Kelowna Manual Therapy Centre Blog

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.

A video of correct technique can be seen below:

ACUTE INJURIES

Acute injuries are initially treated with the PRICEM principles.  The sooner the PRICEM principles are initiated the better.  Remember that swelling may increase over the first 48 hours.

P - protect the injured area from further injury such as the use of crutches, limited weight bearing, etc
R - rest the injured area</li>
I - ice the injured area 10-15 minutes at a time up to every hour
C - compression to limit swelling through use of a tensor bandage, etc
E - elevation of the injured area
M - medication/modalities such as anti-inflammatory medication, ultrasound, electrical stimulation, etc.

Injured tissue goes through three overlapping stages of healing

1. Inflammatory - the body reacts to the injury by swelling and begin to lay down new collagen tissue.  The new collagen is weak therefore stress should be minimized.  This stage lasts 7-10 days.
2. Fibroblastic - this stage lasts 4-6 weeks and is characterized by increased density of new collagen tissue.  Gradual stress through the injured area is critical to resume optimal function.
3. Maturation - this stage can last up to one year and the collagen tissue remodels itself in reaction to the stress placed upon it.

The key to rehabilitation during the acute phase is to gradually increase the stress placed upon the tissue matching the stages of healing and the severity of the injury.

OVERUSE INJURIES

Overuse injuries take two forms, which often overlap.  The first is simple overuse where an athlete has increased their training or has a sudden change in training to a level that has over stressed the tissue.  Treatment is to identifying the stressful event(s); decrease the inflammation and providing rest to the injured area.

The more common overuse injury is where the painful injured tissue can no longer handle the demands placed upon it.  This requires a more in depth assessment to determine what is the cause of the injury.  Quite commonly the injured area is the ‘victim’ of stiffness / lack of mobility and or control elsewhere in the body termed the ‘culprit’.  For example if a runner is complaining of lower back pain ‘the victim’, while ‘the culprit’ might be a lack of hip mobility, putting extra stress on the lower back.  The assessment should include looking at the intrinsic and extrinsic factors of each individual.

Intrinsic Factors:

• Biomechanical examination of joint mobility and stability
• Bony structure: Spine and limbs
• Ligament stability
• Muscles Activation /Strength
• Body Awareness / Balance
• Posture

Extrinsic Factors:

• Training Methods
• Shoes, bike, other equipment

Injuries are common in recreational and elite athletes training for endurance events.

Injuries can be roughly classified as acute, such as rolling the ankle while trail running or overuse.  Overuse injuries can be caused by a sudden increase in training or the injured tissue can no longer cope with the demands placed upon it.

PREVENTION

Active Recovery
An active recovery of cool down is very important after hard workouts to help flush out lactic acid; it should consist of 15-20 minutes of gentle movement.

Differentiate Muscles soreness from Injury soreness
Delayed onset muscle soreness is common a day or two after a strenuous session, other than putting up with the soreness there is no harm done in continuing to exercise.  Joint soreness is an indication that the joint itself has been stressed and requires more rest.  Signs would include swelling or a ‘puffy’ joint and tenderness.  If other areas continue to ache or are painful, longer than 1-2 weeks should be assessed.

Correct Training
A gradual increase in training in necessary, a 10% increase seems to be a good rule of thumb.  Remember that while it is important to gradually increase training volume and intensity, adequate recovery allows the body to build up stronger.  High intensity training requires around 36-48 hours of recovery before another high intensity session should be undertaken.  A good rule of thumb is the higher intensity the session the longer that recovery.  Knowing your body is key for any athlete, knowing when to push and when to rest.

Cadence
Stride rate 180-200 strides per minute for runners, 90-100 RPM for cyclists

Technique
Runners should consider softer landing (midfoot/forefoot), slight lean forwards at the ankle, tall chest.  A proper bike fit is important for cyclists and triathletes.  A coach should be employed for swim technique analysis.

Strong Core
A strong stable core provided a good base to propel and transfer energy.  This allows an athlete to maintain good form and technique even when fatigued.

Adequate Flexibility
Adequate flexibility for the demands place on the individual ie. Hip mobility for runners, hamstring flexibility for cyclists, shoulder and thoracic mobility for swimmers.  This is probably more important as we age.  Static stretching should not be performed prior to a work out, dynamic stretching and a good warm up is better.   Static stretching prior to a work out has been shown to be detrimental to performance.  Static stretching (20-30 second hold) should be performed after a workout.

Old Injuries
Deal with those old injuries in the off-season that linger after your competitive season.  With an increased training load they will most likely reappear.

Adequate Sleep
There is some research that ongoing sleep deprivation, longer than 1-2 nights, interferes with our hormonal balance that regulates recovery.

