STRESS FRACTURE WITH NO CHANGE IN RUNNING HABITS?

by jim zouch

A young female distance runner reminded me of the importance of discussing diet, sleep, stress and the menstrual cycle/or absence of, in a recent presentation for  acute pain in the shin. Often patients, particularly runners are quite aware of their running mileage and the changes in their running volume that might be linked to injury. Less frequently are patients aware of other factors that may contribute to an injury such as a stress fracture.

This was the case in a young runner who presented at the start of autumn following a few weeks of shin pain. She had reported her running volume had been really consistent and had not experienced an injury. Because of these factors, she had decided to continue to run through the pain believing she hadn’t sustained any major damage. When I mentioned that other factors may contribute to running injuries, she volunteered that she had been a little more tired than usual and had recently changed her diet to reduce calories. I mentioned that absence of a menstrual cycle may be a symptom of what we term RED-S or Relative Energy Deficiency in Sport – a name given to describe a potentially serious syndrome that essentially results from a lack of nutrition to support the body’s demands.

She volunteered that she hadn’t experienced a menstrual cycle in the last three months. We discussed the various ways that relative energy deficiency can affect many of the body’s functions and I directed her toward some further reading. In this situation we discussed the stress fracture may be a symptom in itself and that it was important to address any potential issues with her diet, sleep and overall health in the first instance.

We decided on a course of non-weight bearing because of her immediate pain with walking and referred her for a discussion with a Sports Medicine doctor to discuss some further investigations. I also recommended she discuss her eating habits with a registered dietician. For the purpose of the article and client confidentiality, I’ve kept the discussion brief but in reality, once we had identified there were some signs and symptoms of RED-S most of our appointment time was allowing this patient to discuss her issues in a safe environment.

As a clinician it reminded me how important it is to create an environment where a client feels comfortable to share all of their issues.  


WAKING UP WITH NECK PAIN

BY JIM ZOUCH

We received a phone call from a young professional, lets call him Tom, who had woken up with acute neck pain. He reported his neck was stiff and painful turning left and right. He was curious to know if this was something physiotherapy could help with. We booked Tom into the clinic that morning and went through his symptoms and recent history. Tom could not remember doing anything differently the days before, and didn’t recall a moment of injury. He did mention that he had been quite busy at work and hadn’t slept as well the last week. Tom reported his pain was all in the neck and did not experience any other symptoms.

We took Tom through a physical examination to determine the movements that irritated his neck as well as a neurological examination involving reflex, sensation and muscle power testing to screen for any potential neural injury. From Tom’s history and examination, I explained to Tom he had what is termed ‘acute wry neck’, a label given to acute neck pain that commonly occurs out of the blue, without a mechanism of injury. I explained to Tom, although the underlying pathology is not well understood, its quite common in younger people and has a favourable outcome with movement and time.

We also discussed how physiotherapy could help reduce the pain and get the neck moving again. Tom was quite relieved after our examination to understand he had not caused himself major harm and that he could expect to get better in a reasonably quick time frame. We spent some time performing some ‘hands on’ therapy to help with pain relief and sent Tom away with some basic exercises to continue to restore his function in the coming days. I explained to Tom, the condition was likely to get better with time but we could help with pain relief and provide some guidance along the way. Tom was quite happy with the pain response and booked in early the following week. I expect Tom will be significantly better by our next session and hope to see him back to normal movement really soon.

FOLLOWING UP ON A HEADACHE PATIENT

By Zac Mackenzie

SESSION 2

This week I followed up with this a patient I wrote about previously. I was interested to see how he fared headache wise. During our session, he advised me that his headaches had significantly improved and his neck was feeling less stiff. So, we planned in this session to do some more hands on treatment to hopefully completely resolve his symptoms then head over to the gym to have a look at his technique with overhead exercises.

