendon strength. Here are some steps to help you get back on your feet:

1. Rest and Modify Activity: Initially, reduce or stop the activities that cause pain. This doesn't mean complete inactivity; low-impact exercises like swimming or cycling can help maintain fitness without stressing the tendon.

2. Ice Therapy: Applying ice to the affected area can help reduce inflammation and pain. Use ice packs for 15-20 minutes several times a day, especially after activity.

3. Stretching and Strengthening Exercises: Gentle stretching of the calf muscles and Achilles tendon can help maintain flexibility. Eccentric strengthening exercises, where the muscle lengthens while contracting, have been shown to be particularly effective for tendon healing. Examples include heel drops and controlled calf raises.

4. Footwear and Orthotics: Proper footwear with good arch support and cushioning can reduce stress on the Achilles tendon. In some cases, orthotic inserts may be recommended to correct biomechanical issues.

5. Physiotherapy: A physiotherapist can provide a tailored rehabilitation program that includes manual therapy, ultrasound, and other modalities to promote healing.

6. Gradual Return to Running: Once the pain has subsided and you have regained strength and flexibility, you can gradually return to running. Start with short, easy runs on soft surfaces, and slowly increase your distance and intensity.

Prevention Tips

To prevent Achilles tendinitis from recurring, consider the following tips:

• Warm-Up Properly: Always start your run with a proper warm-up to prepare your muscles and tendons for the activity.

• Increase Training Gradually: Avoid sudden increases in mileage or intensity. Follow the 10% rule, where you increase your weekly mileage by no more than 10%.

• Strength Training: Incorporate regular strength training for your lower legs to improve overall stability and reduce the load on your Achilles tendon.

• Listen to Your Body: Pay attention to any signs of discomfort or pain in your Achilles tendon, and address them early before they become a more serious issue.

Conclusion

Achilles tendinitis can be a frustrating setback for recreational runners, but with the right approach, you can recover and return to running stronger than ever. Understanding the pathology behind the pain can help you appreciate the importance of proper treatment and prevention strategies. Remember, patience and consistency are key to a successful recovery. Happy running!

Managing Forefoot Pain: a guide for Runners

Hello fellow runners!

I've noticed a few members asking questions about forefoot pain located near the 2nd and 3rd metatarsophalangeal (MTP) joints, so I decided to write this blog to provide some helpful information.

Forefoot pain is a common complaint among runners, and it can significantly impact your performance and enjoyment of the sport. As a physiotherapist with a passion for running, I want to share some insights and tips to help you prevent and better manage forefoot pain. Whether you're a seasoned marathoner or a weekend jogger, this guide is for you.

The Role of Training Load in Running Injuries

One of the more critical, but often overlooked factors in the development of running injuries, including forefoot pain, is training load. It is tempting to seek out other more cut-and-dry treatments that can be implemented without having to change other aspects of your running routine. For example, it would be great if there was a single exercise that would solve the problem or a special treatment that could be done to fix everything in one fell swoop. The promise of a quick fix is easy to market, but before considering any of these options, the first port of call should be a review of your training load parameters and being open to the idea that a full recovery might be dependent on a good number of weeks of reduced training load:

Intensity (Speed of Running): In the 4-6 weeks leading up to the onset of your foot pain, have you significantly changed the intensity of your running? Perhaps you have been going harder to get your minutes per km down to a certain goal? Or maybe you’ve started a bunch of speed sessions that you previously haven’t done a lot of. Or maybe you’ve changed your running course, and your new routes involve a lot more hill work?

Duration (Distance): Have you had any sudden increases in overall mileage? If you’re training for a marathon or half marathon, it might be that your foot pain is related to the increases in distances you’ve been clocking up. Sometimes, even if you stick with a training program with graded increases in kilometres, it might just be that the rate of increase in distance is too much for the adaptive potential of your particular feet.

Frequency (Intervals Within a Training Session and Number of Sessions per Week): Have you increased the number of running sessions you are doing per week? Or have you increased the number of intervals within a given training session? Maybe you’ve gone from being an occasional, once-per-week jogger to running five to six times per week? This sort of rate of increase in running frequency carries a risk of injury because your joint structures and soft tissues aren’t adapted to the demands, and there is not enough time between sessions for recovery.

What if Your Training Loads Have Been Well Monitored and Progressed, but You Still Have an Injury?

It’s not uncommon for runners to present to our clinic with a complaint of foot pain (or knee pain, hip pain, back pain…), and for them to express frustration that they thought they had done the right thing by following a training program that was designed to assist runners in building up gradually. I can certainly understand the frustration. For myself, I have had to take a break from running for six weeks to look after a peroneal tendon irritation that I can only attribute to my attempts to improve my time for my usual 10km training route. I thought I had done a good job building up my efforts gradually, but over a few weeks I developed pain that became progressively worse.

In these scenarios, it’s important to understand that there is no recipe that applies equally across a whole population of runners. The truth is that, as a group of professionals (trainers, physios, sports doctors, coaches, etc.), we suck at predicting injuries in athletes. The best we can say is that events that lead to an injury and the number of factors at play are super complex.

So there really is no foolproof option for injury prevention. The best we can do (in terms of controlling training loads) is to err on the side of caution. And be okay with the idea that some of our performance goals need to be balanced out against the potential for injury.

Elite versus Weekend Warrior Training

With that in mind, it's important to distinguish between exercise programming designed to maximize performance and programming intended to avoid injury and keep you consistently participating in regular running. While it can be tempting to adopt elite training programs in an attempt to boost performance, for most of us, sticking with a program that has longer-term performance goals and less rapid progressions in training parameters is more beneficial. This approach minimizes the risk of injury and ensures sustainable improvement.

Forefoot Pain at the 2nd and 3rd Metatarsal Heads

If you're experiencing pain specifically near the head of the 2nd and 3rd metatarsal heads, it is likely to be one of three conditions:

• Stress Fracture of the Metatarsal: Repetitive stress and overuse can lead to small cracks in the metatarsal bones, resulting in pain and swelling that worsen with activity and improve with rest.

• Pathology within the MTP Joint: Various issues can arise in the metatarsophalangeal (MTP) joints, including:

• Plantar Plate Injuries: Damage to the ligament that supports the base of the toes can cause pain and instability.

• Joint Capsule Sprain: Overstretching or tearing the joint capsule can lead to inflammation and pain.

• Degenerative Pathology: Conditions like osteoarthritis can cause joint pain and stiffness.

• Freiberg Disease: In adolescent populations, particularly females, a condition known as osteochondritis can develop in the joint surfaces of the MTP joints. This condition, known as Freiberg disease, leads to joint pain and limited motion due to the death of bone tissue.

• Morton's Neuroma: This condition involves the thickening of tissue around one of the nerves leading to your toes, causing sharp, burning pain in the ball of your foot. You might also feel stinging or numbness in the toes.

