Physio News

Headaches – Neck Related

Headaches are a common complaint. There are various causes of headaches and practitioners need to be aware of these.

The most common causes are:
– Headaches associated with viral illness, such as the ‘flu’, common cold and sinusitis.
– Vascular headaches also know as migraines.
– Cervical headaches (headaches arising from the neck).

Sometimes headaches show features of more than one cause that is overlapping. This is important as the outcome will depend on an accurate diagnosis. This article will focus on cervical headaches or neck-related headaches. These headaches may or may not be associated with neck pain. They can be felt at the back of the head, in the temporal region or even behind the eye. They tend to be on one side of the head and if there is neck pain on the same side. Less frequently headaches occur on both sides. These headaches tend to be dull, be constantly present during the day and may last days.  Sometimes these headaches may also be associated with dizziness or light headedness. If you have these symptoms and your GP has checked for other causes, physiotherapy for your cervical headaches will help sort your problem out.

Cervical joints, muscles and nerves can causes these headaches. If the joints are the cause it is usually high up in the neck (C1/C2/C3) or low down (C6/C7). These joints are usually stiff and tender to move (palpation).Sometimes knots in the muscles can generate headaches. Trapezius, Levator Scapulae and Sternocleidomastoid muscles are often the source of these trigger points. Neural tension or tightness of cervical spinal nerves can also be the source of headaches.

Once the source of the headaches is identified (it can be a combination of these) treatment to relieve stiffness of the cervical facet joints, reduce muscles tension (trigger points) and stretching cervical nerves is given .Applying ultrasound to the neck prior is effective in improving the success and extent of stretching the above structures. Home exercises are given to continue the stretching process. But what caused these structures to become tight and cause headaches?

Sometimes anxiety and stress is the cause. Some people carry stress in the muscles of their neck and shoulders, so stressful times seem to trigger headaches.  For these people ways to combat stress, heat and muscles stretches are very important. Sometimes it may be due to poor sitting posture at work or home and sitting too long. It is important to point out correct posture and demonstrate this to the patient. It is also important to remind the patient to get up frequently during the day as we are not designed for long periods of sitting. Too much sitting, particularly with poor posture means that cervical joints, nerves and muscles are put under stress and can be injured and then stiffen/tighten up.

Finally, injuries to the neck such as motor vehicle accidents can cause headaches. Cervical joints, muscles and nerves may be injured and then tighten up. Neck pain is commonly associated with headaches if this is the case.

How do we prevent headaches? Here is come useful advice.

• Keep good posture – think tall, shoulders relaxed, chin tucked in.
• Sleeping – a soft down pillow is usually best, the height of which depends on how you sleep.
• Relaxation – be aware when you are tense- you may be clenching your teeth and hunching your shoulder.
• Exercise – keep the muscles and joints in your neck strong and flexible. A physiotherapist can show you how.
• Work – keep good posture at work when sitting. Make sure the computer is at eye level and your arms are supported on your desk. Remember we are not designed for prolonged sitting so try to get up every 30-40 minutes.

So if you have a headache and you think it is coming from your neck, see your physiotherapist!

Post – Surgical Rehabilitation

Surgery repairs tears in tendons and ligaments, replaces ruptured ligaments and stabilises broken bones. High velocity impact sports and falls can produce enough force to cause such injuries. This article will discuss common surgeries and why you may have physiotherapy afterwards.

Reconstructive surgery of the knee, ankle and shoulder joints involve replacing completely torn or very weak ligaments with tendon harvested from nearby. It may also involve tightening stretched ligaments that are still intact. Healthy ligaments stabilise a joint so repeated dislocations (joint pops out) or instability (very loose joint) may require this type of surgery following injury.

Anterior Cruciate Ligament (ACL) reconstruction involves using either the hamstring or patellar tendon to replace the ruptured ACL. .A crack or a pop in the knee is often felt and heard at the time of injury. Physiotherapy is important to regain strength, balance and flexibility of the knee .A knee brace and crutches are often needed initially with some period of weight bearing restriction. Patients can usually start bike riding 6 weeks following surgery and start running at the 3-4 month mark when the ACL graft is strong enough. It may take 9-12 months before returning to your chosen sport.

