The never-ending continued propagating myth that perfect alignment is necessary is entirely wrong. Some of the more common types of hocus pocus that you’ll find on the internet and through google searches claim the ability to speculate that a majority of your joint pain and pathology is due to misalignment of the body. They state: for you to resolve your pain and pathology, you must be perfectly aligned. Otherwise, this will cause long term pain and issues as you get older. Some of the common myths that “cause your pain” include:
Your shoulders sit unevenly.
“Overpronation of the foot”, which causes knee collapse (valgus), which eventually leads to shoulder and neck pain
Leaning, slouching, favouring one side is the root of all your pain and dysfunction in your lower back and hips.
But one of my lungs is smaller than the other…
Unfortunately for the pundits, basic human anatomy already suggests that we are “out of alignment.” The anatomy of our body is already sufficient evidence to suggest that we can live and be alive without “perfect” and proper alignment. For example:
The left lung is smaller than the right due to the placement of the heart, which:
Is placed slightly to the left in an area named the cardiac notch
One interesting way that we can further elaborate on the complexity of the human body and the “asymmetries” that are present throughout is subdividing the ‘abdominopelvic cavity’ (basically the space from the abdomen/bottom of the sternum to the bottom of your pelvis). The subdivisions are named the right upper quadrant (RUQ), left upper quadrant (LUQ), right lower quadrant (RLQ) and left lower quadrant (LLQ) (Marieb & Hoehn, 2019).
RUQ: Right portion of the liver, gallbladder, right kidney, the smaller part of your stomach
LUQ: The left portion of your liver, larger portion of the stomach, the pancreas, spleen and left kidney
RLQ: Appendix, part of the small intestines, the cecum, right ureter
LLQ: Majority of the small intestine, some of the large intestine, left ureter
(LibreTexts, 2020)
As you can see, the contents of each quadrant of the body are different. There isn’t an identical distribution and allocation of organs that perfectly balances and aligns the body. Around us, there are even more common sense examples of imperfect alignment being completely healthy, including:
Being right-handed or left-handed
Driving a car (especially a manual car)
Which hand we hold our coffee in
Getting out of your bed or sleeping on one particular side of your bed
Unbelievable, “imperfect” and amazing athletes
Adam Meakins is currently (as of 24/08/20) making a fantastic series on Instagram (@adammeakins) called: Amazing Asymmetries. The concept of the Instagram posts outlines individuals who are asymmetrical due to:
Limb deficiencies
Genetic variations
Spinal scoliosis
This is a fantastic representation of how those with predefined “imbalances” and “asymmetries” can perform at the very highest levels of their sport. Even without these imbalances, there are various examples of one-sided or one-handed sports. One of the most notable and evident is tennis. Some of the most famous tennis athletes including Rafael Nadal, Novak Djokovic and Roger Federer don’t switch hands when they play tennis to “optimise” their symmetry and are still able to dominate at their sport.
Not much… Trying to “optimise” and create perfect alignment is an imperfect practise and shouldn’t be pursued. Unfortunately, there are still many clinicians that strive by this mantra and will ask you to see them over and over again because they feel the need to achieve this impossible standard.
Instead, clinicians should be focusing on the root of your problem/issue and identifying the direct and clear reasons to why you may be suffering pain and pathology. Often, we may be directed to look away from just the pain and pathology site, as various factors can affect pain, including:
Stress (e.g. looking after three young children, or approaching deadline for work)
Sleep (e.g. less than 8 – 10 hours of sleep)
Other health concerns (e.g. heart health, liver health, kidney health)
Negative beliefs (i.e. Doctor told you you needed surgery, injections or multiple scans)
Go live your life without worrying that your left foot drifts slightly more than your right. Lift your kids into the air without worrying about that left arm that rotates internally marginally more than the other. Go and squat down to reach for something in the bottom drawer and disregarding the 2 degrees of scoliosis you have in your lower back.
Worrying about unnecessary and over-detailed analysis of every fault in your body is exceptionally detrimental, unhealthy and completely unnecessary. If your health practitioner directs you to do this and suggests that you come in every few weeks or months for a tune-up… Then a consultation with a new practitioner might be recommended.
References:
Marieb, E. N., & Hoehn, K. (2019). Human anatomy & physiology (Eleventh edition.). Pearson Education, Inc.
LibreTexts, 2020. 1.4F: Abdominopelvic Regions. [online] Medicine LibreTexts. Available at: <https://med.libretexts.org/Bookshelves/Anatomy_and_Physiology/Book%3A_Anatomy_and_Physiology_(Boundless)/1%3A_Introduction_to_Anatomy_and_Physiology/1.4%3A_Mapping_the_Body/1.4F%3A_Abdominopelvic_Regions> [Accessed 16 August 2020].
I recently had a patient who had come in for a consultation with minimal knee pain. When he came to me, he was worried, distressed and anxious.
Why?
Because his doctor had told him that he might need a total knee replacement, as the cracking in his knees “…didn’t sound good”. However, this is an absurd notion, and this blog post is here to help you understand why. Fortunately, knee cracking, popping and snapping sounds in the knee are a common and completely normal process in the knees.
Physiological vs pathological sounds
The vital differentiation in knee sounds is the presence of ‘painful sounds’ versus ‘non-painful sounds’. In more formal terms, physiological (normal knee sounds) versus pathological knee noises (Song et al., 2018). In most cases, many individuals have normal physiological knee noises, which are associated with:
No worsening of sounds or increased symptoms (such as loss of ROM, increases in pain, decreases in functional ability)
No association with a history of injury
Sporadic or inconsistent noise characteristics (e.g. Usually the most common way to describe this is: “It sometimes cracks, but other times doesn’t.”)
Pathological noise is often associated with symptoms such as:
Swelling and effusion in and around the joint
On injury, a loud “POP” sound with pain was noticed
Consistent cracking with careful examination
A proper assessment and diagnosis will need to be completed by your physiotherapist to create an accurate diagnosis of your knee pain. In this situation, a trip to the doctor is not always necessary, as physiotherapists can assess and diagnose your knee pain and other surrounding tissues.
What EXACTLY causes noises in the knees?
Physiological Knee Noise
The exact origin of normal, physiological knee noises is variable. Some proposed mechanisms include:
Buildup or bursting of tiny bubbles in the synovial fluid
Ligaments and tendons may stretch as over a small bony lump and then snap back into place – causing the clicking sound
Catching of the synovium or physiological plica
Hypermobile meniscus
Discoid meniscus
After surgery
(Song et al., 2018)
The buildup of cavitation bubbles in the synovial fluid of the knee joint is the commonly circulated explanation for knee joint noises. The sudden collapse of the bubble during regular joint movements can create the “popping” sound. The nature of this sound is sporadic due to the air buildup, which means that immediately after cracking your knee, it’s often hard to reproduce the same sounds again.
Pathological Knee Noise
There are many causes of pathological noise, which include degenerative changes (i.e. osteoarthritis), pathological plica, patellofemoral instability, pathological snapping knee syndrome and post-surgical crepitus (Song et al., 2018).
The Osteoarthritic Knee
The general characteristics of osteoarthritis may cause crepitus in the knee secondary to osteoarthritis—namely, gradual loss of cartilage, development of bony spurs and cysts. Crepitus in the knee can be synonymous with symptoms of patellofemoral osteoarthritis.
It comes at no surprise that greater severity of knee osteoarthritis is highly correlated with more significant pain levels and decreased functional abilities (Neogi et al., 2009; Sowers et al., 2011). Those with the highest pain had a higher likelihood and severity of pathological abnormalities such as:
Full thickness cartilage defects
Synovitis
Complex or mascerated meniscus tears
Large osteophytes
(Neogi et al., 2009; Sowers et al., 2011)
However, exercise can slow the progression and development of knee osteoarthritis (Bosomworth, 2009). In some cases, there is an associated improvement in pain and function in those who perform regular moderate exercise compared to those who engage in sedentary lifestyles (Bosomworth, 2009).
So what is the management of knee noises and/or osteoarthritis?