When we reviewed his overhead technique, I noticed that he had significant recruitment of the neck and upper back muscles as he started to fatigue. I suggested that he utilized a simple cue such as keeping the point of his shoulder away from his ears during above head exercises which will reduce the activation of these muscles. I also suggested that over the next week or so until his headaches had completely settled that with above head and shoulder exercises he keeps a few reps in the tank during his sets, which will make sure that he doesn’t utilize the neck muscles as his shoulder fatigues.

We also went over a few neck and upper back strengthening exercises to work into his routine. The aim of these will be to progress them over time as part of his headache prevention program to perform 2x a wk. We planned to review again next week where we would look to complete his program. After this we will look at monthly reviews to progress these exercises.

I followed up with this patient again this week. We had a chat about how his symptoms had been going in the past week. He advised me that his headache symptoms had all but resolved. He also said that he’d been concentrating on those cues we spoke about when lifting overhead although he hadn’t been lifting too heavy. He also said that he’d had a couple of sessions of the upper back and neck strengthening exercises and they seemed to go okay.

SESSION 3

Our plan this week was just to review those existing exercises as part of the maintenance program and add in 2 more exercises. I showed him a good way of progressing the exercises as they became too easy, and how to regress them if he found that they aggravated his symptoms. We also spoke about how he could manage relapses, by going over the mobility exercises and dropping the overhead work until symptoms settle. We also spoke about how he can gradually increase his overhead lifting over the next couple of weeks back to his normal level.

We planned to review again in one month to go over the exercises and see if we can progress.

session 4

Following up with this patient again, I was pleased to hear that he had no headache symptoms since the previous visit. We used this session to again go over his technique when lifting over head in the gym. This time we increased load back to similar weight that he was lifting before the headache episode. Again we looked at keeping his shoulders away from his ears, and concentrated on this as he begun to fatigue. After the session he said he felt fine headache wise which was pleasing.

We went over 1 more exercise to complete his neck and headache strengthening program and agreed to review again in a month to update the exercises. 



AN EPISODE OF SEVERE LOWER BACK PAIN

by patrick lyons

Two weeks and five Physio sessions ago, a fit and healthy 45 year old woman came to see me for severe and disabling lower back pain. The pain was on her left side and spread to her left buttocks and down the back of her thigh to the knee. Her pain began insidiously. Although there was no event or trauma that triggered the onset of symptoms, she did report that she had been unwell for the week or so preceding the onset of symptoms. She had been more sedentary than normal and had been coughing frequently.


She previously came to see me for left sided lower back pain a few months ago. This earlier episode was her first experience of lower back pain. It also began insidiously but was not as severe or disabling as her current symptoms. It resolved with three sessions of treatment. For both the previous and current episode, the patient, lets call her Sophie, had a significant lateral shift to the right side in standing. In the current episode it was more severe. Sophie’s movements were severely hampered. She was unable to stand tall, unable to sit for more than a minute or two, and she could not lie down on her left side at all. She also reported a pins and needles sensation over her left buttock.


 


Clinical Impression


Sophie’s symptoms and movement limitations are best explained by an irritation of her left S1 nerve root, perhaps as a consequence of an acute injury to her L5/S1 intervertebral disc or facet joint. Her laterally shifted posture could be interpreted as a reflexive attempt by Sophie’s body to unload and protect her injured body tissues from further compression and irritation. She is feeling pain as a consequence of the injury itself but also as a consequence of her body’s own protective mechanisms which bring about a degree of nerve sensitivity and muscular guarding. Importantly, the initial injury itself can be quite minor, meaning that Sophie’s severe pain is likely mostly a result of her body’s protective response to the injury.


This a very common presentation of symptoms. Nearly always, this injury follows a predictable trajectory of recovery. Initially, there is a period of severe, disabling pain where basic movements such as getting out of bed, siting, rising from sitting, bending at the waist or standing tall are very difficult. This period of usually lasts a few days. As inflammatory processes begin to subside and muscular guarding begins to lessen, movements become a little freer and less painful. By about day 7-10 following the initial onset of symptoms, most report that they feel about “75% back to normal”. By this stage people can usually walk normally but will still have difficulty with prolonged sitting and will find it difficult to get up and moving if they have been static for more than 20-30min.


