Musculoskeletal Conditions

Neck

Cervical Radiculopathy

Cervical radiculopathy (CR) is becoming increasingly common due to our modern society. Cervical radiculopathy is a result of degenerative changes in the cervical spine either at disc level or bone level resulting in nerve root inflammation, impingement, or both. It is characterised by neck pain, numbness and tingling that radiates down from neck to shoulder and beyond. Currently there are both surgical and non-surgical treatments, with surgical treatment posing some risk of post-operative complications. Conservative measures including manual therapy, cervical traction, postural education, exercise and NDIS can relieve pain and improve neurologic function and quality of life. Primary evidence suggests that this multimodal treatment program provides positive outcomes.

Exercise is effective in promoting analgesia in a variety of chronic musculoskeletal conditions. This is achieved via the ability to activate conditioned pain modulation descending inhibitory pathways which results in subsequent pain relief. Studies have supported that the improvement of cervical function can be achieved by restoring the normal muscle balance through strengthening muscles and stretching tight muscles. Strengthening exercises aim to improve resting neck posture, reduce pain, and may decompress neural elements. A program tailored to the individual can address these main rehabilitation goals and reduce and manage pain in cervical radiculopathy.

Whiplash

Whiplash is the mechanism of injury that occurs as a result of indirect trauma from acceleration-deacceleration forces, most commonly caused by motor vehicle and sporting accidents. Whiplash associated disorder (WAD) describes the injuries sustained as a result of these forces and can be a complex and disabling disorder. Symptoms of whiplash associated disorder include pain, stiffness and reduce cervical mobility, muscle spasm, headache and neurological symptoms such as tingling, numbness and weakness in one or both arms. These symptoms occur in the absence of lesion or other structural pathology. Whiplash associated disorder symptoms can arise acutely and for some patients these symptoms can become chronic and disabling. Not only do physical symptoms manifest, but psychological symptoms and factors surrounding the mechanism of injury can arise and result in increased levels of anxiety, depression and fear, including fear of movement of the neck. Early intervention and mobilisation is best practice when treating whiplash associated disorder. The goals of treatment are to alleviate pain, improve muscle function and neuromuscular control. Exercise management has been shown to reduce pain and disability, improve self-efficacy and reduce the fear of movement and re-injury. Active treatment involves early mobilisation, improving range of motion, strengthening and stretching exercises to improve functional capacity to pre-injury level.

Knee

ACL Tear/Rupture

“ACL” refers to the Anterior Cruciate Ligament within the knee joint. It is located behind the kneecap and acts to provide stability to the knee whilst moving and pivoting. An ACL injury occurs when the femur (Thigh bone) moves forward in relation to the rest of the joint, causing the ACL to overstretch and tear. ACL injuries occur more often in non-contact accidents whereby the person is pivoting, decelerating, or landing from a jump yet can also occur when someone or something falls onto the knee.

Although the occurrence of ACL injuries is vast, this often devastating injury is largely preventable with muscular and neuromuscular exercise training.
ACL Injury Treatment
Once the injury is established, the first (and often only) treatment strategy considered is surgical ACL repair. This involves repair of reconstructing the ACL with a graft to provide stability for the knee. With the incidence of surgical reconstructions and revisions (Secondary ACL surgeries) in Australia being amongst the highest in the world and lead studies finding no significant difference in reported outcomes between surgery and conservative (Exercise) treatment, it is high time for considering exercise as the first treatment strategy.

This treatment involves gradual progression through evidence based flexibility, balance and strength exercises with an objective of returning to pre-injury function. This has been shown to not only successfully provide stability for the knee, but also allow reconnection of ACL tissue in some cases. It has also been repeatedly proven to improve surgical outcomes. Therefore if function is not achieved with conservative treatment it has increased your chances for success with surgical treatment, making for perfect pre-operative preparation and minimising recovery times.

Patellofemoral Pain Syndrome (Runner’s Knee)

Patellofemoral Pain Syndrome (often referred to as “Runner’s Knee”) is a common overuse injury of the knee soft tissue causing pain, discomfort and/or inflammation about the patella or kneecap. Patellofemoral Pain Syndrome is characterised as an overuse injury rather than an impact condition. Normal daily tasks such as running, walking, climbing up and down stairs / hills, as well as squatting become painful with Patellofemoral Pain Syndrome. It typically occurs after a sudden increase in load, or use of your legs above and beyond your normal amount of activity. Although it has earned its colloquial title from the sport this injury is not limited to runners and can occur even with a sudden increase in walking or gym activities.

The pain develops typically due to an imbalance between the muscles of the hips and thighs which move the knee and kneecap, resulting in a shift in the direction the kneecap moves during bending and straightening of the knee. Usually, your kneecap slides in a groove created between your thigh and shin bone at the knee joint with no issues. When it is “grumpy” due to a sudden change in your physical activity levels, the kneecap no longer slides smoothly causing pain and discomfort.

