Articles in Category: Chiropractic

Tendinopathy - What Is It?

on Thursday, 15 October 2015. Posted in General Health, Chiropractic

Tendinopathy - What Is It?

As we are all aware pain can be a debilitating thing to live with and manage. In past months I typed some overviews on understanding discal pain, shin splints and neck pain. Today we'll be covering something a little trickier to manage, Tendon irritation and pain, often known as either tendinopathy, tendonitis, or tendinosis (these terms differentiate the pathophysiological mechanism of the injury – we won't go into that today).

 

Tendons are the tough fibres that connect muscle to bone. For example, the achilles tendon connects the calf muscle (gastrocnemius and Soleus) to the heel bone. Most tendon injuries occur near joints, such as the shoulder, elbow, knee, and ankle, although the can also occur in the buttocks (gluts and hamstring insertions) and other areas.

 

Most tendon injuries are the result of gradual wear and tear to the tendon from overuse or aging. Anyone can have a tendon injury. But people who make the same motions over and over in their jobs, sports, or daily activities are more likely to damage a tendon. A tendon injury can happen suddenly or little by little. You are more likely to have a sudden injury if the tendon has been weakened over time – this may be related to previous traumas, injuries, or surgeries (which may have not been managed as well as they should/could have in the past -we all have those little gremlins in the closet unfortunately – me included!).

 

Symptoms of tendinopathy can include:

  • Pain, tenderness, redness, warmth, and/or swelling near the injured tendon. Pain may increase with activity. Insertional tendon pain may affect the local area where the injured tendon is, or can radiate out from the joint area along the associated muscle's distribution.

  • Crepitus, or a crunchy sound or feeling when the tendon is used. This can be uncomfortable or painful.

  • Pain and stiffness that may be worse at the night or when getting up in the morning.

  • Stiffness in the joint near the affected area.

 

Movement or mild exercise of the joint usually reduces the stiffness. But a tendon injury typically gets worse if the affected tendon is not allowed to rest and heal. Too much movement may make existing symptoms worse or bring the pain and stiffness back.

As mentioned above, The joint areas most commonly affected by tendinopathy are the shoulders (rotator cuff), elbow (and forearm/wrist), hips (gluteal), knees (knee cap), and ankles (achillies).

 

More chronic tendinopathies can be caused by inflammation around calcium crystals in or around the tendon (calcific tendinitis). The cause of the deposits often isn't known. These crystal deposits can be very painful, and a little more difficult to manage.

Tendinopathy pain may be similar to those of inflammation of the bursa (bursitis) and are often diagnosed concurrently because of the proximity and function/role of both structures

 

Diagnosis, Treatment and Management Considerations

Early diagnosis and treatment of a tendinopathy is important for recovery times as the turnaround for an acute tendinopathy to progress to a more degenerative chronic tendon injury can be as rapid as 6 weeks. Often orthopaedic assessment and provocation testing is necessary to identify the problem. Though if the injury is more complicated (obviously depending on the location and mode of injury) further assessment may need to be made, or if the problem is not responding to conservative treatment. Often xrays, ultrasounds and occasionally MRI is the most commonly used imaging tools for assessment and diagnosis.

 

Initially the focus on an acute tendinopathy is primarily based on reducing load on the tendon, stabilising the pain and protecting the area. Often topical applications of ice/heat and taping methods can be utilised, as well as the use of anti-inflammatory medications. In more severe cases the administration of a guided cortisone injection may also need to be considered. This can only be referred by your GP and performed by a specialist medical practitioner.

 

Understanding the mechanism of injury can go a long way towards recovery from a tendon injury. The tendon is the primary structure that deals with the load and force to move a joint (via muscle contraction) the primary focus of exercises for tendinopathies has to be based on reintroducing load onto a tendon gradually – thereby strengthening the tendon to adapt with load. Studies support the use of isometric exercise initially. (Isometric being defined as a contraction of any muscle without a change in the length of the muscle – thus performing isometric contraction of a muscle over a progressively increasing period of time allows the tendon to strengthen over time.)

 

Other more dynamic loading of the tendon can occur once clinical markers have been reached during treatment. These include less pain, improved strength and functional capabilities in more everyday tasks depending on the location of the tendon injury.

 

Do you have unusual pain in the shoulder, knee, hips ankles that seem to worsen with trivial tasks then assessment and diagnosis is always the first step. Problems such as these can lead to more sinister and traumatic problems which we would hope to avoid. These could be anything from chronic disability, tendon ruptures, and Adhesive Capsulitis (frozen shoulder) which can take anywhere from months to years to improve. Please contact the team at IOSAS and we'll help you find a plan forward for problems such as these.