Tips for Managing Forefoot Pain

While managing your training load is crucial, there are additional tips to help manage forefoot pain. Remember, all of these tips are likely to be limited in effect if your training load is not balanced:

• Footwear: Invest in running shoes that offer good cushioning, arch support, and a wide toe box. Avoid high heels and shoes with pointed toes in your everyday life.

• Strengthening Exercises: Strengthening the muscles in your feet and lower legs can improve foot mechanics and reduce pain. Exercises like toe curls, calf raises, and arch lifts can be beneficial.

• Stretching: Regularly stretch your calves, Achilles tendon, and plantar fascia to maintain flexibility and reduce strain on your forefoot.

• Running Mechanics: There is no such thing as a perfect technique to aspire to, but it’s worth assessing your patterns to see if there is scope for some running technique adjustment.

• Seek Professional Help: If the pain persists despite self-care measures, consult a physiotherapist for a thorough assessment and personalized treatment plan.

When to See a Physiotherapist

Persistent or severe forefoot pain should not be ignored. We can help clarify the likely driver(s) of your pain and develop a comprehensive treatment plan tailored to your needs and goals. Treatment may include manual therapy, specific exercises, and advice on footwear and orthotics. Above all, though, treatment is built around an assessment of your training load parameters and the construction of a plan to reduce your training load just enough so that your injury can heal, but not so much that you have to miss out on running any more than is necessary.

At our clinic, we specialize in treating running injuries and helping runners get back on track. If you’re struggling with forefoot pain or any other running-related issue, don’t hesitate to reach out. Let’s work together to keep you running pain-free and enjoying every step.

Stay healthy and happy running!

Shoulder Pain & Swimming

For the most part swimming is an activity that helps prevent injury and assist with improving one's sense of mobility vitality. It can however become a problematic activity for some people. Many swimmers present for Physiotherapy with a complaint of shoulder or neck symptoms. Perhaps the most common presentation is a sense of pinching in the shoulder during freestyle (that's front crawl for all the poms reading on) swimming.

Shoulder problems usually emerge from a recent alteration to the intensity, frequency or duration of training load. Stated more plainly, swimmers often get a sore shoulder when they increase how hard, often or far they swim. When a swimmer ramps up their distance or speed, the extra stress on the shoulder joint can be enough to irritate some structures within the shoulder, which can set up a localised region of sensitive tissue that is less tolerant of loads than it would usually be. Once the shoulder is in a sensitive or if you like "angry" state, it simply won't be able to perform as well as it usually does.

In its “angry” state, a swimmer will feel pain and a sense of weakness as he or she tries to pull his or her arm through the water with each stroke. There may also be a catching pain as the arm moves overhead with each stroke. If the swimmer decides to keep swimming and attempt to swim "through the pain", things are likely to become more irritated, and symptoms may then creep into other daily activities such as putting on a jacket, pushing open a heavy door or overhead activities. A sore and sensitive shoulder will eventually also become tight as motor output changes kick in to "protect the shoulder". Once these muscular changes occur, there tends to be a sort of feedback loop where the tension limits movements, and the movement limitations make it easier for the structures to remain irritated, which in turn sustains the “guarded” state of the shoulder.

The best way to manage a sore shoulder from swimming is to give it a break from the loads that are keeping it sensitive and irritated. Following a couple of weeks of rest you may find that a gradual return to swimming is pain free. Often though, a sore shoulder needs a bit of help to get going again. There are a few mobilisation maneuvers we can do in the treatment setting to help resolve the muscular guarding in and around the shoulder. This is useful because it helps to break the cycle of sensitivity and localised tension that the shoulder is stuck in.

In cases where the symptoms have been present for a longer period of time (let's say months rather than weeks), it will probably take longer for things to settle down. For some shoulders, Physio and activity modification alone may not be sufficient to bring about a resolution of symptoms. If we don't see significant improvements in your shoulder symptoms within 4-5 sessions of physio, we need to start thinking about other options. I find about 1 in 20 shoulders to be stubborn enough to warrant me sending the patient for an ultrasound to investigate for the presence of a structural injury within the shoulder. Usually the ultrasound will reveal a subdeltoid bursitis that requires treatment with a cortisone injection. Or it may reveal structural damage to a rotator cuff tendon. When these findings are present, it is usually an indicator that the overall trajectory of recovery will be a little slower and drawn out (perhaps a matter of 6-8 weeks as opposed to 2-3 weeks).

The keys to effective treatment of a swimmer's shoulder are;

1. identify and reduce / eliminate aggravating daily activities.

2. identify presence of underlying structural injury (including assessment of neck and upper back).

3. determine the contribution of underlying structural injury to symptoms (e.g. there may be a rotator cuff tear that has little to no contribution to symptoms).

4. carry out treatment aimed at resolving sensitivity and tension in and around the shoulder and neck. The treatment does not need to be painful.

5. once symptoms have settled, commence a graded strengthening program and a gradual return to swimming.

If you battling with a sore shoulder, and its limiting your ability to get out and swim your laps, reach out to us for a consultation.

Navigating a Knee Problem: A Self-Assessment Guide

Dealing with a knee problem can be tricky, especially if you're unsure of its severity or what steps to take next. Whether you've been grappling with a longstanding issue or it's a recent onset, a self-assessment process can helpful. Let's break it down into three key steps:

Step 1: Understanding What Happened

The first step is to understand the nature of your knee problem. This involves analysing the mechanism of injury and pinpointing the location of your symptoms. By correlating these factors, you can make educated guesses about the underlying structural cause.

For instance, if your knee pain originated from a tackle that forced your knee to bend inward, and the pain is primarily on the inner side of your knee, it's likely that you've injured your medial ligament.

Step 2: Assessing Severity

Determining the severity of your knee problem is crucial for appropriate management. Traumatic events with significant force are more likely to cause serious damage compared to minor incidents.

Consider the behaviour of your symptoms since the injury. If they're gradually improving in terms of pain intensity and stiffness, that's a positive sign. Conversely, persistent or worsening symptoms, along with swelling or bruising, may indicate a more serious issue.

Pay attention to sensations of instability or giving way in the knee, as well as any new clicking or cracking sensations since the injury. These can be indicators of underlying structural damage.

Additionally, be vigilant for signs that your knee problem may be linked to other medical conditions, such as infection or cancer. Symptoms like redness, swelling, fever, unexplained weight changes, or unusual neurological sensations should not be overlooked.

Step 3: Taking Action

Based on your self-assessment, you can determine an appropriate course of action. If you identify several indicators of a serious knee problem or are uncertain about your condition, it's wise to seek a thorough assessment from a Physiotherapist.

A Physiotherapist can provide clarity on the extent of your injury and guide you on the necessary steps for recovery. Treatment strategies will vary depending on the specific findings of your assessment.