Managing ‘noisy knees’ really does depend on the underlying reason and the presence of physiological knee noise vs pathological knee noise. Like many other joints or spine-related pathology/pain, the most significant factor for knee noise may be the psychological factors associated with the sound or feeling. For those who don’t understand the fundamental reasoning behind knee noise, they may have anxious and negative thoughts, which can lead to decreased self-confidence, avoidance of movement/exercise and just general heightened sensitivity to any stimulus around the knee. Unfortunately, many times this may be compounded by your surrounding family and friends (unintentionally) when they make comments such as:
Those knees make you sound 20 years older
You have old people’s knees
Your knees sound arthritic
That doesn’t sound good for your knees
It is important to remember that knee noise isn’t something we need to worry about unless there are painful or functional changes to your knee. However, you should attend an appointment with your local physiotherapist if you have ongoing concerns.
Knee noises are scary if you don’t know what causes them. Most noise in your knee is generally non-painful physiological noises, which are naturally occurring sounds that happen in almost every person’s knees. If you have ongoing pain or functional limitations associated with the noise, then the recommendation would be to seek out your local health practitioner to get it checked.
In the meantime, it’s important to keep moving and keep exercising as you can! As this has the best chance of delaying chronic conditions like osteoarthritis of the knees.
Do you have noises in your knee?
References
Bosomworth N. J. (2009). Exercise and knee osteoarthritis: benefit or hazard?. Canadian family physician Medecin de famille canadien, 55(9), 871–878.
Neogi, T., Felson, D., Niu, J., Nevitt, M., Lewis, C. E., Aliabadi, P., Sack, B., Torner, J., Bradley, L., & Zhang, Y. (2009). Association between radiographic features of knee osteoarthritis and pain: results from two cohort studies. BMJ (Clinical research ed.), 339, b2844. https://doi.org/10.1136/bmj.b2844
Song, S. J., Park, C. H., Liang, H., & Kim, S. J. (2018). Noise around the knee. Clinics in Orthopedic Surgery, 10, 1 – 8.
Sowers, M., Karvonen-Gutierrez, C. A., Jacobson, J. A., Jiang, Y., & Yosef, M. (2011). Associations of anatomical measures from MRI with radiographically defined knee osteoarthritis score, pain, and physical functioning. The Journal of bone and joint surgery. American volume, 93(3), 241–251. https://doi.org/10.2106/JBJS.I.00667
Knee pain is annoying, and can often impact almost everything in your daily life. Whether that be walking to and from work, squatting down to get or getting in and out of your car. Unfortunately, there isn’t a band-aid solution that can solve your particular knee pain. Knee pain is multifaceted and requires a proper diagnosis of what particular structure might be causing the discomfort or pain.
However, for a specific type of knee pain – or even for any knee pain – taping can be an effective way to get some quick pain relief and help you get through your day. The purpose of this post is an informative guide on a specific taping technique called: “Modified McConnell Taping“. This is not encouraging the use of knee taping without proper rehabilitation advice from your healthcare professional.
Before We Begin: Contact Dermatitis
Before application of tape, you must test if you are allergic or have a reaction to the tape itself. Some individuals may have a reaction to certain components of the tape which may results in symptoms such as:
Redness
Itchiness
Swelling
Tender to touch
Occasionally, specific brands of tape can cause allergic reactions, so you may have to ask your pharmacist on recommendations and to trial different types. This usually involves getting a small piece of tape placed on your hand or wrist, then seeing if there’s a reaction.
Diagnosis of knee pain
The diagnosis of knee pain is quite difficult as there are a multitude of structures that surround the knee. The particular structure this taping works well for is something colloquially coined: “Fat pad impingement“. Unfortunately, with the huge amount of variability within the physiotherapy profession, there is a large amount of variation behind the diagnosis and treatment behind this specific pathology.
The following signs and symptoms may indicate you have “fat pad impingement”. However, many of these symptoms are all common knee pain symptoms for any pathology.
Knee pain signs and symptoms:
Pain directly under the knee cap
Generally achy but sometimes sharp depending on movements
Sometimes may radiate to the sides of the knee cap
Pain with putting weight in a bent position (e.g. up and down stairs, lunging / squatting)
Usually settles with rest and not moving it
Returns after resuming activities, especially high impact exercise such as running or jumping
I must reiterate. Each of these symptoms individually will not mean anything, but collectively when combined with physical tests from a physiotherapist may reveal evidence of “fat pad impingement.”
The Taping Technique
After taping
General guidelines after the application of tape are:
Check for any adverse reactions, such as those mentioned in the Before We Begin: Contact Dermatitis section.
Tape can be kept on for 3 – 5 days, so long as you haven’t been sweating excessively
Tape can get wet, and just needs to be pat dried after showering
If the tape begins to come off, it is recommended to reapply as opposed to trying to fix it
Removing the tape: Roll the tape, do not rip the tape off. This can help with reducing skin irritation after taking off tape. (Hint: Don’t just rip it like a band-aid).
Final Words
Let’s get one thing straight… Taping of the knee is not a long-lasting solution and will not be useful in the prevention of further knee pain. If the underlying reason behind the knee pain is not resolved, then recurrence of knee pain is common. However, this knee taping technique can still be useful in providing some pain relief with general knee pain.
A recommendation would be to follow this knee pain guideline as well as trial the application of this taping technique.
To summarise the knee pain guideline, knee pain can be improved by:
Short-term pain relief strategies, such as massaging, myofascial release and trigger point therapy
Passive stretches
Education on pain management and understanding the pain cycle
Long-term management through a structured exercise programme
Have you ever had the weird sensation where your neck pain seemed to cause headaches, but was unable to describe why?
It is theorised that the pathophysiology of cervicogenic headaches involves a specific structure in the neck called the “cervicotrigeminal nucleus.” Essentially, the sensory input from this region coincides with both the head and neck, and the brain can sometimes confuse this input and interpret neck pain as headaches. However, neck pain of any type has been suggested to cause headaches regardless of location, so the exact reason is still unknown.
Cervicogenic Headaches
As with many other pathologies, there are different types of headaches. The one we will focus on today is “cervicogenic headaches” and neck pain. There are unique symptoms that arise with cervicogenic headaches, including:
Headache originates from muscular, articular, osseous (bony), neurologic (nerve) or vascular (artery / veins) structures of the neck
Neck pain should trigger or precede the headache
Travels from the occipital area (see figure below) and spreads towards the front of the face
Cervicogenic Headache Pattern
It is usually unilateral (one-sided)
Aggravated or worsened by neck movement
May have some associated restricted range of motion in the neck or shoulder
Potentially associated shoulder or arm pain
Headaches can also cause:
Nausea
Photophobia (Light sensitivity)
Phonophobia (Sound sensitivity)
(Gallagher, 2007)
In future posts, we will touch more on the different types of headaches and how each of them can affect you!
Treating the neck pain / headaches
Treatment of the neck can help with headaches and decrease the frequency and severity of symptoms of headache. This includes common treatment procedures such as massage, strengthening of associated muscles and stretching of involved muscles (Gallagher, 2007).
The combination of manual therapy (e.g. massage, trigger point release etc.) and exercise has proven an effective treatment for neck pain compared to many other alternative treatment types (Miller et al., 2010). The combination of these treatments is important, as mobilisation and manipulation only provides short-term relief. Exercise appears to have the added benefit of improving pain and function over long term (Miller et al., 2010). Therefore, the combination of both treatments can combine pain reduction with long-term changes (Miller et al., 2010). The exact type of manual therapy and manipulative treatments is still speculative and varies according to individual practitioners. Similarly, exercise therapy requires further research and the exact type of strengthening is difficult to determine.
Learning new behaviours associated with common tasks, such as sitting down and looking down to read a book or read your phone for long periods of time can also assist with treating your neck pain. As prolonged postures in a specific posture can increase neck pain frequency, and subsequently induce more headaches (Gallagher, 2007).
So what can we do?
Step 1: Postural Adjustments
Posture… Is really not that important. Now before you explode with utter outrage on the blasphemous nature of this statement, hear me out! There seems to be a lack of high quality evidence on the relationship between posture and pain (Mahmoud et al., 2019; Slater et al., 2019). However, what we do seem to know is that prolonged time in one particular posture is detrimental and can lead to increased pain and discomfort (Mahmoud et al., 2019; Slater et al., 2019).
Instead, what we should be focused on is regular postural adjustments. As discussed in my shoulder pain blog post, small postural adjustments in sitting, especially while doing desk work can provide many benefits to your pain and discomfort.