Nutrition Replacement
A great resource is the coach.ca website, that has a sport nutrition section found at http://www.coach.ca/sport-nutrition-tips-p138189. Eating properly is important on a routine basis but a post workout combination of carbohydrates and protein is critical for recovery.  Good information can be found at http://www.coach.ca/recharge-and-replenish-recovery-nutrition-p144453.

Compression
Compression socks have become quite popular, with some claims of improved athletic performance.  Best scientific evidence is that they assist with lactate acid clearance post exercise and decrease swelling.

Cold Baths
Cold baths have become popular and are theorized to reduce the inflammation that has occurred with a strenuous workout. Cold water may help recovery, and can be used for around 10 minutes. It is not necessary to have an ice bath; cold water of 24 Celsius is okay.  Standing in our lake after a workout is also recommended.  Contrast baths of cold and warm water may also be beneficial though not very practical 1 minute cold 10-15 Celcius then 1 minute warm  (37-40 Celcius) for 7 cycles was advocated.

Footwear
Consider changing running shoes every 1000 km or so.  It is also wise to have two different pairs of shoes that you can rotate.  Make sure you have your footwear checked by a store with knowledgeable staff that can help you pick the right shoe.

Most people have heard about it, but many are confused as to what this acronym stands for and how important it is to kick start the healing process.

The “R.I.C.E.” principle in its expanded form stands for REST, ICE, COMPRESSION, and ELEVATION. After injury, following the R.I.C.E. principle can limit swelling, protect the injured area, and relieve pain if used immediately.

In order to effectively put the “R.I.C.E.” principal to work for your injury, follow these steps:

1. REST - this is important following injury in order to protect the injured area from further damage. Resting allows the body to use its energy effectively to heal the injured area. For instance, if you sprain your ankle, walking on the injured ankle can disrupt the healing process and prolong recovery.
2. ICE - Applying ice to the injured area reduces blood flow and therefore reduces swelling. By reducing the swelling you are there by reducing the pain. There are many ways to apply ice, such as using crushed ice or a bag of peas, however it is good practice to place a moist thin towel between the ice and your skin. Apply ice for 15 to 20 minutes only. Leaving ice on for more than 20 minutes may cause unwanted damage to the skin and tissues. Leave ice off the area for at least 20 minutes before icing again. This process can be repeated many times throughout the day.
3. COMPRESSION - Compression is another way to control swelling. Some people get temporary pain relief from compression. Use a tensor bandage to wrap the injured area If the injured area throbs or the bandage feels too tight, remove the bandage and wrap it more loosely. Compression is also a good way to protect the injured area from further damage.
4. ELEVATION - Elevation is yet another way to reduce swelling and speed up the healing process. It involves raising the injured area above the level of the heart. For example, if you sprain your ankle, lie down on a bed or couch with your foot propped up on two or three pillows. Ideally, you can ice your ankle in this position, also.

If you are unsure as to the severity of the injury or you are unsure how to treat the injury, this is where an assessment by a physiotherapist can help guide your speedy recovery. Physiotherapy modalities such as electro physical agents, acupuncture and simple safe exercises can also assist in the healing process.

Frozen shoulder (FS) is a common condition treated by physiotherapy.  There are three classic stages to the FS: a freezing stage, a frozen stage and a thawing phase.

The freezing stage is characterized by a gradual stiffening with a increase in pain.

The pain usually starts locally around the shoulder and is progressive in nature. Early on pain tends to be felt mostly at night or when the shoulder is moved close to the end of its range of motion. Common painful movements include doing up a bra, reaching into the back pocket, shampooing hair and pulling on a shirt overhead. The pain usually progresses to a constant intense pain at rest, which is aggravated by any movement of the shoulder.

A stiff shoulder with less pain characterizes the frozen stage.

The thawing phase is characterized by a gradual return of mobility and a further decrease in pain.

In the thawing phase, forward motion of the shoulder typically returns first. The mobility of the arm out to the side and behind the back will return later. To raise the arm, an individual will hike their shoulder blade to compensate for the lack of mobility.

The FS can last from 1-2 years. Most people will regain full use of their arm, although some individuals continue to experience a lack of mobility.

FS affects women more than men and is more common in the non-dominant shoulder.

Common risk factors for FS include:

• Trauma to the shoulder
• Diabetes
• Thyroid disease
• Increased cholesterol

Physiotherapy treatment should consist of manual physical therapy, exercises for mobility and modalities to decrease pain. The manual physical therapy is directed at the neck, upper back, shoulder blade and shoulder. The manual therapy can consist of joint manipulation, joint mobilization and soft tissue techniques. Exercises for range of motion help to improve mobility and are critical to maintain progress between visits.

