Lumbar spinal stenosis is the medical term used to describe a condition where a segment or segments of the spine are narrow. While there are many forms of spinal stenosis, this article will concentrate on the two most common types. Lumbar spinal stenosis is described as central or lateral. Central stenosis is narrowing around the spinal canal (Fig 1), whereas lateral canal stenosis is narrowing where the nerves exit the spine at the intervertebral foramen (Fig 1). Stenosis becomes common as we age and our spine undergoes wear and tear, termed 'degeneration'. The Degenerative changes are termed "degenerative disc disease', "facet joint arthritis', etc. Degenerative changes are a normal process of aging and our body can typically adapt to these changes. However, if the body's natural adaptation becomes overloaded with extra stress and strain, in combination with these degenerative changes, then the nerves can become irritated. These degenerative changes have the effect of reducing the space that the nerves have to exit the spine i.e. there is a narrower tunnel.
The typical symptom of lumbar stenosis are an increase in leg pain (either one or both legs) and / or pins and needles while walking or standing. Walking and standing reduce the space that the nerve has to exit the spine. The combination of the normal narrowing and the degenerative changes can, over time, create the nerve irritation. Walking with a flexed spine, sitting or bending forward will ease the symptoms, as these positions increase the space for the nerve(s). Symptoms will usually, but not always, develop gradually and are almost always associated with a history of lower back pain.
It is important to properly diagnose lumbar spinal stenosis as other conditions, like vascular claudication, should be ruled out. An examination will consist of taking your history and a physical examination of both the spine and nervous system.
The goal of treatment is to improve spinal mobility and open the space for the nerve(s). While it is impossible to reverse the degenerative changes of the spine, lumbar spinal stenosis symptoms will typically improve with Manual Physical Therapy treatment. Treatment can include:
Manual Therapy including joint mobilization and soft tissue mobilization.
IMS dry needling - needling the muscles of the spine to relieve muscle spasm that will limit spinal mobility.
Lumbar Traction - to open the space for the nerve.
Electrical Stimulation - for pain relief and muscle relaxation.
Specific Therapeutic Exercise - to improve mobility and strength of the spine, pelvis and hips.
Education - on activity modification, aerobic exercise and posture.
If your symptoms are not improving with Manual Physical Therapy then you should follow-up with your family doctor for other options i.e. medication, injections, surgical consultation, etc.
This is a brand new video demonstrating how to apply an arch taping technique called 'low dye'. This taping technique is great for supporting the arch of the foot to relieve a lot of painful conditions including plantar fasciitis, tendinitis, tendinopathy, achilles pain and even knee pain. I also use it as a trial to see if orthotic therapy would be of benefit. The taping is quite simple, with practice, and is something I teach patients to do themselves.
Osgoode-Schlatters - How can physical therapy help?
Osgoode-Schlatters is a fairly common condition affecting the tibial tubercle (the bump about 2” below the knee cap). The condition is more common in boys than girls during large growth spurts. The tibial tubercle is the site where the patellar tendon attaches to the tibial bone. The patellar tendon is part of the quadriceps muscle group. The tibial tubercle is also the site of a growth plate. So, during times of growth, the bone is softer and the tubercle becomes painful and often is enlarged as the patellar tendon pulls on the bone during activity.
The pain is typically worse with running and jumping activities and eases with rest. The diagnosis is made from both the history and clinical examination. X-rays are typically not helpful as they won’t provide any help in establishing the diagnosis.
Physical Therapy management will include:
A thorough clinical examination determining any biomechanical dysfunctions that will put extra stress on the knee. Muscle tightness, poor muscle control and altered biomechanics can all put extra stress on the knee.
Advice on specific therapeutic exercises for stretching and strengthening.
Knee taping. If this provides significant relief a patellar tendon strap can be prescribed.
Orthotics and/or proper running shoes can also help if there is an increase in pronation (excessive foot flattening).
Advice on activity modification.
The good news is that the condition is self-limiting, i.e. when the knee is sore it is best to reduce activity. The soreness will increase when there is a large growth spurt and will disappear in between growth spurts and will entirely disappear once growing is completed. Often there will be a prominent bump that remains at the tibial tubercle into adulthood.
Neck Pain - A combination of exercise and manual therapy to both the neck and upper back results in speedy recovery
Manual Physical Therapists have long recognized the importance of treating the thoracic spine in conjunction with treatment to the neck. “Mechanical neck pain” is the name used when joint and muscle problems result in neck pain. Mechanical neck pain is pain that it typically centred around the neck, shoulders and upper back. Current evidence supports that a combination of manual therapy and exercise is effective for patients with mechanical neck pain. Three categories of manual therapy treatments for the neck and upper back are used to lessen neck pain:
Joint Mobilization can be a rhythmic oscillation or a sustained pressure applied to the joints of the body. This will help to decrease pain as well as restore normal mobility and function.