In Sophie’s case, there was no traumatic event or incident that triggered her symptoms. So the likelihood that she has a significant structural injury in her spine is low. I suspect that if we were to do an MRI of her lumbar spine, we may see evidence of some degenerative changes to her L5/S1 intervertebral disc. Perhaps with her recent bout of illness and frequent coughing, she managed to irritate the L5/S1 disc and set off a sequence of inflammatory processes that ultimately triggered her body to suddenly become “protective”.


Over the two weeks that Sophie has been attending Physio, my focus has been on helping Sophie understand that it is unlikely that her injury is as severe as her pain may be leading her to believe. I have been reiterating that the severity of her pain is partly (perhaps mostly) explained by her own body’s capacity to ramp up its sensitivity to movement and load. So long as her body is in a sensitive, protective state, her movement and function is likely to limited and painful. With this in mind, we have been implementing treatment that serves the purpose of reducing her body’s movement sensitivity with gentle manual therapy and appropriate exercises for her to do at home.


To date, Sophie’s back pain has resolved 100%. And she is now able to move through a full range of motion into forward bending, backwards bending and side-bending. She is however, still dealing with pain in the buttock region, with occasional spreading to the back of her thigh. She also is still experiencing some tingling in the buttock region. It appears that her body has let go of much of the muscular guarding that was initially limiting her movement, but she still has symptoms that suggest her S1 nerve root remains irritated.


I hope to see an ongoing reduction in these “nervey” symptoms over the coming weeks. It’not uncommon for such nerveroot symptoms to hang around for months after one of these lower back pain episodes. However, if these symptoms plateau and are preventing Sophie from participating in her normal daily activities, I will speak with her about a possible MRI to rule out the presence of structural pathology in the lower back that may require further investigation +/- review by a spinal or neurosurgeon. In my experience I would estimate that less than 1% of the cases of lower back pain end up requiring a surgical solution.


 


Update


It’s now a week since I wrote the post above. Sophie is now three weeks and 6 physio sessions post onset of symptoms. She reported that over the past week, particularly the past 3 days, her symptoms have significantly decreased. The tingling she was experiencing over her left buttock is “shrinking” in the sense that it is less intense and is distributed over a smaller surface area of her buttock. She is also finding her movements through the lumbar spine to be easier… previously she could reproduce her pain with movement quite easily, now she reports that she has to move nearer to the end range of her normal movement in order for her to feel the pain in her left leg.


These are all great signs that suggest to me that the irritation around her S1 nerve root is settling down. The rapid improvements help to reinforce the idea that even though she was in severe pain for a few days, her initial injury was more likely only mild (in terms of severity of damage to tissues). Severe symptoms are unlikely to resolve quickly if they have arisen from significant damage to a structure in the spine. In Sophie’s case, I suspect she has some degenerative changes at her L5/S1 disc, and that her initial symptoms were triggered by a rapid ramping up nerve ending sensitivity subsequent to a mechanical irritation of the disc.


I expect her symptoms to continue to diminish over the upcoming weeks. The challenge for Sophie for the next few weeks will be avoiding flare up of symptoms. It will be important for her to get back to her usual daily activities and exercise outline gradually.


 


5 Week Update


It’s been 5 weeks since Sophie’s last Physio session. I have reached out to her to see how she is doing and she reports that she is doing very well. It is very common for these really acute episodes of lower back pain to completely resolve over a 10-12 week period as has been the case with Sophie.


Now that Sophie is feeling relatively normal again, she has a great opportunity to integrate some new exercises into her day to day activities with a view to preventing a recurrence of her pain. I have suggested this to her… now I wait to see if she takes the offer up.