On the other hand, if your symptoms are relatively mild, and you notice improvement over time, you can gradually resume your usual activities. However, if symptoms persist or recur, don't hesitate to seek further evaluation.

Remember, proactive self-assessment and timely intervention are key to managing knee problems effectively. By staying informed and attentive to your body's signals, you can take control of your knee health and work towards a swift recovery.

Are Deadlifting and Squatting Worth the Hype? Debunking Myths and Exploring Alternatives

In the world of gym training, certain exercises tend to reign supreme, often touted as the pinnacle of strength and athleticism. Among these, the barbell squat and deadlift stand out as the crown jewels of gym culture. But are they truly indispensable, or are they merely overhyped?

The Passion and Stigma Surrounding Squats and Deadlifts

If you've ever stepped foot in a gym, chances are you've witnessed enthusiasts passionately engaging in these exercises. Trainers, too, often emphasise their importance, prescribing them as essential components of any workout regimen. Yet, despite their popularity, squats and deadlifts also carry a stigma – they're frequently demonised as high-risk movements, particularly for lower back injuries.

Cultural Perspectives and Contrasting Views

It’s a strange status quo. The general consensus among everyday individuals seems to be influenced by contrasting cultural perspectives: one advocating for the necessity of squats and deadlifts in fitness routines, while the other perceives these exercises as inherently hazardous or risky.

The Nuanced Truth About Squats and Deadlifts

Stepping outside of the cultural norms, the truth is more nuanced. Deadlifts and squats aren't inherently riskier than other exercises. However, they also don't possess such exceptional benefits that they're an absolute necessity in every gym program.

Mitigating Risks through Proper Progression

The greater risk lies in improper progression of load intensity, duration, or frequency. Too often, individuals push themselves to lift near-maximal weights without allowing their bodies sufficient time to adapt, setting the stage for injury.

Understanding Back Injuries and Multifaceted Factors

Lower back injuries are commonly associated with squatting and deadlifting, with many attributing their pain to these specific movements. But it's helpful to recognise that back injuries are multifaceted, influenced by a myriad of factors including stress, sleep quality, and overall well-being.

Strategies for Injury Prevention and Long-Term Resilience

Fortunately, there are steps we can take to mitigate these risks. A well-designed exercise program prioritises gradual progression, allowing muscles and tissues to adapt over time. This principle of graded exposure can help minimise the likelihood of injury and build a foundation for long-term strength and resilience.

Challenging Conventional Wisdom on Technique

Moreover, it's crucial to challenge conventional wisdom regarding squat and deadlift technique. While the notion of maintaining a "straight back" and "engaged core" is pervasive, it's not supported by strong evidence. In fact, there's ample room for experimentation and customisation to suit individual needs and goals.

Exploring Alternatives and Personal Preferences

For those who aren't particularly passionate about squats and deadlifts, alternatives abound. Don’t feel pressured to do exercises you aren’t comfortable doing. There's no one-size-fits-all approach to your health and wellbeing, and exploring different exercises and techniques can yield equally effective results. The key is to find what works best for you and your body.

Seeking Professional Guidance

If you're unsure how to navigate the world of strength training on your own, seeking guidance from a qualified professional can provide invaluable support. Our Physiotherapists and Exercise Physiologists can tailor a program to your unique needs and circumstances, helping you achieve your goals while minimising the risk of injury.

Empowering Your health Journey with Coogee Bay Physio

At Coogee Bay Physio, we're dedicated to helping you move better, feel better, and live better. Contact us today to learn more about how we can support your fitness journey.

Understanding and Managing Wry Neck: A Guide to Recovery

Ever experienced a day where you wake up with a neck that seems frozen, making simple movements feel excruciatingly painful? If so, you might have encountered what's commonly known as a "wry neck." Despite the discomfort, the good news is that most of these can be seen as painful episodes rather than severe injuries, especially if there's no significant trauma involved. Let’s delve into the mechanics of a wry neck, and discuss its nature, causes, and steps to facilitate recovery.

The Nature of Wry Neck: A typical wry neck episode doesn't necessarily result from a major injury like a torn muscle or ligament. Instead, it often stems from a mild strain or sprain to a neck vertebra joint or disc. While not a serious injury, the associated pain and limited movement can be quite distressing.

Understanding the Pain: The intense pain and restricted movement associated with wry neck are more related to our body's response to the mild injury than the injury itself. Protective spasms and heightened sensitivity lead to a feeling of being "stuck," making turning or tilting the head challenging. It's crucial to recognise that the pain doesn't indicate further damage but rather the limits imposed by muscle spasms.

Navigating Recovery: By understanding that the underlying injury is typically not severe and that most pain results from the body's protective response, you can approach recovery with confidence. Recognising that the primary focus should be on resolving the protective spasm and stiffness opens up a clear pathway to recovery.

A Path to Recovery: Recovery from a wry neck involves addressing the protective spasms and stiffness. While the pain may persist, knowing it's not indicative of ongoing damage can alleviate fear. Taking steps to reduce inflammation, applying heat or cold packs, gentle stretching, and over-the-counter pain relievers are common strategies to ease symptoms.

Seeking Professional Assessment: While wry neck episodes are often manageable, it's essential to consider a professional assessment, especially if the underlying injury might be more serious than initially suspected. Physical assessments can provide clarity on the extent of the injury, guiding appropriate treatment measures.

Summary: Experiencing a wry neck can be a painful and frustrating ordeal, but understanding its nature can make the recovery process more manageable. By recognising that the injury is typically mild and that the majority of the pain is a result of the body's protective response, you can approach recovery with confidence. If in doubt, seeking professional assessment ensures a comprehensive understanding of the situation, facilitating a quicker and more effective recovery.

Understanding the Enigma of Chronic Pain: Breaking the Cycle

Chronic pain presents a significant challenge, disrupting lives and perplexing experts in the field who grapple with its enduring mysteries. The transition from acute pain to a chronic, persistent struggle remains elusive, leaving healthcare professionals puzzled.

Diagnostic Dilemmas: Traditional Approaches Fall Short

Typically, treatments for chronic pain involve an array of scans, blood tests, and thorough investigations to reveal an underlying cause. Unfortunately, these efforts often yield little clarity on the pain's source, suggesting that chronic pain appears to operate beyond the scope of traditional diagnostic tools.

Adaptive Movements: Navigating the "Protection Mode"

A noteworthy aspect of chronic pain is the changed movement behaviours adopted by those experiencing it. Pain serves as a powerful motivator, prompting individuals to alter behaviour to either avoid future discomfort or minimise existing pain. These adaptive movements can be viewed as a type of "protection mode."

While a protection mode proves beneficial for acute injuries, aiding healing by modifying movement and load on injured structures, its persistence in chronic pain scenarios is less constructive. In many cases, there may not be a specific injury to safeguard against, resulting in a self-sustaining loop where pain and protective movement behaviour reinforce each other.