Lateral Ligament reconstruction of the ankle may involve tightening of stretched ligaments if they are intact. Otherwise tendon is harvested if lateral ligaments are ruptured. Similarly rehab involves regaining strength, flexibility and balance of the ankle and leg. If ankle taping or an ankle brace can stabilise the ankle joint for sport, surgery may not be necessary.

Shoulder reconstruction involves repairing torn or stretched ligaments and usually repairing part of the shoulder socket (labrum) as well. This is done to stabilise the shoulder joint and prevent dislocations. A sling may need to be worn for 4-6 weeks following surgery but the shoulder needs to be mobilised (stretched) and strengthened during that period and afterwards to enable a good recovery.

Menisci (cartilage) knee injuries often occur as a twisting injury of the knee. The medial (inner) menisci and lateral (outer) menisci are shock absorbers that protect the knee. They also help stabilise the knee. A small tear will heal with physiotherapy treatment. A larger tear may need surgery for repair. Return to sport is the goal and it is important to build up strong knee muscles, full range of knee movement and balance.

Tendons can be torn during heavy lifting (shoulder rotator cuff tendons) or in running and jumping sports (Achilles tendon rupture). Surgery involves stitching the ends together to enable continuity of the tendon. Tendons are very strong so it takes a lot of force and repeated trauma before there is a rupture.

In the shoulder, rotator cuff tendon tears are common and in young people these tears if severe enough are surgically repaired to give a good result. The supraspinatus tendon is the most common   of the four tendons injured that make up the rotator cuff. The shoulder is immobilised in a sling following surgery, but physiotherapy is started straight away to prevent shoulder joint stiffness and to strengthen the shoulder.

Achilles tendon ruptures are usually surgically repaired and the leg is placed in a boot initially. Physiotherapy rehabilitation is lengthy and involves regaining foot and ankle movement and gradually strengthening the lower leg/calf to prepare for a return to sports. At approximately 6 weeks following surgery the scar surrounding the Achilles tendon repair will be stable and soft tissue stretching and massage will speed up ankle movement. Light calf strengthening also begins at this stage and the patient can walk without heel lifts soon after. Light jogging begins at around 4 months post surgery.

Falls or sporting accidents can result in fractures (broken bones) commonly of the ankle, foot and knee requiring surgery to stabilise the fractures. Pins and plates may be needed to do this and patients often present on crutches with a boot on. Weight bearing on the leg may not be possible for a number of weeks depending on the fracture. Regaining full leg strength, movement and balance is the aim.

Lower back surgeries are still common. Lifting a heavy object incorrectly is the usual cause. Lumbar spine disc damage with nerve irritation can cause leg and back pain, leg weakness and numbness and tingling. Lumbar discs may be removed (discectomy) or removal of spinal bone (laminectomy). This takes pressure off nerves. If there is degenerative disc disease a section of the lower back may be fused (back fusion). Physiotherapy is important following back surgery to regain full strength and movement of the spine.

No one wants to have surgery but physiotherapy rehabilitation will help you get back on track- quickly and safely.

Localised Pain or Referred Pain?

Pain-where is it coming from?

Pain, at a physiological level, is stimulation of sensitive nerve endings (nociceptive) either by chemical or mechanical means.

This commonly occurs through injury and its purpose is to inform us of tissue damage.

These nerve endings are found everywhere in the body-bone, joints (including ligaments), cartilage, muscle, tendon, discs and neural structures. Also on our skin and internal organs. We will be more concerned with the ones that cause musculoskeletal pain.

Joints, muscles and neural structures are richly innervated (supplied by many nerves) and are common sources of pain.

Sometimes the source of pain gives rise to pain at that spot. Sometimes however the pain is perceived at a distant spot. This is called referred pain.
The best known example is someone experiencing a heart attack. Pain is commonly felt in the left arm and shoulder but the source is a blood flow disturbance of the heart.

Referred pain is not well understood but is thought to be due to common pathways of nerve endings that the brain is unable to distinguish between.
There are two types of referred pain. Radicular pain is caused by nerve irritation/compression that gives rise to sharp, shooting pain and paraesthesia (pins and needles/numbness) and perhaps muscle weakness.