It is very common for patients to lose their motivation for the injury prevention component of a rehabilitation program. Hopefully Sophie can see the value in coming back to learn some skills to look after her back in the future.


 


12 Week Update


Sophie reports she is doing well. Back to normal function but too busy to return to the clinic to work on some injury prevention strategies



A CASE OF RECURRING HEADACHE

by zac mackenzie

This week I had the pleasure of treating a young man who suffered from recurrent headaches. These headaches would come on usually every 2-3 months and would generally settle within 1-2 weeks. He was extremely physically active and these headaches would often occur after a gym session that involved a lot of overhead exercises. He seemed frustrated with the recurrence as it stopped him from training and although he knew that the pain would subside with treatment he was more interested in getting an understanding of how to prevent this from happening again.

On assessment, I found that most of his symptoms were on the left side of his head and neck and he was restricted in movements of his neck towards that side. A quick look at his neck muscle function also demonstrated that he had some weakness in his neck muscles which is a common finding in neck related headache patients. We discussed a treatment plan looking at firstly reducing his symptoms with some hands-on treatment as well as some home exercises this week with the aim of getting in the gym to go over his technique with overhead exercises next week when his symptoms had improved.

We also spoke about long term treatment of his headache symptoms and that once his symptoms had resolved it would be worth investing time into a neck and upper back strengthening program which will prevent the headaches from occurring again. We discussed the research surrounding recurring neck related headaches and how often these are linked to neck and upper back weakness. We will aim to address these deficits through a targeted strengthening program.

I provided him with some manual therapy which seemed to reduce his neck pain and headache and prescribed some neck and back mobility exercises to do at home.

I look forward to seeing how he has progressed next week. 


THE START OF THE SPORTING SEASON

 By Jim Zouch

As a physiotherapist it’s a common story I hear at the start of every sporting season. Typically, it involves a client presenting with a ‘pull’ in one of their lower leg muscles upon returning to training or within the first few matches of the season. More often than not, it’s the second or third ‘pull’ the client has experienced in a matter of weeks as they have tried to navigate their way through the injury, often resting until the pain disappears then returning back to sport.

One such client presented last week having felt a ‘pull’ in her quadriceps while sprinting during a training session. She rested the leg for a week and upon feeling no pain with her day-to-day activities returned to training only to have a recurrence of the same sensation.  She was visibly frustrated having had a season off sport due to covid and was extremely enthusiastic to get back into the game she loved. 

She was aware that she had likely injured one of her quadriceps muscles but wasn’t sure of how to go from her current state, back to sport without the same thing occurring. At the time of presentation, the client was able to perform most functional activities I threw at her without pain or discomfort. As part of our assessment, we used a hand-held dynamometer to assess her ability to generate power in a kicking motion, testing both legs individually. We observed a 30% difference in strength between sides. The client found this extremely interesting and it helped us frame why returning to sport prior to regaining strength might leave her at an increased risk of another injury. It also serves as our ‘baseline’ measurement that we will use for upcoming sessions to test her improvement in strength that occurs as a result of both natural healing alongside an appropriate strength programme.

The testing opened a really nice line of questioning from the patient about ‘how strong should she be’ and ‘how long will it take to get these numbers higher’.  We discussed setting some goals over the coming weeks and establishing a minimum score (within 10% of her other side) that she should achieve, before we discussed higher intensity return to sport activities. The strength testing also gave us some information about what of training was likely to be safe during her upcoming training sessions without comprising her healing. 

I’m looking forward to seeing the improvements in strength over the next few weeks!


PATIENT CONTEMPLATES KNEE REPLACEMENT SURGERY

Nice-blonde-woman-touching-her-patients-knee-1200x628-facebook-1200x628.jpg

by patrick lyons

This week I met a new patient with a long (four year) history of knee pain. He described his pain as mostly manageable… except for the past six months or so, over which time the pain had become worse for no obvious reason. He had had some x-rays of his knees done three years ago, and consulted with an orthopaedic surgeon at the time. The patient said that the surgeon thought his knee pain was a product of osteoarthritis in the medial compartment of his knee and the patellofemoral joint. The surgeon didn’t recommend surgery at the time, but he did predict that he would eventually need to have total knee replacement surgery.