 

The Forward Head Posture

on Friday, 26 May 2017. Posted in Newsletters, General Health, Ergonomics, Chiropractic

The Forward Head Posture

The Forward Head Posture

In the January newsletter, we discussed the different types of common postures observed in people and how ideally the spine likes to be in an as neutral position as possible (not leaning forward too far and not overextending backwards). 

 

This month, we will start fixing those with a Kyphotic posture (the slouching and neck protrusion). 

 

First we start by correcting the top of the spine; the neck.

 

Kyphosis 1 

To minimize the stress and strains on the neck, the cervical spine ideally has to be in a vertical line with the body's centre of gravity. This position is balanced off by the front neck muscles (the sternocleidomastoid) and the back neck muscles (levator scapulae and trapezius). Like the wires holding a bridge.

 

This abnormal posture can cause headaches, neck pain, sometimes jaw pain and rounded shoulders. Most people also often feel pain/tightness starting from the neck radiating up to the base of the skull. In a prolonged period, an excessive load on the joint and muscles are imposed which can then degenerate the cervical spine leading to irritation of the nerves.  

 

In Forward Head Posture, the SCM shortens and the middle fibres of trapezius and levator increases in length and weakness. Most of the time the commonly prescribed treatment for FHP is to stretch the levator and trapezius (which is good short term) but it doesn't give you a long term solution as the SCM is still shortened and the levator and middle trapezius are in a lengthened position. 

 

What needs to be done is to relax the SCM and bring posterior cervical muscles to a correct length. To do so, the best exercise to begin with is the chin tuck exercise.  

 

Rolled Towel Chin Tucks:

YouTube Link: https://youtu.be/m3smFwVGy7s

Chin Tucks 

 

A FHP not only increases load on the cervical spine, it also leads to a rounded shoulder which enhances the flexion of the mid back (the slouch).

 

Being in this position long term can affect your lung expansion capabilities, digestion rate, shoulder impingement and also cause loss of height. 

 

Kyphosis 2

 

Correcting your mid back will help your neck feel better in the long period. If you find that doing the chin tuck exercise does not make you feel any better at all, it probably means you will have to start fixing the thoracic spine first. 

 

The seated thoracic extension exercise is one of our clinics favourite. All you need is a chair and it can be practiced anywhere. Try doing these 2 exercises 10-20 reps throughout the day and feel the difference it makes on your neck and back!

 

Seated Thoracic Stretch:

YouTube Link: https://youtu.be/YcURm7DWXko

Seated Thoracic 1 Seated Thoracic 2 Seated Thoracic 3

    

By Iris Tan

B.App.Sc (Chiropractic) M.Clin.Chiropractic. 

Memb: CA, Gonstead (Australia)

Iris picture new contrast 

Reference 

1.Lee, K.-J., Han, H.-Y., Cheon, S.-H., Park, S.-H., & Yong, M.-(2015). The effect of forward head posture on muscle activity during neck protraction and retraction. Journal of Physical Therapy Science27(3), 977–979. http://doi.org/10.1589/jpts.27.977

2.Dalkilinç, (2015). The benefits of good posture - Murat DalkilinçYouTube. Retrieved 8 March 2017, from https://www.youtube.com/watch?v=OyK0oE5rwFY

The Knee

Written by Don Williams BSc, MChiro, ICSSD. on Wednesday, 23 September 2015. Posted in General Health, Sporting Injuries, Training and Performance, Chiropractic

The Knee

By Don Williams

B.Sc., M.Chiro., ICSSD., PG Dip. NMS Rehabilitation,

Cert. DNS.   Memb: CAA, FICS, CEA.

 

This month I thought I would write a brief article about the knee.

 

The Knee is such a fascinating joint and unfortunately, is a regularly injured joint, necessitating visits to our clinic for many people.  We regularly receive referrals to assess knee injuries to identify what is actually wrong and how to manage the problem. This often necessitates us referring out for MRI scans and in some cases on referral to some of the excellent orthopaedic surgeons that we deal with.

 

The Knee 1  

 

Types of Knee Injuries:

Knee injuries and pain associated with those injuries generally fall into 3 categories.

 

Firstly, degenerative problems:

This can be osteoarthritic change or general wear and tear due to age or overuse of the knee.

Often age correlated or a result of lots of aggressive sport in the younger years.

 

Secondarily, biomechanical overload injuries:

These are often the result of;  genetic mechanical issues such as pronation of the feet and ankles, “Knock knee”, “bow legged” posture of the knees,  inappropriate footwear, poor technique in running, walking and other fitness activities, poor setup on bike position or sporting equipment or weaknesses and imbalances of the supporting musculature.