Step 2: Regular Movement
To reiterate the previous point, prolonged postures or positioning in one specific posture can be detrimental and lead to increased pain and discomfort. Therefore, to counteract this, regular movement is encouraged of the neck and shoulders. One particularly important structure that requires movement is the shoulder blade, and ensuring adequate movement of your shoulder blade during various movements.
A particular muscle is of interest when interpreting the link between neck pain and scapula function. This muscle is called the “Levator Scapulae.” This muscle originates from the transverse processes of C1-4 (your upper cervical spine), and attaches to the superior-medial border (top-middle) of the shoulder blade. Its role in shoulder function is the elevation and downward rotation of the shoulder blade.
The Levator Scapulae Muscle
Without getting too in depth in this post, the reason why this muscle and shoulder blade is important is that many individuals can get neck pain and tightness within this muscle. Which can subsequently lead to headaches to the neck pain nature. Fortunately, the fix for this is generally very simple, and only requires more awareness of the shoulder and shoulder blade region. Simple exercises that can fix this issue include:
Neck rolls
Ear to shoulder
Shoulder roll
Overhead arms stretch
There are not any specific repetition or set ranges for these exercises. Instead, they should just be performed when you remember or feel like you need some movement in your shoulders and neck!
Step 3: Strengthening of upper body and neck
General strengthening exercises of the upper body are extremely beneficial and important in treating neck and shoulder pain. However, what needs to be focused on in these situations is the positioning and the movement of the shoulder blades. This will be further explored within a gym setting in a future blog post.
For now, the general recommendations will be to be aware of shoulder positioning and scapula position during movements. Essentially, the scapula should have freedom of movement when performing any exercise, rather than being stuck onto the ribcage wall.
Conclusions
Neck pain can be the cause of a very specific type of headache called “cervicogenic headaches.” However, despite the complex sounding name, the treatment and prevention of further headaches is quite simple and can be resolved with proper diagnosis and treatment strategies. This includes strategies such as postural adjustments, continuous movement and upper body strengthening practices.
Do you think your neck pain is causing your headache?
References
Gallagher, R. M. (2007). Cervicogenic Headache. Expert Review of Neurotherapeutics, 7(10), 1279 – 1283.
Mahmoud, N. F., Hassan, K. A., Abdelmajeed, S. F., Moustafa, I. M., & Silva, A. G. (2019). The relationship between forward head posture and neck pain: A systematic review and meta-analysis. Musculoskeletal Medicine, 12, 562 – 577.
Miller, J., Gross, A., D’Sylva, J., Burnie, S. J., Goldsmith, C. H., Graham, N., Haines, T., Brønfort, G., & Hoving, J. L. (2010). Manual therapy and exercise for neck pain: A systematic review. Manual Therapy, 15(4), 334 – 354.
Slater, D., Korakakis, V., O’Sullivan, P., Nolan, D., & O’Sullivan, K. (2019). “Sit up straight”: time to re-evaluate. Journal of Orthopaedic & Sports Physical Therapy, 49(8), 562 – 564
Red flags should be the first point of assessment in any condition. Regardless if it is neck pain, shoulder pain, lower back pain or even foot pain. Red flags are important as they can indicate to the health professional of any serious underlying pathology or anything that would need to be sent to the emergency department for immediate investigations. Across each of the joints, there are some specific red flag signs and symptoms we need to be aware of.
These signs and symptoms should never be interpreted as a direct causation or diagnosis of the conditions that may be associated with them. Instead, a cluster of symptoms are what is commonly used in order to diagnose and correctly identify the condition (Sizer Jr et al., 2007). Therefore, when analysing these red flags, contact with your local doctor is usually the recommended course of action. As in these situations, if an allied health practitioner (e.g. physiotherapist, occupational therapist etc.) identifies any red flags, the usual procedure is to refer onto a doctor for immediate review or referral.
From a clinicians point of view, there are several factors that we need to be aware of (Sizer Jr et al., 2007):
Patient history
Physical changes (e.g. changes in bowel and bladder function, blood in sputum, bilateral or unilateral radiculopathy pain)
Unresponsive to conservative treatment
Report of present fluctuations in signs and symptoms. Presence of serious pathology is indicated by:
Pain that is worse during rest vs activity
Worsened at night or not relieved in any position
Poor response to conservative care including a lack of pain relief with prescribed bed rest
Poor success with comparable treatment
Physical examination and laboratory findings
E.g. Abnormal reflexes, gait (movement) changes, strength disturbances / differences, changes to sensation (i.e. numbness, tingling)
The Three Category System
A three categorical classification system has been developed and proposed by Sizer Jr et al. (2007). In this paper Medical Screening for Red Flags in the Diagnosis and Management of Musculoskeletal Spine Pain, he outlines this three step categorical system for each part of the spine. Namely, the cervical, thoracic and lumbar.
The classification system that he uses is as follows:
Category 1: Factors that require immediate medical attention
Category 2: Factors that require subjective questioning and precautionary examination and treatment procedures
Category 3: Factors that require further physical testing and differentiation analysis
Category 1
Category 2
Category 3
Blood in sputum Loss of consciousness or altered mental status Neurological deficit not explained by monoradiculopathy Numbness or paresthesia in the perianal region Pathological changes in bowel and bladder Patterns of symptoms not compatible with mechanical pain (on physical examination) Progressive neurological deficit Pulsatile abdominal mass
Age >50 Clonus Fever Elevated sedimentation rate Gait deficits History of a disorder with predilection for infection or hemorrhage History of a metabolic bone disorder History of cancer Impairment precipitated by recent trauma Long-term corticosteroid use Long-term worker’s compensation Nonhealing sores or wounds Recent history of unexplained weight loss Writhing pain
Abnormal reflexes Bilateral or unilateral radiculopathy or paresthesia Unexplained referral pain Unexplained significant upper or lower limb weakness
Sizer Jr et al. (2007)
Cervical Region
Category 1 Findings:
These examinations are usually performed as a result of a trip to the emergency department as a result of motor vehicle accident or fall. Major injuries to this area include fracture or dislocation.
National Emergency X-Radiography Utilisation Group (NEXUS)
These two decision-making criteria can be used as a screening device to rule out the need for radiography of the cervical spine.
Category 2 Findings:
Mechanical conditions of the cervical spine that require special attention in category 2 are upper cervical instability (atlantoaxial laxity) and vertebrobasilar insufficiency (VBI).
Atlantoaxial laxity
Suspicion of ligament laxity in the upper cervical spine may be tested through two specific physiotherapy ligament tests – The Sharp Purser test and TLA laxity test. Further radiographic evaluation must be undertaken to confirm any upper cervical instability.
Vertebrobasilar insufficiency (VBI)
VBI circulation is important as it can lead to transient ischemic attacks and cerebrovascular accidents. However, difficulties arise as the signs and symptoms of VBI overlap with more common diagnosis, especially vertigo. The red flags that are relevant to this diagnosis are:
Visual disturbances (diplopia) – Blurry or double vision
Auditory phenomena (sudden sensorineural hearing loss) – Hearing loss
Facial numbness or paresthesias – Numbness, tingling or pins and needles especially around the lips or tongue
Dysphagia – Difficulty swallowing
Dysarthria – Difficulty speaking
Syncope (drop attacks) – Sudden syncope episodes
Category 3 Findings:
Finally, the cervical spine should be screened for radiculopathies (pinched nerves) and myelopathies (compression of the spinal cord).
Radiculopathy can be screened through inspection for muscle atrophy (wastage / loss of muscle), sensory changes (numbness, tingling, pins and needles), tendon reflex testing and a positive Spurlings test.
Cervical spine myelopathies can include symptoms such as: loss of dexterity (e.g. difficulty writing or handling small objects), nonspecific weakness (e.g. unable to grip) and abnormal sensations. Lower cervical myelopathies can also include weakness and stiffness in the legs, as well as changes to their walking. The most common cause for myelopathies is a traumatic injury or incident, usually from a stabbing / gunshot wounds, motor vehicle accident or falls.
Thoracic Spine
Category 1 Findings:
There are numerous category 1 red flags that can be found within the thoracic region. Primarily because the same signals that arise from the organs often coincides with a selected region of the musculoskeletal system. Essentially what this means is that the pain felt in a muscle, bone or general upper back area can be caused by pathology involving the organs.