Fast forward to today and this patient is reasonably certain that joint replacement surgery is the only way forward. But before making the final decision to have surgery, he was convinced by his wife to trial a period of physio first.

The patient seemed keen to better understand the need for surgery, relative to non-surgical options, as he was keen to avoid surgery if it was possible. We had what I thought was a really useful conversations about the pros and cons of proceeding with the knee replacement surgery.

I’ll provide a summary of that conversation as well as some details of the treatment I provided in the entries below.

***UPDATE***

For this patient, who for simplicity’s sake I’ll refer to as John, a major concern was that there were no viable non-surgical options to manage his knee problem. John’s view was that his knee was arthritic, and that the arthritis was causing his knee symptoms. So the only way to resolve his symptoms would be to remove the influence of arthritis by way of a joint replacement. He had assumed that the recent worsening of his pain was a result of accelerating progression of his arthritis.

John was relieved to hear that a plausible explanation for his recent increase in symptoms was his daily activity levels. John has been more sedentary over the few months. His usual golf routine had been disrupted by covid19 restrictions, and he had fallen out of the habit of walking around centennial park in an attempt to avoid crowds of people.

I explained that arthritic knees tend to be happier when we use them. And that they get cranky when we trend toward being sedentary. I felt really confident that at the very least, we could get John back to his “pre-flare up” level of symptoms… which was a level he was managing well. And I’d also be hopeful that there is room for further improvement.

The plan to get John there revolves around an initial focus on symptom reduction and setting up activity parameters so that we don’t keep stirring up the knee. And then progressing to a graded walking program to get him going on the golf course and coastal path again!

TWO YEARS OF BACK & RIB PAIN

BY ZAC MACKENZIE

Today I had the pleasure of treating a patient who had been suffering from 2 years of persistent mid back and rib pain commencing from a skiing accident which resulted in multiple fractures to his thoracic. The patient told me that pain seemed to be worse when sitting for long periods which was required for his job, and his pain also seemed to increase gradually throughout the day. He also complained of chronic stiffness around the mid back region and rib area which he did seem to find relief with stretches but often returned shortly after. He had seen multiple health with only short-term improvements in symptoms. He said he wasn’t as physically active as he would like to be but felt interested in beginning gym exercises and getting back to swimming which occasionally caused him increased pain.

During assessment, he seemed to have a very stiff mid back region worse so on the left compared to the right with provocation of his rib pain. He also seemed to be quite stiff through the shoulders as he was unable to raise his arms fully. He also experiences pain when palpating his mid back joints as well as his upper ribs. From these findings, it was clear that he needed to improve his range of motion to reduce both stiffness and pain as well as improve his overall upper body strength to tolerate the hours of sitting that he was currently doing. We established some goals around becoming more physically active, with an aim to get into gym type exercising and back to swimming.

During our treatment, we talked about how we could begin to move more throughout the day, as often it’s the prolonged positions throughout a day that increase pain and stiffness. We established that every 30mins he will get up and move, perform some general stretches for a couple of minutes before returning to work. We also spoke about general activity such as a morning or evening walk and how that could also help improve pain and stiffness. We spoke about that the best exercise for him is one that he enjoys and one that he would be happy to do often and that it’s important that exercise is increased gradually as often it’s not necessarily the specific exercise that we are doing that is the problem but the amount that we are doing that is increasing pain.

We planned to gradually increase daily exercise over the coming weeks and look to begin swimming again at a low intensity. We combined this plan with some releases and mobilizations for pain relief as well as some general mobility exercises to be performed throughout the day and some upper body strengthening exercises which we will progress next week with an aim to getting into the gym in the future.