Unlocking Recovery: Addressing Protective Movement Behaviours

Addressing and where possible, dismantling these protective movement behaviours can be helpful for unlocking a path towards recovery. In cases where chronic pain is primarily driven by an unhelpful protection mode rather than an underlying cause, there is a high potential for improvement. However, it's essential not to dismiss the possibility that chronic pain may result from an undiscovered cause. For instance, a chronic pain state could be linked to a genetic susceptibility that activates pain areas in the central nervous system.

Navigating Uncertainty: The Interplay of Pain and Protective Movements

Even in scenarios where a specific cause has not been identified, it's reasonable to assume that protective movement behaviours are still at play. Pain, regardless of its origin, influences how we move and behave. The key question is the extent to which a person's pain is attributable to an unhelpful protection mode versus an as-yet-undiscovered cause. Regrettably, we currently lack a definitive answer to this question and can only speculate based on the available information. However, this uncertainty should not deter us from offering assistance.

Toward Relief: Targeted Approaches and Potential for Recovery

By recognising the role of protective movement behaviours in perpetuating chronic pain, there is potential for relief. The journey towards recovery involves not only uncovering underlying causes but also dismantling layers of pain added by an unhelpful protection movement behaviours. With a targeted approach to these dynamics, overcoming chronic pain can become an achievable reality.

Unveiling the Back Pain Mystery: Beyond the Disc Dilemma

Have you ever been told that x-ray findings like a bulging or herniated disc are solely to blame for your back pain? It's time to rewrite that narrative. While those bulges or herniations might grab your attention, they aren't the main driver of your problem. Let's delve into the fascinating world of back pain, where things aren't always as straightforward as they seem.

Decoding Scans and Pain: Understanding Scan Signals

Scans like x-rays, CT scans and MRIs can be both informative and misleading. Disc abnormalities revealed on your scan results shouldn't automatically be assumed as the cause of your back pain. Many people, even those without a history of back problems, show these irregularities on MRI and x-rays. It's a reminder that what appears on the scan doesn't always tell the whole story of your back pain.

But if you don’t know, or no one has ever explained to you that your scan result is only part of the story, it’s easy to get sucked in by a scary looking x-ray report. For instance, if scans make you believe your disc is the root of the problem, it's natural to think that any back pain means the disc is getting squeezed or damaged. But this is unhelpful because it leaves you with a very disc-centric view of your back problem that will make it difficult to engage in helpful treatment.

Revealing the True Culprits of Persistent Pain: Moving Beyond the Initial Trigger

Even if we knew for sure that your back pain started with a disc injury, it's crucial to understand that the disc is never the sole troublemaker. Once pain is on the scene, regardless of which structure initially got hurt, the way we move and behave changes. We consciously change our actions or avoid certain activities, and our instincts kick in to protect us. And these changes in movement behaviours affect our pain.

The Dance of Pain and Movement: Breaking the Cycle

The way we move influences our pain, with our protective movements paving the way for more pain, and the pain setting the stage for more protective behavior. This cycle is able to persist independently of whatever structure, like a disc, might have initially triggered your back pain. It's common for people to endure pain for years, well beyond the time their initial injury healed, because they never found a way to break free from the cycle of unhelpful guarding and pain.

Breaking Free from the Cycle: Liberating Yourself from Pain's Grasp

It's time to break free from the cycle. Recognising that the cause of back pain isn't always a straightforward issue with your spinal discs is the first step. An approach that considers how we move and factors beyond the disc issue is the way forward. If we can identify and minimise unhelpful movement behaviours, we can go a long way towards resolving your back problem.

"Navigating the ACL Journey: Debunking Myths and Embracing Options!"

Have you ever heard that an ACL injury means surgery and the end of your season, or worse, your entire sports career? Let's chat about some misconceptions and explore a more optimistic approach to ACL recovery.

So, here's the scoop: many folks believe ACL injuries don't heal on their own, leading to the assumption that surgery is the only way out. The usual narrative involves a lengthy 9-12 month hiatus from sports. Sounds familiar, right?

Well, let's untangle this web of assumptions. The perceived severity of ACL injuries stems from confusion surrounding the time it takes to return to sports versus returning to daily activities. But guess what? It's time to rewrite the script because ACL tears need not be seen as such a huge deal. They can indeed heal without surgery!

This revelation opens up a whole new realm of possibilities, where a non-surgical approach takes the spotlight. Now, choosing between surgery and a non-surgical pathway may seem like a tough decision, often presented as an either/or scenario. But let's hit the brakes and look at what the evidence really tells us.

Instead of defaulting to surgical management, we can pivot our approach. Picture this: saving surgery as a last resort. We can kickstart the journey with non-surgical management immediately. Why? Because it might be all you need to get back on the field. Imagine that! And if it’s not enough to get you back in action, it can lay the groundwork for a stronger, more coordinated you if surgery becomes the ultimate route.

So, if you find yourself with an ACL injury, take a breather. Surgical repair isn't your only ticket to recovery, and there's certainly no need to rush into it. Time is on your side. Begin with non-surgical rehab, see how far you can go, and if needed, surgery can always be a choice down the road.

Remember, your ACL journey is uniquely yours, and options are your best friend. Stay positive, stay patient, and let's redefine the narrative together!

Shoulder Problems: Beyond Classical Diagnosis

The stories behind shoulder problems are as diverse as the individuals seeking relief in our clinic. Some recall a specific injury, a fall, or a traumatic event. Others, however, are puzzled by the insidious onset of pain, with no clear culprit in sight. The story behind the shoulder problem helps us work out what injury or condition you’re dealing with. What’s interesting though, is that we don’t need to hone in on a specific diagnosis in order to commence effective treatment; it's about unveiling and addressing the hidden culprit – Your body’s protection mode.

Defensive Movements: Similar to how we adjust our gait on a slippery surface, our shoulders adapt to injury or pain by altering movement. From cradling the arm close to the body to avoiding certain activities, these defensive behaviours, while initially protective, can become a hindrance to recovery if prolonged.

Breaking the Cycle: The key to commencing effective treatment lies in taking steps to disrupt a cycle of pain and guarding. By identifying and addressing defensive movement behaviours, we can pave the way for a smoother recovery. We only want helpful defensive movements, we can do without superfluous guarding; we want to allow injured structures the chance to get the benefit of just the right amount of protection from movement.

Defence vs. Defect: We can think about it as a process of treating "defence" in parallel with treating "defect." This approach ensures that serious pathology is not overlooked while avoiding the pitfalls of treatments being too narrowly targeted at specific pathologies. It's about giving your shoulder a chance to be nothing more than a simple, solvable problem.