A common example of this relates to acute myocardial infarction (i.e. heart attack). Pain can often be felt in the left pectoral region (i.e. around the left nipple of the chest) and the upper arms or sternum. This is often associated with pallor (pale color of skin), sweating and nausea.
Tumours, metastatic disease, metabolic diseases and fractures can also create pain signals around the area. These conditions can often be marked by severe thoracic pain, decreased range of movement of the thoracic region and potential intercostal neuralgia (i.e. stabbing, burning pain between the ribs).
Category 2 Findings:
Of particular concerns are osteoporotic changes to the thoracic vertebrae, which can lead to severe changes of postural deviations, vertebral fractures or spinal cord injury. A red flags can be evaluated to identify the potential likelihood, including:
Age over 50
Long-term corticosteroid use
Presence of menopause
Category 3 Findings:
As discussed previously, category symptoms require further physical testing and differential analysis. Within the category 3 classification for thoracic level related pathology, many of these symptoms must be clustered together to provide any meaningful reasoning. These symptoms include:
Referral pain to the front and side of the rib cage
Parathesia or dysthesia (e.g. numbness, tingling, pins and needles, abnormal changes to touch and feeling)
Sensory loss (e.g. absence of feeling)
Bowel and bladder changes
Hyper-reflexia (associated with reflex testing)
Coordination loss
Lumbar Spine
Lower back pain is extremely common and these red flags are important, as they can indicate more serious diagnosis such as: malignancy, spinal fracture, infection or cauda equina syndrome (Downie et al., 2013).
Category 1 Findings:
The category 1 symptoms as mentioned in Table 1 outline many of the symptoms that are evaluated in lumbar spine pain for red flags, particularly of which include:
Numbness or paresthesia in the perianal region
Pathological changes in bowel and bladder
Patterns of symptoms not compatible with mechanical pain (on physical examination)
Progressive neurological deficit
Category 2 Findings:
Similar to the thoracic spine, lumbar vertebrae are also at risk of compression fractures. The risk factors relative to the lumbar spine remain the same as the thoracic region. Infections can also arise in the lumbosacral region, which produce symptoms such as:
Fever
Malaise
Potential bowel and bladder symptoms
Severe lower back pain
History of drug use
Prior spinal implementation or surgery
Severe lower back pain radiating into both buttock and thighs
Category 3 Findings:
Lower back pathology can sometimes be associated with altered or changes in sensory, motor and reflexes. These can be tested through physiotherapy sensation tests, muscle tests and reflex testing. Two common tests we also use to assess nerve involvement is the straight leg raise test or slump sitting test.
Other serious pathology
Signs and symptoms unrelated to the spine can also manifest in other serious conditions. These include infections, malignancy (cancer) or a more serious pathology called ankylosing spondylitis.
Chou et al. (2007) briefly outlines some of the symptoms that are associated with a more severe diagnosis:
Cancer:
History of cancer
Unexplained weight loss
Failure to improve after 1 month
Age >50 years old
Infection:
Fever
Previous drug use
Recent infection
Ankylosing Spondylitis
Younger age
Morning stiffness
Improvements with exercise
Alternating buttock pain
Awakening due to back pain during the second part of the night only
Conclusions
As you can probably tell, there is a lot of overlap between symptoms for each region as well as other pathologies. Many of the findings in category 3 also present in category 1. Which is why a cluster of testing is required in order to rule in or out any certain pathologies.
The world of diagnosis through the use of signs and symptoms is still evolving, and there is certainty more ongoing research require to create established clinical guidelines for clinicians (Chou et al., 2007; Downie et al., 2013; Verhagen et al., 2016).
So if you do have any of these red flags, the important thing to remember is to take a deep breath, relax and go seek a professional opinion from a healthcare professional. Ideally in these situations, a doctor would be first point of call, as they can directly refer or treat many underlying pathologies not related to the musculoskeletal system.
References
Chou, R., Qaseem, A., Snow, V., Casey, D., Cross, J. T., Jr, Shekelle, P., Owens, D. K., Clinical Efficacy Assessment Subcommittee of the American College of Physicians, American College of Physicians, & American Pain Society Low Back Pain Guidelines Panel (2007). Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Annals of internal medicine, 147(7), 478–491.
Downie, A., Williams, C. M., Henschke, N., Hancock, M. J., Ostelo, R. W., de Vet, H. C., Macaskill, P., Irwig, L., van Tulder, M. W., Koes, B. W., & Maher, C. G. (2013). Red flags to screen for malignancy and fracture in patients with low back pain: systematic review. BMJ (Clinical research ed.), 347, f7095. https://doi.org/10.1136/bmj.f7095
Sizer Jr, P. S., Brismée, J., & Cook, C. (2007). Medical screening for red flags in the diagnosis and management of musculoskeletal spine pain. Pain Practice, 7(1), 53 – 71.
Verhagen, A. P., Downie, A., Maher, C., & Koes, B. W. (2016). Red flags presented in current low back pain guidelines: a review. European Spine Journal, 25, 2788 – 2802
Tennis elbow, otherwise known by its anatomical name – lateral epicondylitis (or epicondylalgia) – is a condition that affects the elbow joint. It is typically categorised as what we call an overuse injury and primarily involves the tendons that attach into the common extensor origin (Tosti et al., 2013). Namely, the muscles of the forearms that help extend the wrist.
Extensor (E.) Carpi radialis longus E. Carpi radialis brevis E. Digitorum communis E. Digiti minimi E. Carpi ulnaris
The wrist extensor muscles
Initially lateral epicondylitis was thought to be an inflammatory condition. However, the current consensus explains the process of “microtrauma” as the primary cause (Tosti et al., 2013). Despite the name “tennis elbow” denoting its sole cause from tennis, many individuals can develop tennis elbow through everyday activities and work.
The specific signs and symptoms for tennis elbow are quite easy to spot, and many individuals will have similar presentations for their tennis elbow. However, the difference generally lies within the length of time, the intensity and the demands of their work.
The Signs and Symptoms of Tennis Elbow
The signs of symptoms of tennis elbow can be different according to an individual’s specific circumstances. However, they do follow a general pattern (Tosti et al., 2013):
Pain over the origin of the common extensor tendon
Pain on touch on the outside of the elbow
Slow and insidious onset, and may coincide with recent increases in work or sport
Discomfort with hand shaking, shaving, lifting luggage or groceries or raising a coffee mug.
Weakness or pain with gripping and lifting objects
Other less common signs include jobs that require holding machinery that have a high amount of vibrations (e.g. using a jackhammer or chainsaw) or require constant opening and closing of hands (e.g. hairdresser).
Treatment: The Operative Route
Tennis elbow can be managed in various ways. The two primary categories of treatment are divided into operative and nonoperative management. Operative management options include:
Percutaneous release
Arthroscopic release
Open release
In most cases, operative management is not required. However, there may be some cases of chronic pain, loss of range of motion, or failed conservative management that may necessitate a release of the common extensor tendon (Nazar et al., 2012; https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3322435/).
Treatment: The Non-Operative Route
In terms of nonoperative management, we must consider the efficacy and evidence of treatment modalities. There are a plethora of treatment options that exist, which can be categorised as:
Physical therapy and activity modification (e.g. manipulations and mobilisations, exercise training regimes or braces)
Non-steroidal anti-inflammatory drugs
Injections (e.g. corticosteroid injection, botulinum toxin – otherwise known as botox, platelet-rich plasma)
This list is by no means exhaustives, and many more recent methods have popped up including friction massage or using different types of elbow splints. However, these treatment methods generally have insufficient scientific evidence to back and support the claims against traditional treatments.
So what does the evidence say?
The evidence for lateral epicondylitis generally trends towards exercise as a primary treatment modality. There seems to be some evidence that other treatment modalities may be effective as an adjunct to exercise or as a stand-alone treatment method. As a summary, treatment options can be bulleted as such:
Exercise for lateral epicondylitis is an effective treatment modality (Cullinane et al., 2013; Dingemanse et al., 2014).
Exercise may provide greater effect for tennis elbow when compared to electrotherapy and placebo (dummy) treatments (Dingemanse et al., 2014).
There may be some short term benefits with regards to ultrasound and corticosteroids, but no differences in long-term outcome (Dingemanse et al., 2014.
Currently, there is a need for further research in the optimal use of biologic injectables, particularly with regards to timing, concentration and dosage (Tosti et al., 2013).