Symptoms of Runner’s knee include:
– Pain or swelling about your kneecap which can extend to the sides or even back of your knee
– Pain when squatting, walking, running, jumping, navigating stairs and hills
– Stiffness/soreness when straightening and bending your knee
– Pain and/or stiffness/tightness in your thighs and hips
Symptoms usually occur only with the above movements, typically disappearing as quickly as they start. They can be acute or have a delayed onset and range from mild discomfort to severe pain and avoidance of function if not treated correctly.
Patellofemoral Pain Treatment
Practical treatments of Patellofemoral Pain Syndrome include range of motion, flexibility and strengthening protocols for the surrounding muscles, including the gluteal muscles, hamstrings, quadriceps, and calves. Current research indicates that progressive, incremental strengthening regimes are an effective treatment tool for increasing pain free function and mitigating the progression of the condition.

Individuals who engage in active rehabilitation early are often able to return to function with minimal discomfort within 1-2 months. However, it is worth noting that pain may persist for some time afterwards. The current consensus for the best treatment method is a combination of exercise therapy, manual therapy, taping and foot orthotics. Surgery will not fix this condition. The general time taken to get better ranges from 2 weeks to 3-4 months depending on the case.

Shoulder

Shoulder Subluxation and Dislocation

Shoulder subluxation is characterised by a partial or incomplete dislocation of the glenohumeral joint. Subluxation occurs when the humeral head slips out of the glenoid cavity and then pops back into its socket, this can be due to weaknesses in the rotator cuff muscles or from external forces to the shoulder joint such as those caused by a sporting injury. In the case of a shoulder dislocation, there is a disruption of stabilising forces of the joint and the humeral head falls outside of the socket (glenoid arc). The three types of subluxations are anterior (forwards), posterior (backwards) and inferior (downwards). Much like subluxation, shoulder dislocation can occur in directions both anteriorly and posteriorly.

The most frequent complication with shoulder subluxation and dislocation is recurrence due to instability. Rehabilitation is important to restore dynamic musculature, proprioceptive restraints from shoulder instability and strengthen the rotator cuff muscles supporting the glenohumeral joint. A three-phase approach is typically recommended for shoulder injuries such as dislocations and subluxations. The main goals are to restore pain free range of motion and create stability in the joint before strengthening the supporting rotator cuff muscles and surrounding stabilising muscles.

Rotator Cuff pathology

The rotator cuff (RC) is made up of muscles and tendons that surround and stabilize the glenohumeral joint of the shoulder. The RC muscles function to initiate joint abduction (lifting arm to the side), provide internal and external rotation, and contribute to dynamic joint stability. The biggest risk factors for injury to the RC are age and history of trauma, although anatomy can be a causative factor as well. RC injuries are the most common cause of shoulder pain. They can be classified as acute, chronic or a combination of both and can be partial or full thickness tears.

Some RC tears can be asymptomatic while others can cause debilitating negative symptoms such as pain, loss of strength and function. It is important to note that asymptomatic injuries may or may not progress to being symptomatic and it is unknown why some tears are asymptomatic to begin with.

So, what treatments are available?

The most invasive treatment is surgery, various surgeries exist to reattach, replace, or reconstruct the RC tendons. Surgery is often used along side more conservative treatments including active exercise therapy pre- and post-surgery. Conservative treatment without the addition of surgery is also a common treatment option, with appropriate exercise prescribed to strengthen the surrounding musculature of the shoulder, improve range of motion, and increase functional strength. As exercise therapy is used in conjunction with surgical interventions it is extremely difficult to determine if outcomes from either one is greater. Therapists are tending to lean more towards prescribing exercise therapy initially, as in a worst-case scenario this will still be great prehab for any potential surgical intervention in the future.

Elbow and upper arm

Medial Epicondylitis (Golfer’s Elbow)

Medial Epicondylitis (often referred to as “Golfers elbow”) is a common overuse injury of the forearm soft tissue causing pain, discomfort and/or inflammation on the medial (inside) of the elbow and forearm. Medial Epicondylitis is characterised as an overuse injury rather than an impact condition. Continuous movement (specifically gripping and rotation) of the forearm can cause microscopic tears in the tissue leading to inflammation and pain. Although it has earned its colloquial title from the sport this injury is not limited to Golfer’s, In fact 95% of individuals who are diagnosed with medial epicondylitis haven’t ever picked up a club. Symptoms of Medial Epicondylitis include:

– Pain or swelling on the inside of elbow and wrist
– Pain when grasping or gripping objects
– Stiffness/soreness when straightening your arm
– Pain when rotating the forearm or wrist

Symptoms can be acute or have a delayed onset and range from mild discomfort to pain and avoidance of function if not treated correctly.

Golfer’s Elbow Treatment
Practical treatments of medial epicondylitis include range of motion and strengthening protocols for the wrist and forearm extensors (particularly for the extensor carpi radialis brevis). Current research indicates that progressive, incremental strengthening regimes are an effective treatment tool for increasing pain free function and mitigating the progression of the condition.

Individuals who engage in active rehabilitation early are often able to return to function with minimal discomfort within two weeks. If the condition is not conservatively managed early, alternative treatment modalities can be used with severe cases such as steroidal injections, autologous blood injections and surgery.