It is worthwhile to try a course of physiotherapy to see if therapy can help speed up the recovery process. It is important that the therapy not increase the pain. It is okay to experience a temporary increase in pain during therapy but this should decrease to its usual level within 40 minutes.  Improvements in mobility should start to be experienced in 3-4 visits, though more physiotherapy will probably be required. If no gains in mobility are noticed in the initial visits, physiotherapy may not be help, but a home exercise program should be continued. If the pain persists or if the therapy exacerbates the pain a cortisone injection may be a good choice.

Physiotherapists have long advocated that patients should try to improve their strength and mobility prior to undertaking any orthopedic surgery.

A previous blog showed the evidence for manual therapy and exercise in treating osteoarthritis of the hip and knee.  If the physiotherapy is not effective or if the pain continues to increase then a total joint replacement may be necessary. A recent study published in the journal of strength and conditioning showed that individuals who undertook a ‘prehabilitation’ program prior to undergoing a total knee replacement demonstrated improved strength and function i.e. walking and stair climbing.

It is very common due to the pain and swelling that the leg muscles become weak. The good news is that no matter how bad the pain is an exercise program can be prescribed to improve strength and mobility.

The exercise program consisted of walking, as well as strengthening and range of motion exercises for the hip and knee muscles. So if you do have to undergo a total knee replacement you should consider seeing a physiotherapist to learn an appropriate ‘prehabilitation program’.

It is reported that 90% of shoulder dislocations are in an anterior (forward) direction. The other 10% are posterior (backward) dislocations. An anterior shoulder dislocation is one of the most common traumatic sports injuries and is caused by a force that pushes the ball forwards in the socket. The most common causes of dislocation is a fall onto the shoulder.

After a dislocation the sooner the shoulder is reduced or “put back in” the better.

Icing and rest are critical in the next 48 hours to minimize inflammation. Gradual mobilization and strengthening can be initiated once soreness allows.  If all goes well one can resume activity over the next 4-8 weeks. Some experts no longer advocate use of a sling although one can be used for short-term comfort. There is no reduced rate of dislocation with prolonged use of a sling and immobilization.

The bad news is that younger people who suffer a dislocation have a much higher rate of recurrence; some experts report an 80-90% rate of recurrence. Individuals aged 25 years and older will typically do well with a program of physiotherapy aimed at regaining proper shoulder mechanics and strength. Individuals aged 40 and older have a smaller dislocation rate of only 10-15% and should do also well with a physiotherapy program mentioned above. Unfortunately, older people who suffer a dislocation have a higher rate of concurrent rotator cuff tear.

A consequence of dislocation can be damage to the shoulders labrum. The labrum is like a rubber ‘O’ ring that works to deepen the socket. This type of labral tear is termed a Bankart lesion. Less common are bony fractures, ligament and muscles tears.

Symptoms of a Bankart Lesion can include:

• A sense of instability i.e. “don’t trust the shoulder”
• Further dislocations
• Catching, locking, grinding, popping sensations
• Aching of the shoulder especially at night
• Loss of strength and mobility

These complaints are common to many other types of shoulder pain but if they occur post dislocation then they require further investigation by your physician.

Low back pain is a very common occurrence and is said to affect 80% of people at some time in their life.  Common causes of acute low back pain are sudden unexpected movements i.e. bending: lifting while twisting, or trauma such as a fall or a motor vehicle accident.

Others can injure their lower back simply if bending to brush their teeth.  The low back pain can come on instantly, with acute muscle spasm or locking.  Sometimes it is impossible to move or to straighten to an upright position.  Other acute low back pain can come on more slowly; up to 2 days post injury, as swelling gradually accumulates.

What to do

• Relax! No matter how bad the pain is it will get better.
• If the pain is less than 48 hours use ice, use heat if the pain has been present for more than 48 hours. Heat can be in the form of hot showers, an electric heating pad, a microwaveable pad or hot water bottle.
• Try to remain as active as the pain will allow. Some discomfort with moving around is normal. Research has proven that keeping active i.e. puttering around (stand a little, sit a little, walk a little) will allow you to get better quicker.
• If you are unable to move or if movement greatly increases the spasm then you may require more rest. See the sleep position article for some advice on the best resting positions.
• There is good evidence that Manual Therapy will get you better quicker. Research has proven that Manual Therapy performed in the first 16 days and when the pain is in the back and thigh is most effective.
• Pain radiating down the leg will also improve with manual therapy but might also require specific exercises and/or positioning to relieve the pain. Traction can be of benefit especially when the leg pain is radiating below the knee.
• Modalities such as electrical stimulation can be of benefit.
• If the pain is constant you may benefit from anti-inflammatory medication, if the pain is keeping you from sleeping you might consider a muscle relaxant.  If the pain is unbearable then you might consider a pain reliever. It is best to discuss this with your physician or pharmacist.