Joint Manipulation involves a skilled, quick, passive movement applied by a manual therapist to a specific joint. This will help decrease pain as well as restore normal mobility and function.
Soft Tissue Mobilization (including massage, trigger point therapy, etc.) is applied to the muscles, tendons and ligaments. This will help relax muscles, increase circulation, break up scar tissue, and ease pain in the soft tissue.
Specific therapeutic exercises are also used to maintain and restore range of motion. The exercises prescribed will be specific to your neck condition.
A Manual Physical Therapist will complete a thorough history taking and physical examination to determine which manual therapy techniques will best help you. Treatment will also include education in specific therapeutic exercise. Advice is also provided on ways to reduce the physical stress and strain you are placing on your neck.
Low back pain is a common complaint for people attending physiotherapy. Quite often the pain is worsened with prolonged positions, especially sitting. This may be sitting at the office, at home or driving.
All soft tissue is subject to ‘creep’, which is a gradual stretch of the tissue in prolonged positions. An important part of the ‘creep’ phenomenon is that the tissue does not immediately go back to its normal state. This ‘creep’ is thought to cause stress and inflammation to the tissue.
Heel pain is a common condition. Pain in the arch of the foot, where it meets the bottom of the heel, is most commonly diagnosed as Plantar Fasciitis.
Typically the pain is worse with the first few steps in the morning or after prolonged sitting. The pain maybe worsened with running or prolonged walking. The pain can be, but is not always, reduced with light activity. The heel pain typically comes on gradually and progressively. On examination there is local tenderness on the bottom of the heel bone towards the arch. The tenderness may extend into the arch itself.
Common causes of heel pain can be due to the bony structure and/ or alignment of the foot, ankle, lower limb and spine. A flattened arch can put excessive strain on the plantar fasciitis. Commonly, there are muscle imbalances around the ankle and lower limb. Work and/or training factors should be considered such as prolonged standing, a sudden increase in activity, etc. Commonly there is a lack of mobility in the joints of the ankle and muscle tightness around the ankle.
Manual Physiotherapy treatment of plantar fasciitis is multifactorial:
Improve the joint mechanics and improve muscular flexibility around the foot and ankle. This is done through hands-on joint and soft tissue mobilization/manipulation.
Check for other underlying biomechanical faults in the leg and spine. Check for altered mobility of the nerves and soft tissue in the leg and spine.
Unload the plantar fasciitis with sports tape or a temporary orthotic. Typically the relief felt is significant with a reduction of pain almost immediately. Taping the plantar fasciitis is also helpful in determining if a referral for orthotics is necessary. With correct taping a 50% improvement in pain with taping is expected before recommending custom orthotics.
Assist the healing through use of physiotherapeutic modalities like ice, electrical stimulation and ultrasound.
Provide an exercise program to improve mobility and strength around the foot and ankle. An exercise program would also address any other muscle imbalances around the spine or leg.
Educate to reduce strain on the plantar fasciitis through change in footwear, work habits, as well as training factors.
Another treatment option with more ‘stubborn’ cases is IMS dry needling of the foot, calf and spine muscles.
If the plantar fascia does not respond to physiotherapy treatment, a night splint, which keeps the foot held at a 90° angle all night can be used. Another option is to see your family doctor to discuss the use of medication or a local cortisone injection.
Headaches that originate from the neck are termed 'Cervicogenic Headaches'. The International Headache Society accepts cervicogenic headaches as a distinct form of headache.
For the purpose of this blog they will be called them neck headaches. Neck headaches are common and affect almost half the population at one point in their lifetime. There is much overlap in the symptomatic complaints between neck, tension-type and migraine headaches. It has been reported that almost 2/3 of headache suffers have neck pain with the headache. So, while there are some similarities in symptoms between the types of headache, assessment by a manual physiotherapist will help determine if the headaches originate from the neck.
Typical complaints of an individual with a neck headache are:
The headache is primarily one sided or one side dominant.
The headache will typically not shift from one side to another during the course of the headache.
The headache can be associated with neck, shoulder or arm pain on the same side.
The pain typically starts in the neck and spreads to the head.
The headache is often worsened with prolonged neck postures or repetitive neck motion.
Other symptoms that can be associated with a neck headache are nausea, visual disturbances such as blurriness and/or light sensitivity, and dizziness.
To help determine if the headache is in fact related to the neck, a manual physiotherapist will evaluate the mobility of the neck and upper back. Joint stiffness of the upper three neck joints, which is evaluated by hands-on palpation, is highly correlated with neck headaches. The neck muscles will also be evaluated for their performance and strength. These assessment findings have been found to be reliable in differentiating between the different forms of headache.
Treatment would consist of joint mobilization and/or manipulation as well as special soft tissue techniques to help restore normal mobility. Specific neck exercises to help restore normal muscle recruitment and control are taught initially. These exercises would then progress to neck strengthening. Muscle imbalances around the shoulder blades are corrected with specific stretching and strengthening exercises. Other exercises for general mobility and specific self-mobilization are taught to help patients self-manage the headache. Other more traditional physiotherapeutic modalities can also be employed to aid with decreasing the symptoms. Education on posture and the other factors that contribute to the headache must also be addressed.