So, if you find yourself with a stubborn shoulder problem, remember, it might just be defensive movement behaviours holding you back. By addressing these unhelpful adaptations, you not only pave the way for recovery but also unravel the mystery behind your shoulder discomfort. It's time to shift the focus from what might be wrong to empowering your shoulder to be its best self.

"Unmasking the Myth: Why Your Rehab Shouldn't Mimic the Pros"

Are you a weekend warrior with dreams of bouncing back like an elite athlete? The allure is strong, but let's face the reality: what works for the pros may not be the golden ticket for everyday individuals like us. Customising your rehab to your unique needs is the key to a successful recovery journey.

Elite rehab programmes might seem like the ultimate solution, but they are tailored for a different league. Professional athletes, under intense scrutiny and tight timelines, push for extra percentages from already peak performance levels. For average individuals, priorities differ. Unlike elite athletes, our pre-injury training routines likely didn't optimise load intensity, frequency, and duration. Weekend warrior injuries often stem from "too much too soon" scenarios, emphasising the need to address load parameters.

In everyday exercise rehab, a strategic overhaul of load intensity, frequency, and exercise duration is where the magic happens. These aspects are often overlooked in the weekend warrior demographic, presenting a golden opportunity for improvement. Rather than diving into biomechanics and technical adjustments right away, we're better off resetting and creating a renewed plan with appropriate load dosaging. Once that foundation is solid, changes to biomechanics and technique can be incorporated where relevant.

Your recovery journey is one-of-a-kind. Before jumping on the elite rehab bandwagon, remember: tailoring your rehab to your everyday needs, starting with load parameter adjustments, lays the groundwork for lasting success. Embrace the concept that slow and steady wins the race. Bid farewell to the fantasy of elite mimicry and welcome a personalised, performance-oriented approach to exercise rehabilitation.

Ready for a comeback that's uniquely yours? Embrace a personalised, performance-driven approach that ensures not only effectiveness but also sustainability. Your path to recovery starts with understanding and addressing your individual needs. Let's make it happen!

Runner’s Knee

By Adrain Ryan | Physiotherapist
BOOK A SESSION WITH ADRIAN

Anterior knee pain

Patello-Femoral Joint Syndrome & Anterior Knee Pain: Anterior knee pain is a common condition affecting the area between the knee-cap (patella) and thigh bone (femur) causing a condition known as ‘Patello-Femoral Joint Syndrome’. The condition may also be known as ‘ Chrondromalacia Patellae’ or ‘Runners Knee’.

• Causes and activity that inflames injury

  Causes:
  The common knee problem may be attributed to muscle weakness or imbalance of the quadriceps muscle group or may be the consequence of tight muscles or other soft tissues in the region around the patella. Various factors may lead to abnormal tracking of the patella as it glides over the front of the femur and consequently may cause symptoms. Biomechanical implications and incorrect footwear may also be the cause of the condition or aggravate the problem once the joint becomes inflamed
  
  Inflammatory Activities :
  The Symptoms are often brought on by hill walking, climbing stairs, running, cycling and other sports involving repetitive knee bending actions. The pain may also be exacerbated by driving and sitting down for prolonged periods. Other leisure activities that involve repetitive knee bending and weight bearing with load can also irritate the problem.

What are the symptoms?

Symptoms associated with the problem include pain and swelling around the patella. The pain may be a general dull ache or sharp pain depending on the nature and irritability of the condition. Clicking, locking, giving way (instability) and crepitus may also be reported. The problem is common in a growing child, as a teenager and throughout adulthood

How does it work?

Held in position by the quadriceps and patella tendons, the patella glides up and down over a groove on the front aspect of the femur allowing smooth movement to take place when the knee bends and straightens. Inflammation in this region may exhibit pain and other associated symptoms around the front of the knee.”

How can I begin to manage my pain?

A correct diagnosis by a physiotherapist will allow for an effective treatment plan to alleviate the pain and inflammation around the joint. A detailed rehabilitation programme in conjunction with the correct advice will assist in the full recovery of the problem.

If you’ve any questions in the interim call
ph:02 9665 9667

Breaking Free from the Posture Trap: Embrace Your Best Movement!

So, let's talk about the whole "movement rules" situation we often find ourselves in, especially when it comes to posture. You know the drill - "Don't slouch, sit up straight, shoulders back!" But is it really making a difference, or are we just stressing ourselves out?

Well, here's the scoop: not all movement rules are created equal. Some are all about minimising stress on joints and tissues, aiming to heal current injuries or prevent future ones. Sounds great, right? But what if these rules are actually doing more harm than good?

Take the classic example of "good posture." We've been told it prevents neck and back problems, but guess what? Research says otherwise. People who slouch aren't doomed to a lifetime of pain compared to the posture perfectionists.

So, why the hype around good posture? It's a case of confusing what looks healthy with what actually is healthy. Sure, walking into a job interview with a straight back looks impressive, but looking healthy doesn't equal being healthy.

Let's face it: maintaining perfect posture all day is a Herculean task. It's like fighting against our body's natural urge to slouch and relax. No wonder people end up in our clinic, tired and frustrated.

Here's the secret: the whole good vs. bad posture thing is a myth. Healthy posture is the one you're most comfortable in, and the key is variety. Humans aren't built for stillness; we're creatures of movement. So, why force ourselves into rigid positions?

Give yourself permission to move! Whether it's standing, sitting, or inventing different sitting styles, mix it up often. We've got jobs that require us to be glued to chairs, but balance is the key. Take breaks, switch it up, and let go of the idea that good-looking posture equals healthy posture.

Remember, your best posture is your next posture. So, let's break free from the posture trap and embrace the movement that truly makes us feel good! 🚀✨

5 Steps to surviving acute onset back pain

1. Stay Calm: It's natural to feel anxious when experiencing severe pain, but try to stay as calm as possible. Stress and tension can amplify your pain

2. Do you have symptoms that need medical assessment? As a general rule, if your back pain is associated with additional symptoms such as loss of muscle power in the legs and / or onset of numbness or tingling in the legs, it would be wise to seek medical attention sooner rather than later. If you experience unusual loss of bladder or bowel control in association with your back pain, you should urgently seek medical care.

3. What brought on your pain? If your back pain was brought on by a physically traumatic event such as a fall from height, it would be wise to seek medical care to rule out the presence of structural pathology such as spinal fracture. If the onset was insidious, or from a relatively innocuous event such as bending to pick up a pencil, there is a good chance that the “bark” of your back pain is worse than it’s “bite”. And in such a scenario, you can allow yourself the benefits of the idea that your back injury is not severe, despite the pain being severe. To be certain, you should discuss your specific symptoms with your trusted health professional.