 

Thirdly, the pathological or traumatic injuries:

These are things like anterior cruciate ruptures (ACL), Meniscal tears (often referred to as the cartilage), fractures, and collateral ligament tears and issues. Bursitis and tendonitis issues are sometimes grouped into this category but are often more accurately grouped into the second category.

 

But what makes the knee so susceptible to injury:

Several factors really. The knee can be thought of as a force transducer. When we are walking, running, turning and jumping, our knee is subjected to high forces or loads in a multitude of directions.

 

The mechanics of the knee are complex and this article will be far from exhaustive in the description of the knee. But in basic terms the knee is a rolling/gliding hinge joint. Thinking simply, the knee is not a simple hinge (like a door), as the knee straightens, the femur glides across the tibia as it rolls towards the straightened position. This is why the end of the femur has a lengthened cam-like shape, in contrast to the relatively flat shape of the top of tibia. This means that the contact point and force vectors through the joint constantly change as the knee bends and straightens, combine this with the fact that the knee also pivots slightly right at the end of the straightening process make the knee a regularly injured joint.

 

Many health practitioners are taught at university that for the knee to have a pathological or major injury, there must be a large impact or nasty injury mechanism occurs to cause the damage. However, this is very clearly not the case with many of the patients we see at Institute of Sports and Spines.

 

In fact, the 2 worst knee injuries I have seen this year came from very low force activities; one from standing up after sitting on the ground and one from walking along the ground at work and turning to speak to someone. In fact, my own knee injury was not the result of a twist, fall or accident, but purely jogging along a flat footpath, the articular cartilage got caught and tore and it has been a problem ever since.

 

Scans and Imaging for the knee:

Depending on the injury or suspected injury, a range of scanning options are used.

Xrays and pretty good for looking at fractures of and around the knee, gross degenerative change and biomechanical position, they are not good at assessing soft tissue and ligament issues.

Ultrasounds are used to look at tendonitis and bursitis issues and muscle tears around the knee.

MRI scans are generally the image of choice for the knee and are the only means to effectively view meniscal tears, cruciate ligament injuries, collateral ligament injuries and articular cartilage defects.

I have included a couple of images below for interest.

 

Image 1                                                                                             Image 2

The Knee  2  The Knee 3 

The Knee 4

                                                                                              

Image 1 above, the green oval shows reasonable articular cartilage with some thinning. The red circle shows a tear or defect in the cartilage (the white area), the end of the bone has a light area which is bone swelling.

 

Image 2 The blue circle shows good articular cartilage and a healthy meniscus in the correct position (black triangle on the right side).

The red circle shows the lateral meniscus in the wrong place (this is bad ;)) and the green arrow shows us where it should be.

 

 Image 3 to the left shows a vertical tear in the meniscus and a little bit of swelling to the left of the arrow.

 

Management of Knee Pain:

When you have knee pain, correct assessment and diagnosis of the problem is critical. We have unfortunately seen many patients who have had a lot of treatment for the wrong diagnosis, resulting in poor outcomes.  A comprehensive physical and orthopaedic examination should give a working diagnosis which may then indicate treatment direction or relevant investigations to confirm the suspected diagnosis.

 

At IOSAS, we generally start our assessment with gait analysis, looking at joggers, work shoes etc, analysis of movement patterns and muscle strength to look for weakness and imbalances, followed by an orthopaedic joint assessment. This then directs how we will manage the presentation to move you towards the outcome you desire.

 

Most biomechanical issues of the knee and overload syndromes can be managed conservatively and don’t progress to surgery.  Advanced degenerative change of the knee will often require joint replacements and ruptures of ligaments and meniscal tears which catch or lock will usually require surgery with a degree of urgency.

 

Treatment options:

For many overload / degenerative and biomechanical issues, addressing mechanical issues and contributing factors can be a big part of the solution. Acupuncture, Massage and Chiropractic and other physical therapy interventions can be useful to address the current pain presentation. Progression towards rehabilitation and retraining may be indicated to prevent recurrence.

 

Due to the nature of the cases that we see, some patients require surgical intervention to help resolve their issues. It is vital in the post-operative phase to focus on rehabilitation and strengthening to make sure there is relatively good balance or symmetry in the strength and control of the knees to hopefully prevent future recurrences.

 

Generally, effective assessment and management of knees gives a greater probability of a good outcome.

 

If you have a new or ongoing issue with your knee, come in and see us, we might be able to help you get a better outcome.