Next week we will discuss the strategies that we put in place around general activity and identify any barriers that he experienced. We will also look to progress his strength exercises.

I look forward to treating this patient and seeing how he progresses.

I was looking forward to reviewing this patient as I was eager to see how the changes we had made had affected his symptoms and function. The patient said that he was diligent most of the time with our goal of getting up to move every 30 mins throughout the day. This helped to ease pain at the end of a work day, however pain did not completely resolve. There were still some occasions of significant rib pain which occurred in the mornings.

He said that he really enjoyed the exercises which he found to be pain relieving and that he was happy with the strength exercises. Our plan for the session was to progress his strength exercises whilst continuing to work on his range of motion.

During our session, we regained a good amount of movement through his mid back and shoulders which we aimed to consolidate with a couple of new mobility exercises. We discussed how often the mornings can be worst for these type of issues as being stationary during sleeping can increase stiffness when waking. The best strategy to combat this was to get up and perform the exercises we had went through to help ease the tension as early as possible.

We progressed our strength exercises and discussed our goals this week to maintain the level of movement throughout the day and walking at night. I encouraged him to look up potential gyms for him to go to and that we would look at some exercises that he could do next week. We also set out a goal to go for 2x swims this week, performing breast stroke as it required less above head shoulder movement which could induce some symptoms.

I looked forward to hearing how he’s going next week.

Again, I was looking forward to seeing this patient and hearing of his progress this week. He said that this week he had struggled again with some early morning pain and stiffness on a couple of occasions however doing the exercises did relief some of the pain. He said that pain throughout the day was manageable and only on one occasion did have significant pain at the end of the day, although he stated that this was a heavy work day. He could only get to the pool to go for one swim however didn’t experience any increase in pain afterwards. He had located a suitable gym close by that he could go to.

I was really pleased with this despite a couple of painful mornings and one afternoon. We discussed that often stress can increase pain and how it’s really important that on these days that he schedule breaks. I took this opportunity to also bring up the importance of sleep on pain, and that especially when we are working hard that sleep should be prioritized.

During our session, we again worked on his range of motion which seemed to be improving and spent the last part going over some exercises in the gym. Our goals for the next week were to maintain 1x swims and I encouraged 2x gym sessions which he could walk to and from.

This week the patient advised me that he was feeling good with now only having minimal pain on occasion throughout the day and the intensity of the morning pain had diminished with some days where he felt nil morning stiffness. He also informed me that he and his family were moving away in one month.

It seemed that symptoms and function were moving in the right direction so we planned to reduce our sessions to once every two weeks. We again looked at progressing his gym exercises. Our plan was to keep his gym sessions to 2x a wk and try for 2x a wk swim, with one of these including some freestyle.

The patient informed me this week that his symptoms had been steady over the past two weeks however he was feeling stronger and more resilient when having busy days at work. He found that he rarely had significant pain, and that most of the time it was quite manageable. He said he had some minor pain after performing freestyle swimming.

We spoke about that it was okay to have some soreness after the freestyle swimming and that to continue at this volume and intensity of swimming whilst performing some mobility exercises prior and after the swimming. Often previously provocative exercises still can produce some soreness and that often the body just needs time to adapt to the new load.

We planned that our next session will be our last before he goes away. I said I would refer him to a physiotherapist that looked suitable in his new area so he can continue his rehab.

This was our last session. We used this time to go over our exercises for self-management and looked at progressing his gym exercises. I encouraged him to make contact with the new physiotherapist in his area and that he should continue his current level of activity and understand that if he does have periods where he isn’t able to be as active then he may experience some increase in pain however this doesn’t reflect a worsening of any structural problem, more so that the sensitive areas will just like to be kept moving.

We discussed how he was on the right track in terms of dealing with his pain and should continue to progress as he feels comfortable with exercises and activity level. He seemed happy with his progress so far.

I wished him all the best and urged him not to hesitate in giving me a call if he was having any problems.