4. Avoid being sedentary: When you’re experiencing severe back pain, it’s tempting to find any relieving position you can, and to simply avoid more movement. But the downside is that getting going again is really difficult. If we can be reasonably sure that there is no serious structural injury causing your pain, it makes sense to keep moving rather than avoiding movement. Exactly what that looks like will be different from person to person. You might be disabled enough by your pain that “keeping moving” means getting out of the office chair every 20min to walk about your apartment. Whereas the next person might be able to hobble down to their local pool and do some gentle swimming.

5. Stay relaxed while you walk and move: When in pain, a common instinct is to move in a braced or tense manner. Moving with lots of tension though, can exacerbate spasm and amplify your back pain. Instead, try using your breathing to relax your trunk muscles, and avoid “holding your breath” when you’re moving about or changing positions

More thoughts…

A typical episode of severe low back pain, for which there is no serious underlying cause will settle down over a 1-2 week period. Most often, people feel about 80% recovered after 7-10days. Half the battle is being able to convince yourself of the idea that the severity of the back pain is more to do with your body being in a kind of “protection mode” than it is to do with a serious underlying injury. It is understandable though, that as a layperson, it is difficult to be sure about the presence or absence of a serious cause for severe back pain.

The best way for you to be sure is to get in touch with your trusted health professional to discuss your unique case. We are happy to help you better understand your situation and put a plan in place for you. Call us on 0296659667. Or book online via the button below

History of the Coogee to Bondi Walk

The Coogee to Bondi walk is a picturesque coastal trail that has become one of Sydney's most popular outdoor attractions, renowned for its stunning ocean views and accessibility. This 7km stretch along the eastern coastline of Australia's New South Wales has a rich history dating back to the early 20th century.

The walk's origins can be traced to the establishment of the Bondi-Coogee Lagoon Baths in the 1880s. These baths, intended to provide a safe swimming area, attracted visitors to the area and laid the groundwork for the development of the walk. As the popularity of beach culture grew in the early 20th century, the need for a connecting coastal path became apparent.

In the 1930s, the walk began to take shape, following the natural contours of the coastline. It provided a scenic route for locals and tourists alike, passing by iconic beaches such as Bronte and Tamarama. As the years went by, the path was gradually improved, with upgrades to provide better accessibility and safety.

Throughout the latter half of the 20th century, the Coogee to Bondi walk underwent significant developments. Community support and efforts led to the creation of proper footpaths, seating areas, and lookout points, enhancing the experience for walkers. Interpretive signs and artwork were also added, providing insights into the history, culture, and natural beauty of the area.

The walk's cultural significance has grown, as it became a hub for community events, outdoor recreation, and a showcase for local art installations. It's now not only a leisurely way to enjoy the coastline but also a symbol of the vibrant coastal lifestyle of Sydney.

Today, the Coogee to Bondi walk continues to be a beloved attraction, drawing thousands of visitors each year. It stands as a testament to the community's dedication to preserving natural beauty, providing recreational opportunities, and sharing the coastal heritage with generations to come. The walk's history is a beautiful story of how a simple coastal path has evolved into an integral part of Sydney's identity, offering a breathtaking journey through its stunning coastal landscape.

You can learn about other walks in and around the Sydney region here.

And if you ever pull a hammy or strain a joint or come unstuck in some other manner, be sure to give us a call at 0296659667, or book an appointment online, here!

Happy Walking!!

Should we put Ice on an injury?

For many years it has been conventional wisdom to follow the RICE principles (rest, ice, compression, elevation) following an acute injury like a muscle strain or joint sprain. With respect to applying ice, the rationale has always been that it will limit the extent to which your injured body part becomes inflamed. And if we can minimise inflammation, the thinking is that we will expedite healing and achieve a more rapid recovery and return to normal function and performance following injury. The implication is that the inflammatory response is somehow superfluous to the healing needs of the injury.

For example, you may have received the advice that “inflammation wil help your injury heal… but we don’t want too much inflammation”. If we follow that line of thought, the application of ice is justified on the basis of an attempt to control or limit inflammation to some kind of optimal level for optimal healing. It sounds plausible enough but if this were the case, when we look to the evidence, we would expect to see some benefit in terms of recovery time when ice is utilised.

Interestingly however, when we look at the research that has been carried out to investigate how useful icing an injury is actually is, we find that recovery times are not improved versus control groups. For example, when researchers compare the use of compression on an injury versus the use of ice and compression, there is no added benefit conferred from for applying ice! If our goal is to faster healing of an injury, it is difficult to justify the application ice.

If icing an injury doesn’t help, the next question to consider is… is there any harm in it? Could icing actually hinder your recovery? There is evidence that icing a body part causes restrictions in blood vessels which limits blood flow for up to six hours. Could this hinder tissue healing and slow recovery time? The idea is plausible. Reduced blood flow (from icing)>>> limits delivery of inflammatory mediators to the site of injury>>> injured tissue does not undergo normal rate of healing processes. It is plausible that restricting blood flow might actually impede optimal healing but again, if we look at the evidence, there is no suggestion that using ice delays injury recovery times. So we don’t have evidence that applying ice slows recovery, but we do have evidence that it doesn’t expedite recovery following time injury.

But is it all about recovering faster? We also have evidence that applying ice is useful for controlling pain. And it might be that rapid pain relief is a greater priority for an individual than the overall recovery timeline of the injury. As far options for temporary pain relief are concerned, ice is cheap, safe and convenient. So on one hand we have a useful option for pain relief. And on the other hand, ice might actually hinder optimal healing of an injury, although we don’t have strong evidence to support that possibility. How do we balance these two? One option is to simply find a different pain relief strategy. But if ice is preferred as a pain relief strategy, it makes sense to dose the application of ice. Dr Gabe Mirkin, the doctor who coined the RICE acronym back in the 1970s, suggests that;

it is acceptable to cool an injured part for short periods soon after the injury occurs. You could apply the ice for up to 10 minutes, remove it for 20 minutes, and repeat the 10 minute application once or twice. There is no reason to apply ice more than six hours after you have injured yourself.

My view is that there isn’t definitive evidence to make a strong statement for or against the application of ice to an injury. It is a practice that is so heavily embedded in our culture as “the thing you do” when you injure yourself, that it is difficult to see it going out of fashion any time soon. I think that given we know there is no benefit to applying ice, and there is a plausible risk that it might delay recovery, it makes sense to consider skipping the bag of frozen peas next time to you have sprain or strain problem. We have evidence that you won’t be any worse off for doing so… and you save your peas from thawing out and being ruined..

REMEDIAL MASSAGE

My name is Shane Kiely. I am Coogee/Randwick local and feel very fortunate to live in a place that has it all, breathtaking natural environment and a diverse vibrant community. I am a qualified remedial massage therapist and APHRA registered Acupuncturist & Chinese Medicine Practitioner. Outside of clinical practice I keep my mind and body in tune through my Aikido practice, spending time with family, reading and research, swimming at Coogee Bay or Wylies Baths and getting out into nature and exploring the wonderful bushwalks of Sydney and its surrounds. I’m delighted to work alongside Pat and the team at Coogee Bay Physio in serving the health needs of my local community.