While these treatment methods may be beneficial for your tennis elbow, they require repeat visits and consultations with your physiotherapist. Unfortunately, this costs time and money that some individuals may not have… so what can we do instead?
Finally, the 3 steps to pain-free Tennis Elbow
Like many of my posts on shoulder, knee and lower back pain, the treatment of tennis elbow can be completed in a few easy steps.
Massage and relaxation of the extensor muscles of the elbow
Massaging your sore forearm muscles are a fantastic say of generating some short term pain relief, and there are a few guidelines we must follow when doing so:
Do not massage directly over the tendon and sore spot. Direct massage over the sore tendon can irritate the already sore tendon, and increase the amount of time needed for recovery.
Avoid stretching the sore muscles. Although stretching the affected sore muscles may feel good, but can cause stress and irritation of the tendon. Which, again, can increase the amount of time needed for recovery.
Massage of the forearm muscles can be done by hand, massage ball or foam roller
Strengthening of the forearm muscles
Isometric strengthening of the wrist extensors is extremely important. Stability of the wrist is often found to be lacking in the affected side of the person’s upper limbs. Some easy exercises include:
Isometric wrist extension – different ROM
General isometric grip strength work
Wrist position during everyday life
Excessive ulna deviation or pronation during lifting activities can irritate your extensor tendons. Being mindful of wrist positions even during working activities and lifting everyday objects is important,such as lifting a full and heavy kettle.
Wrist position is often overlooked when treatment of tennis elbow. Particularly when performing activities in the gym, wrist position is extremely important and we must be mindful of it when performing various activities. A few particular examples include:
Wrist position during horizontal pushing movements and vertical pushing movements – avoiding excessive radial or ulnar deviation of the wrist.
Wrist position during heavy dumbbell holds e.g. farmer carry – We want to ensure a neutral wrist position when we are carrying the weight. As we fatigue, the wrists will naturally drop, which is normal. However, we want to try to actively maintain a neutral wrist position for as long as possible.
Now that’s not to say that lifting heavy loads should be avoided entirely, but through strengthening and awareness of wrist positions we should be able to build tolerance of the extensor muscles and the wrist itself to be able to tolerate heavier loads.
Conclusion
Tennis elbow is a common condition that affects many people and often has its origins outside of playing tennis. Unfortunately, the current research on how to treat tennis elbow can lead into a rabbit hole of complex equipment or requiring a in-person physiotherapy consultation. However, as this isn’t financially viable for many people, this post highlights some easy ways to resolve your tennis elbow at home!
References
Cullinane, F. L., Boocock, M. G., & Trevelyan, F. C. (2013). Is eccentric exercise an effective treatment for lateral epicondylitis? A systematic review. Clin Rehabil, 28(1), 3 – 19.
Dingemanse, R., Randsdorp, M., Koes, B. W., & Huisstede, B. M. A. (2014). Evidence for the effectiveness of electrophysical modalities for treatment of medial and lateral epicondylitis: A systematic review. British Journal of Sports Medicine, 48(12), 957.
Nazar, M. A., Lipscombe, S., Morapudi, S., Tuvo, G., Kebrle, R., Marlow, W., & Waseem, M. (2012). Percutaneous Tennis Elbow Release Under Local Anaesthesia. Open Orthop J, 6, 129 – 132.
Tosti, R., Jennings, J., & Sewards, M. (2013). Lateral Epicondylitis of the Elbow. The American Journal of Medicine, 126(4), 357.e1 – 357e6
Lower back pain… It’s an emotional rollercoaster. For some of us, it is a constant battle to encourage ourselves that our lower back pain will get better and facing the harsh reality of the actual pain. This is a common issue, and research indicates that up to 4 in 5 people will experience lower back pain during their lifetime (Rubin, 2007). That statistic is staggering, and highlights the need for good information regarding lower back pain.
Lower back pain can occur from sport, lifting something too heavy or even during random occurrences that happen bending over to do something trivial. What does happen following the onset of lower back pain can be a flood of emotion, anxiety, worry and anger. Then, the sudden flurry of how did I do this, what should I do, how can I prevent lower back pain from happening to me, why me…?
The Golden Rule
Our number one rule for dealing with any back pain is:
Do Not Worry.
Lower back pain happens, and is a natural occurring part of life. Do not get hyper focused on the cause and the pathology of your lower back pain. Even experienced health practitioners are unable to diagnose you and deduce the exact anatomical reasons for your lower back pain. Investigations may be warranted in SOME situations, but are rarely necessary. What we want to make sure is we:
Take a deep breath
Calmly analyse the situations and rule out red flags
Plan and formulate a structured program for long-term pain management and prevention
Keep calm and keep moving!
Often following onset of lower back pain, our muscles will seize up. We will stress and worry about whether the next move we make will hurt our back. Good thing is, any movement you do is unlikely to cause any harm to your lower back (provided you don’t have any red flags). Instead, all kinds of movement is much more beneficial and can have fantastic effects on your pain and functional movement.
The One Big Myth
However, there is one myth in particular that can be damaging to your recovery and refuses to die. That is:
You must keep your back straight when you lift.
But in today’s world of modern science and medicine, is this actually relevant? Will you break your back if you lift from the ground with a bent back?
First things first… Slipped discs and broken backs are terms of the old. There’s now more than enough evidence to suggest that even with a “broken back” you could also have very little pain or issues. Even the MRI results that you receive is usually insignificant in establishing the link to your lower back pain. Instead, we should be focusing on aspects of your life including your physical activity levels, psychological barriers or even variables such as home or work stress.
What does the research say?
There is a large plethora of research to support the notion that lower back pain is not increased when bending your lower back while lifting (Nolan et al., 2018; Saraceni et al., 2020; Swain et al., 2020) . With no consistency of evidence that support the belief that lifting with a straight back is safer, why is it recommended?
In fact, the implementation of lifting advice in health care HAS NOT resulted in reduced lower back pain in occupational environments.
Well it seems that for many health professionals, previous experience and negative beliefs of lower back pains drives these recommendations (Nolan et al., 2018). Fortunately, with the advent of new research healthcare practitioners are steadily becoming informed. So why is this important?
Negative Beliefs and Lower Back Pain
Well, your lower back pain can improve by reducing the amount of factors that we need to worry about. Particularly, when considering the link between the severity of lower back pain AND negative beliefs (Urquhart et al., 2008). In a study of 506 participants, it was found that negative beliefs were associated with high pain intensity of those with lower back pain (Urquhart et al., 2008).
Through the use of a negative beliefs questionnaire, they were able to establish which individuals had poor perceptions of their lower back pain. An example of a negative beliefs questionnaire is the Fear Avoidance Belief Questionnaire (FABQ). Which includes questions such as:
I should not do physical activities which (might) make my pain worse
My work makes or would make my pain worse
I do no think that I will be back to my normal work within 3 months
What should we be worrying about?
There is emerging evidence that loading of the lumbar spine may be a risk factor for the risk and persistence of lower back pain (Saraceni et al., 2020). Essentially what this means is:
Heavier objects to lift = more stress on lower back
The natural response for most people would be to avoid lifting heavy objects. However, what do you do when lifting heavy objects is your job? In these situations, avoiding lifting is impossible and another solution is required. A simple principle can be applied when identifying these issues, and is one primarily built on the principle of “load tolerance.”
Take these two case studies for example:
Case Study 1
John initially came in complaining of lower back pain during a lifting task of his workplace equipment ~20kg. John started off lifting the bar (20kg) for the deadlift exercise in the gym. Initially he is hesitant, and lifting the 20kg bar was heavy and difficult to complete.
Over the next few weeks, John improves his strength and is able to lift progressively more and more weight. 12 weeks later, John is able to lift 60kg for the deadlift exercise in the gym. Now when John warms up for his session, the 20kg bar is now warmup weight and he does not need to be mentally focused or ready to complete this exercise.
This is because John has built up “load tolerance,” and now has 40kg off leeway from his heaviest attempts to complete his warm-up deadlifts. Now when John goes to work, lifting the 20kg equipment is significantly easier.
Practical Takeaways
Have no fear, because… Unless you have clearly identified red flags that warrant immediate medical attention, your lower back pain will get better. While not having a straight back doesn’t have evidence to support its utility from any normal lifting motions, doing whatever feels comfortable for you and what will let you go through daily life is the most important.