A common example is sciatica-which is pain and paraesthesia down the back of the leg due to sciatic nerve injury. This is usually caused by lumbar spine(low back) disc pathology that impinges on the sciatic nerve as it exits the spinal cord. It can also be caused by irritation anywhere along its course. An example of this is piriformis syndrome where the piriformis muscle irritates the sciatic nerve.

Less common is arm pain due to brachial plexus nerve damage or irritation occurring at the cervical spine(neck).Disc pathology again is the usual cause.
The other type of referred pain is called somatic pain. It is not associated with paraesthesia and the nature of the pain is harder to localise and not as sharp as radicular pain.

Discs, joints, muscles and ligaments can cause this type of pain. In fact pain down the back of the leg is usually somatic referred pain and not sciatica.
Shoulder pain is commonly referred pain from the cervical spine joints. Treating the shoulder does little to help if it is not the cause-but mobilising (stretching) the neck does.

Trigger points in muscles feel like painful knots and often refer pain to other areas of the body. These are areas of tightness – structures do not need to be damaged to be causing pain.

Nerves, ligaments and joints also when tight can do the same-cause pain either locally or referred. Usually these structures are injured first and tightness follows. The longer the pain has been present the more likely surrounding structures will also be affected.

Understanding pain-what type of pain it is and where it is coming from-is crucial to a positive treatment outcome. Physiotherapists are expert in diagnosing injury and treatment of musculoskeletal disorders.

If you have pain that is not going away and or getting worse-see your physiotherapist.

Ankle Sprains

Almost everyone has rolled or sprained their ankle at some point in time. Ankle sprains usually settle down in a couple of days but sometimes it takes longer. Sports that attract these ankle injuries involve twisting and turning at speed. Football, soccer, rugby, basketball and netball come to mind. Players have their ankles strapped now before the game to prevent these injuries.

Sometimes the same ankle rolls again a short time later- surprisingly easily. Why does this happen? And why does it tend to roll in and not out? Let’s look at the anatomy first.
The ankle contains three joints. The talocrural (ankle) joint is formed between the lower ends of the tibia and fibula (leg bones) and talus (foot bone). This joint is a hinge joint and permits your foot to move up and down.

The subtalar joint is formed between the bottom of the talus and calcaneus (heel bone). It permits your foot to move sideways to the left and right.
The third joint is an almost immovable joint between the lower ends of the tibia and fibula. A bit of rotation occurs here. This joint is named the inferior tibiofibular joint.
Ligaments bind these joints together.  Muscles and tendons move these joints and protect ligaments from injuries by checking excessive movement.
Let’s get back to that rolled ankle.
The ankle is looser, or more mobile, on the outside than the inside. This combined with the relative weakness of the ligaments that support the outside make it easier to injure.

The outside ankle ligaments are called the lateral ligament complex and have three parts. The anterior talofibularligament is easier to damage of the three. The calcaneofibular ligament and the posterior talofibular ligaments are injured in more severe cases. The inside ankle ligament is called the deltoid ligament and is a strong, fan shaped ligament. Stronger than the lateral ligament complex and much harder to damage.
So this is why you have a swollen, painful, bruised ankle after you have rolled your ankle in. If you have landed from a height and rolled your ankle you may have injured the inferior tibiofibular joint. This injury takes longer to heal than a lateral ligament strain and return to sport is delayed.

It is important to assess the severe of the damage first. The amount of swelling is not always a good indicator of severity of injury .X-rays taken in emergency departments of very swollen ankles often show no fractures. Being able to continue playing sport and the ability to weight bear should be noted.

Ligament laxity is important to determine. This means how far have the lateral ligaments overstretched. Like an elastic band too much stretching can cause a complete tear also known as a rupture. If ruptured the ankle may be unstable and ongoing pain, swelling and disability may follow. A thorough physiotherapy assessment is therefore very important. As is a thorough, comprehensive treatment plan.
Initially tape is used to protect the ligaments and allow weight bearing. Crutches may also be necessary. A compression bandage is used to reduce swelling.
RICE is followed in the first 72 hours. This is rest, ice, compression and elevation. Pulsed ultrasound is used to encourage healing. Following 72 hours ankle stretching, ligament massage, electrotherapy, and exercises to strengthen and stretch the ankle are given. Also balance exercises often involving a rocker board or wobble board.
In the absence of physiotherapy treatment, ankles may roll again due to excessive scar tissue, muscle weakness and loss of balance.