REMEDIAL MASSAGE WITH SHANE

Shane is friendly, approachable, a great listener and is adept at building a strong rapport with his clients. Shane tailors the depth and pressure of his massage treatments to suit your needs and personal preferences. Shane treats each presenting person as an individual with a unique set of issues and causes. Shane’s role within the clinic is diverse. He sees clients who are otherwise well and just feel like a massage. clinic.And at the other end of the spectrum, he sees clients with complex needs as part of a collaborative management approach incorporating our Physiotherapists and other Medical Professionals.

OUR FACILITIES

Our massage room is a private, walled room (no curtains functioning as walls!). The room has its own reverse cycle air conditioner for optimal temperature control. We also have plenty of pillows and towels to support your unique anatomy. And we use hypoallergenic massage oils.

Tendinopathy Explained

Tendinopathy is the term we used to describe a tendon that exhibits signs of structural disorganisation on imaging studies such as ultrasound. The term tendinopathy was coined as a replacement for the more commonly known term- tendinitis. The term tendinits dropped out of favour once it was discovered that clinical presentations of pain in or near a tendon, tend not reveal the presence of inflammatory markers within tendon tissue. In other words tendon problems are generally not inflammatory in nature- so the use of the term tendinitis, which infers the presence of inflammation has been considered inappropriate. Confounding the issue is the fact that while a tendon may itself not be inflamed, the lining on the tendon, known as the tenosynovium, can become inflamed.

So we can have a tendon which shows sign of disorganisation under ultrasound, which would justify the use of the term tendinopathy. And we can have an inflamed lining of the tendon, which we would label as a tenosynovitis. Sounds confusing? Yep- It doesn’t need to be, but unfortunately as science drives knowledge forward, it often leaves a trail of outdated and redundant terms in its wake. And often these terms take a hold in the common vernacular. This is unfortunate and confusing for patients but probably unavoidable.

My hope in writing this piece is that if you have a tendon injury, or if you have pain in or near a tendon, you can better understand the different diagnostic terms that you’re likely to hear if/when you seek out information or treatment. I hope that we can cut through some of the confusion and provide a framework for understanding how to recover from tendon injury, tendon surgery or tendon pain.

Should we call it a tendinopathy or tendinitis?

Technically, it is more correct to use the term tendinopathy for the reasons provided above. But the term tendinitis has been used so widely and for so long that it isn’t likely that it will stop being used. The bottom line is that from your perspective as a patient, it is really only a matter of semantics. I say this because the treatment we carry out for tendon problems is much the same, regardless of whether we call it a tendinitis or a tendinopathy. I suggest that we leave the nomenclature to the researchers and focus on those aspects of symptoms that we can affect in the treatment setting.

Ok, then how do we treat tendon problems?

There are basically three phases of treatment to follow. The first is a “desensitizing phase” where the focus is on activity modification. Essentially, if you’ve got a symptomatic achilles tendon, or tennis elbow, or golfer’s elbow, rotator cuff tendon problems, the main reason there is pain, is that the nerve endings that are plugged into the tendon have become highly sensitized. This means that loading the tendon is more painful than it would normally be.

In order to normalize the sensitivity of the nerve endings within and around the tendon tissue, we need to stop subjecting it to loads that will continue to keep the system sensitized and irritated. Identifying the activities that we need you to back off from can be tricky, and may require a bit of trial and error. We don’t always need to cut activities out altogether, it may be sufficient to simply modify how you perform an activity. Or it may be a matter of modifying how long or how often you carry out the aggravating activity. Manual therapy to the soft tissues and joints near the symptomatic tendon can also help to reduce the sensitivity to loading. So the initial desensitizing phase usually comprises a bout of manual therapy over a couple of weeks in parallel with some modifications to those daily activities that we suspect are maintaining an unnecessarily high state of sensitivity.

What happens after the sensitivity has been normalized?

Usually your symptoms overall will be much less severe. At this stage we begin to expose the tendon to load again with exercise. The idea is to reintroduce load to the tendon gradually, so as not to trigger another increase in sensitivity. The most sensible way to do this is to start with low loads and build up gradually. It’s also important to load your tendon tissues in such a way that they are more likely to respond favourably. Tendons generally respond well to tensile load (like someone pulling on a rope), as opposed to transverse load (like someone stepping on garden hose). Determining which exercises are appropriate for your condition can be tricky. We need to consider the biomechanics of nearby joints and how this plays into the load profile that is placed on a tendon during a given exercise. For some conditions, such as achilles tendon problems, we have some reasonable protocols to follows. For other body regions, getting this part right can take a little experimenting and progress may be slower.

What’s the third phase?

The third phase of tendon rehabilitation is a guided return to pre-injury activities. Essentially, it is the transition from rehab exercises to those occupational or sporting activities that you’ve been avoiding during phases one and two. For some people, returning to these activities is not a problem. For others, there can be flare up of symptoms. If this is the case, we need to respond quickly and discuss longer term options. Is the activity necessary for your sport or occupation? Can we modify how you perform it in the long term? Can we manage how often or for how long you perform it in the long term?

If you’ve been diagnosed with tendinitis, tenosynovitis, tendinopathy, golfer’s elbow, tennis elbow, rotator cuff impingement, runner’s knee or plantar fascitis, your symptoms should respond well to the management approach outlined above. While some of these conditions can require surgical or medical intervention, the need is quite rare. All of these diagnoses are driven, at least in part by sensitized nerve endings in and around the affected tendon tissue. If it doesn’t bring about a resolution of symptoms, tidying up such sensitivity will at least provide a clearer clinical picture to guide a progression to medical or surgical management. For more information give us a call 9665 9667.

Core Stability

The concept of “core” strength and it’s role in back pain and rehabilitative exercise programs emerged from research carried out in the early 1990s. The popularity of core stability training soared as this research made its way into the practice patterns of clinicians and trainers throughout the 1990s and into the 2000s. The message that has long since been propagated is two fold:

1. that a weak core predisposes one to lower back injury and pain

2. that the resolution of back pain is contingent upon strengthening of the core

We now know that there is more to back pain than what is implied by these two propositions… things just aren’t that black and white. The utility of the core stability concept is also hampered by inconsistencies in the operational definitions of the “core” across and within health and fitness professions. Some will define “the core” as it was initially described in the research by Paul Hodges. That being the canister formed by the diaphragm, transversus abdominus and the pelvic floor. Others will describe “the core” as including all the trunk muscles, hip and buttocks muscles.