However, we must learn to limit the amount of negative connotations and thoughts we have associated with lower back. As negative mental status can lead to detrimental outcomes in lower back pain.
References
Nolan, D., O’Sullivan, K., Stephenson, J., O’Sullivan, P., & Lucock, Mi. (2018). What do physiotherapists and manual handling advisors consider the safest lifting posture, and do back beliefs influence their choice? Musculoskeletal Science and Practice, 33, 35 – 40.
Rubin, D. (2007). Epidemiology and Risk Factors for Spine Pain. Neurol Clin, 25(2), 353 – 71
Saraceni, N., Kent, P., Ng, L., Campbell, A., Straker, L., & O’Sullivan, P. (2020). To Flex Or Not to Flex? Is There A Relationship Between Lumbar Spine Flexion During Lifting and Low Back Pain? A Systematic Review With Meta-analysis. Journal of Orthopaedic & Sports Physical Therapy, 50(3), 121-130.
Swain, C., Pan, F., Owen, P. J., Schmidt, H., & Belavy, D. L. (2020). No consensus on causality of spine postures or physical exposure and low back pain: A systematic review of systematic reviews. Journal of biomechanics, 102, 109312.
Urquhart, D. M., Bell, R, J., Cicuttini, F. M., Cui, J., Forbes, A., & Davis, S. R. (2008). Negative beliefs about low back pain are associated with high pain intensity and high level disability in community-based women
Many of us roll our ankles throughout our lives. An ankle sprain seem to be a common occurrence in life. Whether that be through playing sport, recreational hobbies like hiking or even just stepping off the sidewalk wrong… It’s a natural and normal part of our lives.
However, one specific ankle sprain requires more attention that most. If it’s managed poorly, it could have profound effects on your livelihood and outcomes in the future.
Case Study: Poor Management of a Ankle Sprain
The history:
A ~30 year old female suffered an ankle sprain after being intoxicated and stepped off the sidewalk poorly.
Initially thought it was a simple ankle sprain – Basic RICE principles (rest, ice, compression and elevation) applied
Doctor review after 2 weeks when it wasn’t getting better.
X-ray was performed that ruled out all fractures
The doctor provided pain medication and told her to rest her ankle.
Physiotherapy consultation at 4 week mark due to worsening ankle pain
The examination:
Ankle felt unstable and had increased laxity on testing
Was unable to pivot on foot due to pain
Decreased ability to put weight on foot and walk
Decreased balance on affected foot
Pain in the middle of ankle on touch
Positive physiotherapy stress tests including: Side-to-side, external rotation and weight bearing lunge test
The treatment:
Immediate referral to a new GP, which created a cascade of events including:
Emergency X-Ray and MRI which revealed a Syndesmosis injury with tibiofibular diatasis (which the previous GP missed)
Referral to orthopaedic specialist from GP
Immediate booking for ankle surgery to stabilise the ankle joint
Surgery performed and referred to physiotherapy for routine post-op care.
Ankle Sprain: Syndesmosis
For the more astute clinicians or health practitioners, many would know that I’m immediately referring to a syndesmosis injury – otherwise known as a high ankle sprain. This case was poorly managed, as the follow-up with the doctor should have included further investigation. Especially because the ankle pain wasn’t resolving. Usually, recommendations should be made to see a physiotherapist before a doctor for most simple ankle sprains.
Unfortunately for this individual, had the right assessments been completed and monitored over weeks, a surgery would have been avoided. The individual would have been able to recover in a earlier time period and eventually would have returned to her daily gym and sport routine.
Epidemiological data suggests as many as 1-2 out of 10 people will suffer a syndesmosis ankle sprain (Williams & Allen, 2010). Although it’s an injury that largely occurs in athletic populations, there have been many cases – like the one above – where syndesmosis injuries happen in every day life.
The Basics: Anatomy
The syndesmosis joint comprised of a few structures, primarily:
Distal tibia and fibula
The ‘syndesmosis’ itself (interosseous tibiofibular ligament connecting the fibula and tibia together)
The many ligaments supporting it (anterior-inferior tibiofibular ligament (AITFL), posterior-inferior tibiofibular ligament (PITFL) and transverse tibiofibular ligament (TTFL)).
Basic outline of anatomy of the ankle syndesmosis.
In a syndesmosis sprain; we are worried about the connection between the two shin bones (tibia and fibula) being pushed apart. Disruption of the ligamentous structures holding these bones can cause the ankle to have excessive movement and mobility through the bones. This is extremely detrimental to all facets of life including walking, running and any form of lower limb exercises. Therefore, recommendations to stay away from excessive weight and pain is imperative, as it allows the ligaments to heal back into it’s natural positions.
Long-term complications including chronic ankle instability and recurrent ankle sprains can arise if this is not treated properly. Other long term complications can include chronic pain in the ankle, loss of strength and range of motion in the ankle.
Common Signs of a High Ankle Sprain
Mechanism of injury (The how of the injury): Forceful external rotation of the ankle (knee turns outwards relative to the ankle)
Swelling around the middle and outer edges of the ankle
Tenderness directly over the middle of the ankle
Positive physiotherapy stress tests, including: external rotation , fibular translation and squeeze test
External Rotation of the Ankle
Tenderness in Middle of Ankle
Therefore, the following few symptoms are indicators you should get your ankle checked ASAP by a qualified health professional:
Pain that increases when your knees go past your toes (i.e lunging, up stairs)
Pain with pivoting on foot
Your ankle feels loose and unstable
Unable to point your toes
Unable to put full weight on ankle
Timeline for Recovery for the Syndesmosis Ankle Sprain
The following guidelines for recovery are based on the recommendations suggested byWilliams & Allen (2010). These are only ‘guidelines’ and do not reflect the recovery that you or anyone else may experience. A host of individual factors can influence the speed in which you recover back to your baseline and must be considered in any injury.
First 6 weeks – Protecting the Ankle
A combination of moonboot / crutches to reduce weight bearing and protect ankle
Gentle ankle movement exercise to reduce stiffness
Prevention of re-injury
Pain management, including: medication, ice or heat therapy and gentle massage
Progression to next stage when: Able to fully put weight onto affected leg and walk stairs and uneven ground with minimal discomfort.
6 – 12 weeks – Normalising walking and movement
Gait retraining
Calf and foot strength exercises
Balancing exercises such as single leg stands, tandem stance.
Ankle stretches and range of motion exercises (pain free)
Progression to next stage when: Hopping and running has minimal discomfort.
12 weeks + Return to sport or hobbies
Reintroduce lateral plane movements
Begin gentle sport specific activities (i.e. agility drills, controlled training drills)
Conditioning and steady-state movement (i.e. jogging and running, jumping rope)
Steadily build on your fitness and strength in the ankle, as well as progress your sport specific activities. When you are able to train pain-free and minimal discomfort, then a return to sport level activity should be warranted.
Caution Signs:
A few warning signs to be wary of include:
Unable to put any weight on your ankle
Feeling severe pins and needles in your feet
Severe pain that is intolerable
The recommendation to go to the emergency department or your local GP is emphasised. During this stage, you must rule out an ankle fracture otherwise this will have profound long term consequences on your recovery.
This specific ankle injury can potentially have serious consequences on your long-term ankle function. If you are unsure about the severity of your ankle sprain, please seek professional advice from a healthcare professional.
Conclusion
This blog post is intended to make the viewer aware that a more serious type of ankle sprain exists. Syndesmosis sprains cannot be managed like a ‘usual’ ankle sprain and can take longer to heal. The main messages for this post are to contact a medical professional if:
You exhibit any of the Caution Signs
The pain doesn’t seem to be improving
You are concerned about your ankle sprain or pain
Like any other injury, syndesmosis sprains can heal. However, proper management and a structured rehabilitation program is necessary to make sure a favourable outcome is made.
References
Bleakley, C. M., McDonough, S. M., & MacAuley, D. C. (2008). Some conservative strategies are effective when added to controlled mobilisation with external support after acute ankle sprain: a systematic review. Australian Journal of Physiotherapy, 54, 7 – 20
This blog post aims to explain to you why you might be getting your shoulder pain and how we can relieve your pain NOW, but also keep it away for good!Shoulder pain is extremely common… In fact, as much as 20% of the population can be suffering from shoulder pain (Pribicevic, 2012). That’s 1 in 5 people!