In summary, neck headaches can be effectively managed through manual physiotherapy and a home-based exercise program.
A recent study in the New England Journal of Medicine compared physical therapy to arthroscopic surgery for knee meniscal tears and early osteoarthritis.
The study was randomized with 351 participants divided into a surgery group and a physical therapy group. To be eligible for the study the participants had to have signs of a meniscal tear that included: clicking localized knee pain, giving way and catching.
The physical therapy group attended therapy 1-2 x per week for 6 weeks.
The treatment consisted of manual therapy, specific therapeutic exercises, cardiovascular conditioning and modalities such as ice and electrical stimulation.
The authors concluded that patients with a meniscal tear and evidence of mild to moderate osteoarthritis that were assigned to the arthroscopic surgery group (with postoperative physical therapy) and physical therapy group both had very similar improvements in function and pain.
Within the physical therapy group 70% percent of the patients had a successful outcome.
However, 30% of patients assigned to the physical therapy group went on to have surgery within the first 6 months (as they did not meet the study’s criteria for success). It is important to note that the patients in the physical therapy group, who did not improve enough, who then went on to have surgery, had as good a final outcome with those that had surgery immediately.
It is important to remember that this study was performed in the U.S. where surgery can be performed immediately, whereas in Canada there typically is a longer wait. So considering this study’s results and our wait times in Canada, if you have a meniscal tear get to physical therapy. Maybe you won’t even need surgery!
Trochanteric bursitis has become a catch all term for any pain on the outside of the hip.
A bursae is a fluid filled balloon that works to reduce friction between a bone and the overlying soft tissue.</h4> A trochanteric bursitis presents with pain on the outside of the hip at the bony prominence below the pelvic crest, the pain may also radiate down the outside of the thigh.
The trochanteric bursitis is a symptom.
The goal of manual physical therapy is to both decrease the pain and determine the underlying cause of the bursitis. Determining the factors that have contributed to the bursitis is critical for a good outcome. A manual physical therapist would like not only at the mechanics of the hip but the sacroiliac joint, lumbar spine and lower leg.
Some common causes of bursitis are:
Differences in leg length
Early osteoarthritis of the hip
Low back or sacroiliac dysfunction (i.e. ‘stuck’ or stiff joints)
Lumbar nerve irritation (especially the 5th lumbar nerve)
Habitual posture (sleeping position, standing and sitting posture)
Overuse i.e. starting or increasing running intensity or mileage
Treatment may include manual therapy (joint manipulation, joint mobilization, soft tissue mobilization), IMS dry needling, stretching, strengthening, posture correction, education on reducing stress on the hip, ultrasound and electrotherapy.
A home exercise program is taught which will include exercises for range of motion, stretching and strengthening.
Tendinopathy has replaced the term tendinitis to reflect the latest research on the source of the tendon pain.
The term tendinitis refers to pain from inflammation.
Current research on tendon health demonstrates that instead of inflammation the tendon has micro tears with evidence of poor tissue healing. A good analogy is that the painful tendon breaks down and is much like the end of a frayed rope. If the tendon continues to be strained the breakdown of tissue and pain continues. Often the tendon becomes thickened around the area of strain as the body creates an increase in the quantity of tendon rather than quality.
Achilles Tendinopathy is common in both elite and recreational athletes.
The most common type of Tendinopathy is a midtendon, i.e. about 1” or so above the attachment to the heel bone. Less common is an insertional Tendinopathy, which is pain at the Achilles attachment into the heel bone. The site of pain can be swollen and thickened or normal in appearance. The pain can be brought on with activity or only become painful after activity.
The goal of manual physical therapy is to decrease the stress on the Achilles while promoting healing.
Reducing stress involves a careful biomechanical assessment of the foot, ankle, knee, hip, pelvis and lumbar spine looking for areas that would increase the stress on the Achilles. The problem areas are addressed by a combination of manipulation, mobilization, stretching, therapeutic exercise, and modalities such as electrical stimulation and taping.
Proper footwear, a heel lift, night splint and possibly orthotics can also be helpful. Often a ‘low dye’ foot (which supports the arch) tape is used to determine if orthotics would be helpful.
A therapeutic exercise program consisting of an eccentric loading program is critical to promote healing.
The eccentric loading program has been well researched and demonstrates good success in both reducing pain and improving function. The key components of the program are heel drops on a stair with the knee bent and knee straight. The program is done in 3 sets of 15 repetitions, twice daily 7 days a week. The program can take up to 3 months. The eccentric loading promotes the tendon to produce better quality tendon cells and promote healing and reducing pain. It is also suggested that some discomfort while doing the exercise program is normal. It is best to check with your physiotherapist about the correct exercise dosage and technique.