More serious ligament tears should have physiotherapy rehabilitation for up to six weeks. If athletes with Grade 3 injuries (lateral ligament rupture) can play with tape or an ankle brace with little problem, surgery is not required.

If after this time and with appropriate physiotherapy, the athlete complains of pain and instability of the ankle, surgical reconstruction of the lateral ligament may be necessary.
Excluding other causes of ongoing pain and disability may be needed. For example if the inferior tibiofibular joint is injured recovery is slower with regard to weight bearing activities that involve running.
Bone scans, CT or MRI scans may be needed to rule out subtle ankle fractures.

Ankle injuries respond very well to physiotherapy treatment. So if you have rolled your ankle or have ankle sprains and you want to get back to walking and sport quickly- see your physiotherapist.

If you like sport, particularly ones that involve your foot striking the ground, you may encounter a  knee injury at some stage in your life.

The knee is in the middle of a long lever (your leg) and it allows movement  between your femur (thigh bone) and tibia (leg bone). Therefore the stresses placed through it are high- especially in sports that involve speed, twisting and turning and collisions/falls. Sports such as football, soccer, basketball, netball and skiing come to mind .You may have lunged at the ball, twisted your  knee, perhaps felt a click with immediate pain. These types of knee injuries are known as acute injuries.

The anatomy of the knee joint complex also includes the patella (kneecap) which sits over the true knee joint (between the femur and tibia). Cartilage or menisci provide shock absorption and stability for the knee and are located within the knee joint. These structures are commonly torn when twisting and turning during weight-bearing activities.

Ligaments stabilize or hold the knee joint together. Cruciate ligaments (anterior and posterior) are important especially the anterior cruciate ligament. If this ligament is ruptured, a knee reconstruction is needed to replace the torn ligament in order to play most sports again. The rehabilitation is lengthy and physiotherapy is very important in this process. If the anterior cruciate is not completely torn and the knee joint is stable (not wobbly) physiotherapy rehabilitation without surgery is enough for recovery.

Lateral and medial ligament injuries of the knee are also common. Again, if ruptured, surgery may be necessary. It is common to see partial tears/strains – physiotherapy and sometimes knee bracing or taping is enough for recovery.

These are the main ligament injuries of the knee and with cartilage injuries common causes  of acute knee injuries.

The Quadriceps and Hamstring muscle group provide power for leg movement but also provide protection and stability for the knee joint. Knee rehabilitation must include strengthening these important muscles. These muscles can be injured too usually with running and kicking sports.

The patella or kneecap forms the patella-femoral joint which as mentioned sits above the knee joint. This area can also be injured while suddenly twisting or turning and responds very well to a taping and strengthening physiotherapy program. Sometimes this joint may dislocate or sublux (partial dislocation).Immobilisation in a splint is often required followed by physiotherapy consisting of taping and strengthening again.

More commonly this area is injured as an overuse injury and known as Runners knee.
An overuse injury results from continuous activity or overload. It starts gradually and usually relates to training methods, footwear and running style or biomechanical factors. A thorough assessment is very important.

The patellar tendon runs from the patella to the leg bone. It is injured, usually with repeated jumping and landing activities.Pain and swelling results making it difficult to play sport. This is commonly known as jumper’s knee and is another common overuse injury of the knee.

Physiotherapy is important to overcome your knee injury whether it is an overuse or acute knee injury. Electrotherapy (Ultrasound and tens) is used to encourage healing and reduce inflammation. Soft tissue and joint therapy as well as exercises, taping and advice regarding avoidance of aggravating factors and return to sport safely is very important.

If  you have an acute knee injury…….

RICE (Rest, Ice, Compression and Elevation) is very important in the first 72 hours of injury, as is early physiotherapy attention.

These are the most common injuries seen around the knee. It is important to examine the knee fully to find out what is injured, so treatments are successful. Sometimes scans are required to show the extent of the injury or if is difficult to diagnose clinically. The amount of swelling and how soon it appears is a good indicator of the severity.

Also how the injury occurred and whether continuation of the activity was possible.

Symptoms such as locking, clicking and giving way of the knee are important to note.

Everyone wants to return to sport quickly following injury but can knee injuries be avoided?