Now the prevalence and especially severity of shoulder pain can have profound economic impacts for the individual and their families (Pribicevic, 2012). This is influenced by a host of factors, including:
Age
Gender
History of shoulder pain
Your occupation / work
Psychological factors
Diagnosis of shoulder pain
Unfortunately, a rigorous diagnosis cannot be made from the comfort of our own home. However, the good news is that many of these issues have one thing in common – that is they don’t actually matter a whole lot. In fact, the research shows us that many asymptomatic (no pain) individuals have these diagnoses on perfectly healthy and non-painful shoulders.
A quick google search of shoulder pain may lead you to finding the following terms:
Bursitis
Tendinitis / tendinopathy
Rotator cuff tears
Shoulder impingement syndrome
Instability
Arthritis
The pathological terms such as bursitis or shoulder impingement syndrome have been contested by a plethora of research. The majority of which is written by Jeremy Lewis, a renowned shoulder specialist in physiotherapy management of shoulder pain. Essentially, shoulder pain should not be necessitated by complicated terms and biomechanical principles. Instead, should focus on simpler subject matters like load tolerance, daily activity and strength of the muscles in the shoulder.
But my doctor told me I needed an injection…
More relevant perhaps, is the increasingly common shoulder procedures recommended by “shoulder specialists” and doctors. These include subacromial decompressions, rotator cuff repairs and corticosteroid injections to resolve shoulder bursitis. Let’s do a quick 13 reasons why compressed into 3 reasons as to why it’s not relevant:
Subacromial decompression: The relevance of the acromion (You may have heard of acromion types) to rotator cuff pathology of pain is not well supported by research.
Rotator cuff repairs: Over 50% of people over the age of 60 without shoulder symptoms had a partial or full thickness rotator cuff tear
Bursitis: 96% of men who did not have shoulder symptoms, had abnormalities including subacromial bursal thickening, supraspinatus tendinosis and tears and glenoid labral abnormalities.
So now that we know that the diagnosis is not necessarily important for the shoulder when considering shoulder pain, what should we do then?
Outlining the six-step process
1. Short term: Immediate pain relief
Some of the following immediate pain relief strategies seem very basic, and common sense. These short term pain relief strategies include:
Over the counter (OTC) pain relief (*DISCLAIMER: I am not a doctor, and am in no way recommending you to go get pain relief. Instead, a consultation with your doctor should be made prior to buying any pain relief, especially if you are taking any other medication).
Heat therapy, such as: a heat pack, a hot shower or hot bath
Cold therapy, such as: a ice bath, cold pack or cold shower
The reason why I don’t have any specific recommendations between ice and heat, is because the effects of both are usually due to preference of the individual. Some do not tolerate ice packs and some do not enjoy the feeling of heat on their shoulders. However, the general precaution is heat should not be applied in the first 72 hours post injury. This is even more important if there is obvious swelling or inflammation around the area, in which case the heat could make the swelling worse.
The other precaution is: avoiding provocative movements. The first and most important rule is donot avoid all movement. This may seem counter intuitive to some, but is especially important for recovery of all injury. That is because avoidance of movements can have profound effects on your recovery, and also your mental and psychological health. This does not just pertain to the shoulder joint, but to all joints and pain. When considering pain, we must consider the impact of a host of other factors, including psychological and social factors. This is called the “Biopsychosocial Model”, which I have mentioned in a separate post.
2. Short term: Self-Massage
Trigger point or self-massage is fantastic for short term pain relief and increasing function in the short term. Usually with any pain, there’s an associated tightness of muscle in and around the affected joint or area. A release of this muscle can provide temporary relief that lasts anywhere from a few minutes, up to a few days. The easiest way to massage is to find a tennis ball, baseball or anything that can help massage your shoulder and then push it into the back of your shoulder blade area:
Massage can be administered for 3 – 5 minutes, or until tolerated. Be aware that massaging for too long or too hard may lead to bruising or increased soreness around the area.
Self-massage or trigger points of these muscles can make your joint feel much ‘looser’ and provide good pain relief. However, massage does not inherently make your shoulder stronger, more flexible, increase durability or provide any long-term benefits; many times the shoulder pain will return after a short time. Therefore, we recommend self-massage in conjunction with the next few steps described.
3. Medium term: Stretching
Stretching of tight muscles around the area may help with additional pain relief. However, similar to the self-massage, stretching only provides moderate short term relief and benefits, and usually your shoulder pain may return once the stretching has ceased or you return to activity.
Shoulder stretches include:
Posterior capsule stretch
Pec stretch
Overhead stretch
Each stretch should be held for 15 – 30 seconds and should not be pushed into painful areas. Repeat throughout the day as needed or tolerated.
4. Medium term: Movement modification
Shoulder position while sitting is… important, but at the same time it isn’t. Think of standing in cue for a long period of time – some of us can stand completely still without moving, but most of us need to shift our weight, move side to side, slouch to one side and then the other. That’s a completely normal process of our body, that allows us to have freedom of movement and essentially allows us to keep our joints moving.
The same concept applies to your shoulder joints – there is no perfect position at a desk or workplace to “set” your shoulders. Anyone who tells you to sit in one position for hours at a time likely doesn’t listen to their own advice. Instead, posture and sitting position is a RANGE. Movement within that range is important, as it allows for your joints, muscles, ligaments and bones to move. As long as you provide some constant movement, you will find that your shoulder pain will ease quite quickly. That being said, there are some modifications that may feel beneficial to your shoulders while they are sore and painful.
4a) Desk position
The ideal posture… Forearms on desk, feet firmly planted on the ground, shoulders upright. This seems to be the quote-on-quote, best posture for many individuals.
The “ideal” posture
However, these postures are also absolutely fine and will not cause your shoulders to suddenly break down.
Understandably, when you’re deep in the middle of a project and you’re not paying attention to body position it becomes easy to forget. Fret not! Just keep moving again and using your shoulder joints and you will feel your shoulder start to relax and relieve itself.
4b) Normal shoulder movement
The common issue that many individuals have – whether it’s natural or learned – is depressing their shoulder blade down when lifting the arms up.
Keeping our shoulders ‘down and back’ may be harmful to your recovery.
Understandably, many were taught at a young age that good posture meant chest out, shoulders down even when reaching up and out rather than shrugging shoulders. However, this is not exactly a natural movement pattern and isn’t something that our bodies are designed for.
Our scapula’s don’t actually have a anatomical attachment to the back of your ribcage. This allows for a large degree of freedom of movement and is what our shoulders are designed for. So instead of keeping our scapula depressed, we should actively engage in their elevation and movement upward as we also move our arms upwards.
Actively shrugging our shoulders up as we move is normal.
5. Long term: Strengthening your shoulder
Strengthening of your shoulder can also occur in two parts. Namely:
Isolated strengthening of the rotator cuff
General upper body strengthening
The rotator cuff is as the name suggests, muscles that help rotate the shoulder. The primary ones that we focus on are your external rotators, called the supraspinatus, infraspinatus and teres minor. These muscles can be trained through isolated exercises such as:
Rotator cuff specific exercises:
Sidelying external rotation exercise
Sitting external rotation exercise
Please, please, please do not do external rotations in a standing position. Gravity works downwards, and if you do rotations in a standing position, you do nothing to work your rotators as they have no resistance to push again. This is why the exercises are so specific, in order to correctly target the rotators in a movement plane that is challenging.
If you want to do these in a standing position, a cable external rotation is a suitable alternative.
General upper body exercises
These exercises are as they suggest. Performing your normal gym or exercise routine that involves upper body strengthening. As all exercises that involve pushing, pulling involve the rotator cuff to some extent, these exercises are all beneficial in improving the strength and functionality of your shoulder.
If you are still having ongoing pain during certain exercises like the shoulder press or bench press, you can try decreased ranges or pauses at different points. For example:
Shoulder press
Single arm variations using dumbbells
Slow controlled reps
Bench press
Top half with pause
Bottom half off the rack
Decreased weight
Long story short, there is no “Best Exercise” for strengthening the rotator cuff, as any upper body strengthening is beneficial in providing stimulus to the muscles.
However, the topics of load management, form and posture will need to be left to another blog post… Otherwise this one will become an essay!