We can’t really say that a “weak core” causes back problems, or that we need to “work on the core” to fix back problems, because we can’t even agree on what we mean when we talk about “the core”. And even if we could agree on a definition, back pain is a really complex phenomenon. Reaching agreement on what constitutes a “weak” versus a “strong” core, and then linking that to one’s back pain in a cause / effect manner is very challenging.

So where to from here? 

The one thing we can be pretty sure about is that exercise helps people with back pain. So I think it makes sense for back pain sufferers to engage in an exercise program of some sort. The specific type of exercise one chooses to engage in really boils down to personal preference. The research is generally equivocal when it comes to asking the question “which type of exercise is the best for back pain?”

I guess we could say that “core exercises” are a type of exercise for back pain. However, since there are varied definitions of what constitutes “the core”, we see different types of programs emerging in the exercise rehabilitation scene. The different types of exercise programs sit on a spectrum ranging from very specific, targeted transversus abdmominus training, to more global trunk, hips and buttocks training.

Specific training of the transversus abdominus

The exercise programs that have been developed to train the transversus abdominus (and other groups such as lumbar multifidus, horizontal fibres of internal oblique) in isolation, perhaps with the assistance of real time ultrasound, provide patients with a novel perspective for understanding the role of motor output in their back pain. I think there is value in the process of learning how to be more aware of what it feels like to contract some groups of muscles near the spine, but not others. People with lower back pain are often very sensitive and reactive to movement or loading of the spine. I suspect that the gentle, small amplitude, low effort movements that characterise specific transversus abdominus training sharpen one’s awareness of movement in the lower back and help restore normal sensitivity to movement in the lower back.

I tend to prescribe this type of exercise to back pain patients who are still in an acute or perhaps just into subacute phase following a recent episode of low back pain. I think it’s important to reiterate though, that I don’t think the benefit lies within “strengthening” of any particular muscle group. Rather, I argue that when this type of thoughtful movement helps with symptoms, it has helped because the movement brought about a reduction in protective tensioning of the trunk musculature. Very often, my focus for the acutely painful lower back patient, is gentle, very low load active movement of the spinal segments in multiple planes, without any particular attention to which muscle is “on” or which is “off”.

As a patient becomes less symptomatic with a course of treatment, or with the natural course of recovery following injury, I like to progress the extent to which we load the spine while a patient attempts to control movement in the lower back or limbs. Again, early in the process, this is more about normalizing the sensitivity of the nerve pathways in and around the lower back than it is with any specific strength gains. It is quite normal for a patient to reports “feeling stronger” from these exercises, but I attribute this experience of “feeling stronger” to a shift out of a “protective” holding pattern.

Higher load and Higher Intensity Exercises

Typically, when a trainer defines “the core” as including all the trunk, hip and buttocks muscles, their “core” workouts tend to be more intense and involve bigger movements and greater loading than the more specific transversus abdominus protocols. Some examples of exercise that spring to mind include, “planks” or “bridges”. There really aren’t many limitations on a “core exercise” when the definition of the core is so broadly framed… under such a broad definition, one could argue that running is a core exercise.

I think these types of higher load, higher intensity exercises are useful for patients who have moved beyond the subacute phase of an episode of back pain. Once a patient is at this point in their rehabilitation, I think we are able to load the system enough to see some measurable changes in “strength” and functional measures that relate specifically to the patients goals, occupation or recreational activities. Putting in place a plan to systematically increase the intensity, frequency or duration of load on a patient’s lower back is a good idea in my books. The key is to make sure that the load parameters are appropriate for the specific patient.

The Core of the problem

Whether or not all these exercises should be described as “core” exercises is really a matter of semantics. I tend to suspect that those who argue very strongly for a very narrow, or a very broad definition of what constitutes “the core”, usually have a vested interest in having it defined in a particular way. I tend to take a view that the terms core stability, core strength, weak core, etc etc have been so loosely defined and reinvented so broadly and so often, for so long that none of them mean anything in particular.

So I tend to steer away from describing any exercises I prescribe as being specifically directed at “the core”. It doesn’t make sense to propagate confusion and misunderstanding among my patients. It makes far more sense to me to frame any prescribed exercises in terms of the patient’s activity limitations, and the mechanism by which the prescribed exercise is thought to assist that limitation.

Whiplash Injury & Whiplash Associated Disorder

Whiplash is the term used to broadly classify injuries resulting from a sudden acceleration / deceleration of the head and neck. The common example is the whiplash motion of the head in motor vehicle accident. Other common scenarios that involve a whiplash motion of the head and neck include a heavy fall onto one’s buttocks or back, resulting in sudden jerking back motion of the head. Similarly, sports involving high force body collisions can create whiplash scenarios.

If you have suffered a whiplash injury, particularly a high force injury such as a car crash, it is important to have the injury assessed by a doctor or physio. We can assess your condition to determine whether or not it is necessary for you to have diagnostic imaging such as an x-ray carried out. The purpose of the x-ray would be to rule out the presence of a suspected fracture to one of your neck bones. In the event that a fracture is present, you will likely be admitted to hospital for monitoring and treatment. Depending on the severity of the fracture, you could require surgery.

When the assessment reveals that there is no fracture, or no clinical signs of a fracture or other serious structural pathology, conservative (meaning non invasive, non surgical) management is indicated. This is where our role as physios is really important. If you’ve had a whiplash, and we know that there is no structural damage that has occurred to your neck, it is really important to commence a guided and graded return to your normal occupational and recreational activities sooner rather than later.

For most whiplash patients, the early days and weeks are very difficult. Typically the neck is very stiff and painful. There may also be associated symptoms such as pins and needles in your arms. Or you may have a headache, dizziness, nausea, a feeling of fatigue, cloudiness or vagueness. If the whiplash injury was a traumatic event like a car crash, you may also be dealing with flashbacks, anxiety or other changes to your emotional stability. Your sleep may be affected by any of these factors.

In short, whiplash injuries are difficult to recover from. The best way to ensure that your whiplash injury is painful and disabling for only a few months rather than years or decades, is to commence treatment early. An early assessment leads to more timely referrals to appropriate services. In addition to Physio, it’s not uncommon for your GP to include psychologists, social workers and other specialists in the management of a whiplash injury. Early assessment allows for more effective education with respect to the pathophysiology of a whiplash injury and your prognosis. Having an understanding of what is going on, and what is likely to happen at the next step, and the next step really helps whiplash patients get through the acute and subacute phases of the rehabilitation with less risk of developing chronic symptoms.

Generally, the early phases of whiplash management involve lots of education, reassurance, manual therapy and gentle exercise. Following that is a steady progression away from passive treatments such as manual therapy, towards active movement and exercise programs.

If you’re a Coogee or Eastern suburbs local and have had a whiplash injury, why not call us to discuss your treatment options on 9665 9667. You can speak directly with Pat our clinic owner to work out the best course of action for your scenario. Alternatively, feel free to complete the form below and we will get in touch with you to answer any questions you may have.