They can by warming up and warming down before and after sport. Gradually increasing sport intensity and duration and backing off if pain starts. This is especially important for overuse knee injuries. Maintaining good leg flexibility, strength and balance is important for all types of knee injuries.

Exercise and sport is great for health and with a little care hopefully injury free.

Good luck!

Sporting Overuse Injuries

The growing trend in all sports is an increased volume or intensity of training. However, the drawback of increased training is that repetitive activity can lead to an overuse injury which is why overuse injuries have become such a common problem in sports medicine.

An overuse injury occurs through repetitive micro trauma to the tendon, bone or ligament which overloads the capacity of the structure to repair itself. This results in an inflammatory response which over time can lead to structural changes to the tissue.

The human body has remarkable capacity to adapt to physical trauma. Adaptations can be positive, for example through being active and participating in regular exercise your bones, muscles, tendons and ligaments get stronger and more functional. This happens through a process of remodelling where tissue is broken down and rebuilt to repair itself. However, if this process is disproportionate and tissue is broken down more rapidly than it is rebuilt injury can occur. This imbalance in the remodelling phase

Overuse injuries are more subtle than acute injuries and usually occur gradually over time and are often associated with your training and technique. These injuries can occur anywhere in the body and with any sport that places constant, high demands on tissue.

Examples in sport:

• Tennis elbow-pain is on the outside of the elbow but caused by overuse of wrist muscles. It is important to reduce inflammation quickly and minimise scar formation.
• Swimmers shoulder (rotator cuff tendonitis) – reducing swimming load may be necessary. Ultrasound, soft tissue massage and exercises are important. Tennis players also get this with serving/overhead smash.
• Runner’s knee – this is due to patellofemoral joint pain (kneecap). Assessment of training methods, running technique is important. Strengthening of the inner quad muscle and taping is very effective. Calf/hamstring/ITB stretching is important too.
• Gluteus medius tendinitis/bursitis-hip pain due to long distance  running. Pain is felt on the outside of the hip and made worse by stairs and getting in/out of car. Pelvic tilt may be present which needs correction if so. Sometimes a cortisone injection is required.
• Shin splints- usually soft tissue attachment to the tibia(shin bone) is the cause. Ultrasound and soft tissue release is important. Sometimes cause is stress fracture of the tibia. High foot arches if present need attention.
• Achilles tendonitis. Often slow to recover. Ice/stretching/ultrasound is important. Precursor to Achilles rupture so carrying this injury without attention is risky. Long distance running is often the cause. Assessment of  foot arches may be needed.
• Plantar Fascitis -heel pain frequently caused by excessive running or dancing. Pain is often worse first thing in the morning. Responds well to ultrasound, frictions and taping/stretches. Fallen foot arches if present need attention.
• ITB friction syndrome. Pain is felt on the outside of the knee..Running, particularly excessive downhill running ,can cause this. Usually quick to respond to treatment.

This lists common examples-there are many more- a thorough assessment is crucial  to positive outcome and speedy recovery.

Treatment:

Relative rest –avoiding aggravating factors-whilst maintaining strength and fitness is important. Addressing the cause is important-is it biomechanics, alignment, sudden increases in  training levels, equipment or shoes? With this, treatment can be successful and includes advice, electrotherapy (ultrasound,TENS) soft tissue and joint mobilisation, icing, exercises and if necessary anti-inflammatory drugs. Scans such as x-rays and diagnostic ultrasound may be necessary.

Working together getting you back to your chosen sport or sports as quickly as possible.