6. Long term: Have no fear!
Pain relief is fantastic, as it will allow you to feel psychologically and mentally better as well as allow you to do more things physically. Unfortunately, if we only focus on getting rid of our pain every time and not trying to create a long-term solution… This is where you start to get frustrated and angry because it just won’t go away.
Many times, we may be able to get temporary relief from massage, dry needling or any other fancy types of pain modulation. However, if we don’t fix the underlying problem, or the cause that may be exacerbating or worsening your shoulder pain, then it is likely to just return time and time again.
Luckily for you, shoulder pain can be fixed, we just need to make sure we are on the right direction and pathway to create a situation that will allow it to fix. However, in order to do this, we must consider the solution from multiple directions and not just pain relief.
Warnings Signs
Fundamentally, shoulder pain is generally not a concern unless you have the following symptoms:
Severe pins and needles down the arms and into the fingers
Heaviness, throbbing, “feels cold”
Significant loss of strength and ability to grasp or lift objects
If you have had a traumatic event prior to the pain starting
If any of these signs and symptoms describe your situation, a urgent consultation with your local health practitioner is recommended to identify if you need further referral to the Emergency Department or investigations.
Conclusions
Shoulder pain can be fixed. All it takes is proper management, understanding the right steps and creating a plan to address it. Hopefully through this blog post you’ve learned the six steps to creating pain free shoulders:
Short term:
Pain relief
Self-massage
Medium Term
Stretching
Movement Modification
Long-Term
Strengthening
Have no fear! (Education)
You’ve also learnt that many of the diagnosis such as bursitis, impingement and rotator cuff tears are not relevant to your outcomes! This has been one of our most comprehensive guides to date for any joint, so I hope you’ve enjoyed the read!
Leave us a comment or share this post with some of your family or friends!
References
Lewis, J. (2016). Rotator cuff related shoulder pain: Assessment, management and uncertainties. Manual Therapy, 23, 57 – 68.
Pribicevic, M. (2012). The epidemiology of shoulder pain: A narrative review of the literature. In Pain in perspective. IntechOpen.
Have you ever seen or heard of a family member who had an MRI of their lower back and were told:
“Your back is degenerative”
“You have a slipped or bulging disc”
“Your back is like an 80 year olds”
Back pain is prevalent, and is increasingly common in members of all ages. It isn’t uncommon to see a 20 year old student experiencing the same debilitating back pain of a person who is 50 years old. Regardless of age, common thoughts that many have following the acute onset of lower back pain is:
Is this permanent
Will this ever go away
Will I ever be the same
The Initial Fear of Lower Back Pain…
The first point of action for most individuals is to seek our professional healthcare advice, usually from a physiotherapist or a doctor. Unfortunately, there are still many healthcare professionals who will immediately send you off for a scan of your lower back. Then, tell you there’s“nothing that we can do about it“ until the scans come back.
This leads into a negative spiral as individuals can depend on the results of the MRI scan as a “life or death” diagnosis. Namely, the severity of their lower back pain and their outcome is dependent on the results seen on the scan.
However, as I have mentioned in my previous lower back pain post, pain is multifaceted and cannot be attributed to only one cause. As I will allude to in a second, there is no supporting evidence that directly links the results of the scan to lower back pain.
Compare the following statements:
Individuals who have severe anatomical or pathological change on their MRI can have minimal or no pain, but
Individuals that have minimal anatomical or pathological change on their MRI can have severe pain
So what’s the difference and why do some people get pain?
The Complexity of Pain…
Pain is complex… If you want to see scientific discourse on the ambiguity of pain, I would highly recommending reading this article by Treede (2018). Our understanding of pain is only continuously evolving and there are still many things that we need to learn in order to truly understand “pain.”
“… Many people report pain in the absence of tissue damage or any likely pathophysiological cause; usually this happens for psychological reasons.”
The interpretation of pain includes cognitive (i.e. our emotional association and relationship with the pain or threat) and social dimensions (i.e. our interaction or lack thereof with family, friends and peers)
When assessing pain, tissue pathology and actual injuries are not the only factors that we must consider. In modern healthcare, we commonly have a paradigm which we follow called: The Biopsychosocial Model of Health / Pain. Essentially, the interpretation of pain can be defined in three seperate factors / cateogories:
Biological factors (e.g. physical health, genetics, age etc.)
Social factors (e.g. relationships with family, friends or peers, work or stress issues)
As we know, emotional factors such as stress and anxiety can elevate and heighten our perception of pain. Similarly, if we were taught pain was a very bad sensation when we were young, then naturally we may develop a fearful response to it when it does happen. However, this is outside the realm of this blog post and will be explored further in the future!
So What About the MRI?
The interpretation of lower back MRI’s often give you insight into many pathological anatomical changes. The most common of which include:
Disc bulge
Disc degeneration
Interestingly enough, lower back pain is not actually synonymous with disc pathology. One study from 1990 by Boden and colleagues researched MRI results on 67 volunteers who had no history or current symptoms of lower back pain. What they found was:
20% of people aged 20 – 59 had abnormal scans
57% of people aged >60 had abnormal scans
54% under 60, and 79% over 60 had bulging discs
Perhaps most extraordinary, 93% of people aged 60 and older had degenerated discs.
Adapted from Boden et al. (1990)
Let me just repeat that last one for you. 93% of people aged 60 and older had degenerated discs, but had no lower back pain. So you’re thinking, that’s insane. There’s no way that you can have degeneration and bulging discs without pain?
Unfortunately, with our current medical technology, we are unable to directly propose that scan result = pain. The only way that we would be able to attribute or interpret your MRI results to lower back pain is:
If you took a scan directly prior to your injury that showed an absence of any pathological changes
If you took a scan directly after your injury that showed a pathological change at the area of your pain
The Slippery Disc
A common fear that many individuals have is “slipped discs.” Fortunately, there’s no scientific literature or reasoning to support discs “slipping.” There’s just too much structural and anatomical stability around the area to allow for a disc to slip. An excellent article written by Dr Jarod Hall titled “Discs don’t slip DAMMIT” outlines these specific concerns and the reasoning behind it.
So if you did have an MRI scan and have been diagnosed with a bulging disc, do not worry! The research shows that a disc can actually REABSORB and present you with a ‘normal’ MRI scan. Yet again another amazing article written by Dr Jarod Hall titled “What if I Told You That……Discs Heal!?!?” talks in detail about the spontaneous healing or “regression” of a bulging disc.
A Word of Caution
As I mentioned in my lower back pain blog post, you need to be aware of any red flags. This includes:
Unexplained weight loss
Night pain not relieved by rest
Saddle anaesthesia (numbness of the buttocks, perineum and inner surfaces of the thigh)
Bowel and bladder incontinence (unable to go) and retention (unable to hold)
This could be indication that you need to have an emergency consultation with your doctor, or visit the emergency department of your local hospital. Similarly, a trip to your local healthcare professional should be considered if you have ongoing concerns regarding your lower back pain or your condition suddenly deteriorates.
Conclusion
Lower back pain is common amongst all ages, and is something that we need to consider as we grow older and change. The main takeaways from this article can be summarised as follows:
Pathological changes on your MRI results DOES NOT equal pain
MRI are usually only required to rule out serious, medical emergencies
93% of people aged 60 and older had degenerated discs, but had no lower back pain.
Discs cannot slip, but they can bulge. Fortunately, bulging discs are not always painful and can also heal by themselves!
Lower back pain is scary, but hopefully these blog posts will help with your knowledge and understanding of them!
How would you explain this to your friend or family or coworker that had lower back pain?
References
Boden, S. D., Davis, D. O., Dina, T. S., Patronas, N. J., & Wiesel, S. W. (1990). Abnormal magnetic-resonance scans of the lumbar spine in asymptomatic subjects. A prospective investigation. The Journal of Bone and Joint Surgery. American Volume, 72(3), 403–408. https://doi.org/10.2106/00004623-199072030-00013
Ramanayake, R. P. J. C., & Basnayake, B. M. T. K. (2018). Evaluation of red flags minimizes missing serious diseases in primary care. J Family Med Prim Care, 7(2), 315 – 318.
Treede R. D. (2018). The International Association for the Study of Pain definition of pain: as valid in 2018 as in 1979, but in need of regularly updated footnotes. Pain reports, 3(2), e643. https://doi.org/10.1097/PR9.0000000000000643
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