Lateral Epicondylalgia (Tennis Elbow)

Lateral Epicondylalgia (often referred to as “Tennis Elbow”) is a common overuse injury of the forearm soft tissue causing pain, discomfort and/or inflammation on the lateral (outside) of the elbow and forearm. Lateral Epicondylalgia is characterised as an overuse injury rather than an impact condition. Continuous movement (specifically gripping and rotation) of the forearm can cause microscopic tears in the tissue leading to inflammation and pain. It can also occur due to a current increase in load, or use of your forearm above and beyond your normal amount of activity. Although it has earned its colloquial title from the sport this injury is not limited to tennis players. In fact, more than 95% of individuals who are diagnosed with lateral epicondylalgia haven’t ever picked up a racket.

Symptoms of Lateral Epicondylalgia include:
– Pain or swelling on the outside of the elbow and wrist
– Pain when grasping or gripping objects
– Stiffness/soreness when straightening and bending your arm
– Pain when rotating the forearm or wrist, such as opening jars and doors
Symptoms can be acute or have a delayed onset and range from mild discomfort to severe pain and avoidance of function if not treated correctly.

Tennis Elbow Treatment
Practical treatments of lateral epicondylalgia include range of motion and strengthening protocols for the wrist and forearm extensors (particularly for the extensor carpi radialis brevis). Current research indicates that progressive, incremental strengthening regimes are an effective treatment tool for increasing pain free function and mitigating the progression of the condition.

Individuals who engage in active rehabilitation early are often able to return to function with minimal discomfort within two weeks. However, it is worth noting that pain may persist for some time afterwards. If the condition is not conservatively managed early, alternative treatment modalities can be used with severe cases such as steroidal injections, autologous blood injections and surgery but current research states this should be avoided for at least 12 weeks.

Hips and Pelvis

Greater Trochanteric Pain Syndrome

Greater Trochanteric Pain Syndrome (GTPS) is pain in the lateral aspect of that thigh that is exacerbated with prolonged sitting, climbing stairs, lying on that side or high impact activity. The presentation of GTPS is typically lateral hip pain that may radiate down the outer thigh, buttock and occasionally the outside of the knee. It is most prevalent between the ages of 40-60 and studies have shown a strong correlation in females and in obesity. The most common underlying causes for pain are gluteal tendinopathy or tendon tears, and/or trochanteric bursitis.

Aetiology is multi-factorial involving both intrinsic and extrinsic factors. Some of the main factors are repetitive activity, mechanical overload, sedentary behaviours, obesity, and training error. Weaknesses around the hip muscles, particularly those of the hip abductors like gluteus medius, can cause increased valgus (knees angling in towards the midline of the body) and therefore increased strain on the gluteus medius and gluteus minimums tendons at the greater trochanter area. With this increase in angle of this femur, the iliotibial band compounds the strain on the gluteal tendons by compressive forces. This explains why pain in the sitting and prolonged sitting position causes pain since compression on these tendons is increased in this position. Exercise management should involve gradual loading of the tendons to recondition them to tolerate load. It is recommended that exercise should start at a low-moderate effort level with low repetitions. Resistance exercises should focus on building strength in the gluteal muscles but also the core muscles and other lumbopelvic stabilising muscles. Exercise management aims to strengthen the gluteal muscles and manage load around the hip joint to reduce pain and restore function.

Ankle and foot

Achilles Tendinopathy

Achilles Tendinopathy is a common overuse injury of the Achilles tendon causing pain, discomfort and/or inflammation about your tendon and heel.

Achilles Tendinopathy occurs when there has been a spike in the amount of exercise or physical activity you are doing. This tends to occur after a layoff and sudden return to exercise, such as in middle-aged people, or in physically active people who have suddenly upped the ante in their exercise routine. It occurs in sports/exercise with repetitive jumping or running, overusing the tissues leading to inflammation and pain.It can also occur due to:

  • Change in training surface
  • Lack of training variation
  • Incorrect footwear
  • Excessive intensity or distance increase

Symptoms of Achilles Tendinopathy include:

– Pain or swelling on the bottom portion of your Achilles into your heel
– Pain with walking, running, jumping or steps
– Stiffness/soreness when straightening and bending your ankle
– Pain worse at night and/or first thing in the morning

Symptoms can be acute or have a delayed onset, ranging from mild discomfort to severe pain and avoidance of function, lasting for years if not treated correctly.

Achilles Tendinopathy Treatment
Practical treatments of Achilles Tendinopathy include range of motion and strengthening protocols for the ankle, calf and leg muscles. Current research indicates that progressive, incremental strengthening regimes are an effective treatment tool for increasing pain free function, enabling a return to your job, sport or recreation activities. You should be able to make a return to these within 2-4 weeks depending on the severity. You will then be able to perform at your fullest with time over the next few months or so. However, your pain may continue for a while then though you are able to function at a much higher level than before.

The addition of manual therapy has also shown to assist with pain relief to help you return to the painful tasks quicker.

If the condition is not conservatively managed early, alternative treatment modalities can be used with severe cases such as steroidal injections and autologous blood injections but current research states this should be avoided for at least 12 weeks.

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