Neck Injuries

Our neck allows us to look around by moving our head. Our ability to scan the environment and process this information is very important.
Our neck is very mobile and because of this easily injured. The neck also supports the heavy head so again easily injured. Lets look at the anatomy first.
Seven bones called vertebrae make up the neck. They are separated by discs and held together at joints by ligaments. Muscles move our head but also help to stabilise and protect our neck.
Nerves from the neck supply the shoulders, upper back and arms. If these nerves are irritated, injured or tight we may feel pain in these areas.
But nerves alone do not cause pain-neck muscles, discs and joint/ligaments, if injured, can also produce pain-in the neck itself or in the shoulders, upper back and arms. Sometimes even headaches.
But what causes these injuries? And what causes tightness and irritation?
Bad sitting posture is a common cause. This is because the muscles work harder to support the heavy head then fatigue and put strain on our neck joints/ligaments.
Good posture means less muscle work and less strain on the neck as a whole. Even with good posture we are not designed for prolonged sitting-try to get up and move around as often as you can.
Another cause of pain is motor vehicle, sports or work injuries. If the head is thrown forward, backwards or sideways with force damage to discs, nerves, muscles and joints/ligaments is possible.
Finally as we get older,  or if we have injured our neck badly when young,  arthritis of the joints and discs can also cause pain. This is essentially wear and tear and stiffness and reduced neck movement is also present.
So what can we do? Look after our neck-keep good posture, limit time spent sitting and keep the neck muscles strong with exercise to protect your neck. Have you seen the size of a swimmers neck?
Physiotherapists have the training to effectively treat you if you have pain.
A thorough assessment determines what is injured. With the neck it is usually more than one structure.
Physiotherapy neck treatment includes manual therapy, ultrasound, massage, traction and exercises. Posture/Ergonomic advice also if you sit for long periods.
If you injure nerves from the neck you may experience pins and needles/numbness (paresthesia) down your arm. If the discs are causing this nerve irritation scans may be necessary to measure the damage.
Almost all neck injuries are treated successfully by physiotherapy and the rule of thumb is the faster you get treatment the faster you recover.
So you can get on with things-pain free.

The shoulder joint is arguably the most interesting joint of the body, both in function and anatomy. It has the most movement of any of our joints. Lift your arm up, move it around, backwards and forwards. No other joint moves as much.

It is allowed to do this because of its anatomy. It is a ball and socket joint but the socket is shallow so the ball moves with great freedom. Ligaments/Joint capsule provide some stability but most important is the rotator cuff.

These are 4 muscles that wrap around the shoulder joint much like a cuff does. They contract when the shoulder moves thus providing dynamic support.
But with all this movement comes a price. The shoulder is easily injured and most commonly it is the rotator cuff that is injured as it works constantly to stabilise the joint. There are tears with lifting or falls and also rotator cuff tendonitis with overuse. Sometimes both conditions co-exist. Young or old people may get these injuries. Supraspinatus is the most commonly injured cuff tendon. Bursitis of the shoulder is frequently associated with these injuries because of friction between cuff tendons and bone which can increase pain.

Shoulder joint dislocations and subluxation (partial dislocations) occur mainly in the young. No other joint in the body dislocates as often and it is due to the anatomy of the shoulder.Anterior shoulder dislocations are more common and a person will feel something pop out usually with a great deal of pain. Significant trauma is required for this to happen usually on the sporting field. It is important for the shoulder to be reduced (popped back in) as soon as possible and a sling is then worn. Starting Physiotherapy as soon as possible is very important for shoulder injuries.

At the tip of your shoulder is the acromioclavicular (AC) joint. AC joint injuries are often described as shoulder injuries. This joint occurs between your collarbone (clavicle) and your shoulder blade (scapula).

This joint is very different to the shoulder joint in that it has very little movement courtesy of the joint capsule and strong ligaments that bind the joint and no muscles that move the joint.

The AC joint is important in allowing the shoulder blade to move and rotate on the collar bone when the arm is elevated. One third of your arm elevation occurs because the shoulder blade rotates upwards as you lift your arm.

A fall on your shoulder can sprain or tear the ligaments that stabilise the AC joint. This injury can be minor or significant depending on the degree of damage. With more severe injuries the clavicle lifts up providing a step deformity. Only very severe injuries require surgery as conservative treatment is very successful.

Physiotherapy treatment of your shoulder injury will depend on which injury you have sustained. Sometimes scans are needed to determine the severity of injury. The three mentioned are the most common sporting injuries.

The principles are to minimise inflammation in the early stages, protect the injured structures and encourage healing. Later on to restore full movement, strength and return to your chosen sport.

Electrotherapy, ice, shoulder slings, tape, and exercises are started straight away and as improvement occurs, joint stretching, soft tissue massage and progression of strengthening exercises. An explanation of the injury is given with an expected return to sport or work if appropriate.
Next time you play tennis, go for a swim or swing a golf club you might marvel at the design of your shoulder.