Category: Musculoskeletal Physiotherapy

‘Osteo’ means bone and ‘pore ‘means hole – it can be explained simply by ‘holes in the bone’.

Osteoporosis is a bone disease where there is loss of minerals and break down of the normal healthy bone structure so the bones become fragile and brittle.

“Over the next 10 years, the total cost of osteoporosis and associated fractures is estimated to be $33.6 billion.” – Osteoporosis Australia

Did you know that by the time you are 35 your skeleton would have remodeled 5 times?

Over a 7-year period cells called ‘osteoclasts’ break down and clean out old bone tissue and cells called ‘osteoblasts’ build new bone. This is due to the mechanical stresses and strains on the skeletal system by gravity and muscle activity.

The process is also influenced by other factors such as genetics, age, hormones, medication (corticosteroids for example), excessive alcohol intake, smoking and nutrition (adequate vitamin D and calcium for example) and conditions such as diabetes and rheumatoid arthritis and prolonged inactivity.

After the age of 35, bone reabsorption starts to exceed bone deposition and we start to lose up to .5 to .75% of bone density per year. Men generally lose bone density at a slower rate until the age of 65 when the rate of bone loss equals that of women.

Osteopenia

This is thinning of the bone and a precursor to osteoporosis. Having osteopenia does not mean you will get osteoporosis but without intervention you are at high risk of progressing.

What does ‘Osteogenic’ mean?

Osteogenic describes something that is important for building and maintaining bone density.

Some interesting and relevant facts

• Currently 4.75 million Australians over 50 have osteoporosis or Osteopenia.
• This figure will increase over the next 10 years to 6.2 million.
• There is one fragility fracture every three and a half minutes – this figure is also likely to increase.
• It is estimated that fractures related to osteoporosis occurs once in every four fractures for men and twice in every five for women over 50. One of the most serious outcomes of osteoporosis is a fracture of the hip.
• In 2011-12 19,000 people over 50 were hospitalized for an osteoporosis related hip fracture. 72% were aged 80+ and 72% were women (Australian Institute of Health and Welfare).

What do bones do?

• They provide attachment for ligaments, tendons and muscle (ligaments join bone to bone and tendons join muscle to bone).
• They Support and protect internal organs eg heart, lungs, bladder, brain.
• Red and white blood cell formation occurs in bone marrow.
• They provide a storehouse for minerals.

Bone density in women

A decline in bone density is a normal part of the ageing process – like getting wrinkles! This bone loss is accelerated in menopausal women who may lose 20-30% of bone over a five-year period. This is thought to be due to the decline in oestrogen during this period of their life. Oestrogen is a stimulant for bone, tendon and muscle health and function. As soon as a woman has reached a plateau in menopause symptoms (usually marked by a resolution of hot flushes and other symptoms) the bone reabsorption will tend to stabilise.

Bone density and smoking

It is important to mention here that smoking causes leaching of calcium from the bones because smoking causes less calcium to be absorbed from the diet. AS calcium is required for many other functions in the body the bone then becomes a source. Women who smoke also tend to have lower oestrogen levels and experience earlier menopause and weaker bones than non-smoking women.

Normal bone loss vs excessive bone loss

During the ageing process we lose muscle, skin tone and bone – this is normal. What many people don’t realise is that just as we can do things to protect and improve our skin condition as we age, we can also be proactive in minimizing the loss of bone and muscle mass through exercise, diet and lifestyle choices.

We know from research that bone remodelling occurs at different rates during different stages of life. As a child your bones are rapidly remodeling responding aggressively to exercise and growth hormone with peak bone density (90%) occurring at around 20 years of age. A further 10% increase in bone density can occur in the next 15 years to age 35. The more active you are as a child the greater the peak of bone density at age 35 and the lower the risk of developing osteoporosis later in life.

Testing for Osteoporosis

The Gold Standard test for detecting osteoporosis or osteopenia is the DEXA (bone densiometry) scan.

As osteoporosis advances the bony bridges within trabecular become thinner and break down and the ‘holes’ become bigger. The bone becomes more fragile and susceptible to deformation or fracture with what was once ‘normal loading’.

Did you know we have two types of bone in our body?

• Cortical bone – long heavier bones, like in your arms and legs – make up 80% of skeletal mass but only 20% of total bone turnover occurs in these bones. They are less likely to develop significant osteoporosis due to the nature of the bone being denser.
• Trabecular or ‘spongy’ looking bone makes up 20% of skeletal mass and yet 80% of bone turnover occurs in this bone, which is more susceptible to fracture. This spongy looking bone is lighter and reduces skeletal weight and is highly responsive to metabolic rates and stress. It is found in the vertebral bodies of the spine and neck and in the ends of long bones such as the end of radius at the wrist. These areas are much more susceptible to fragility fractures wills.

T – Scores

• T-scores compare your bone mineral density (BMD) with that of young healthy adults of the same sex.
• Osteoporosis is diagnosed when the T-score is -4 (or less) to -2.5 standard deviations (SD’s) below that of a young healthy adult of the same sex. This indicates porous bone that can lead to fractures.
• A T-score of -1 or higher is considered normal compared to an average 30 year old of the same sex.
• A T-score of -2.5 to -1 is considered ‘borderline’ and a warning sign where life style management is important to reduce further loss even of no increase occurs.
• A T-score indicating Osteopenia would be -2.5 to -1. This is considered a ‘high risk’ zone and again a very important signal to become proactive in management.

Z – Scores

Z-score compares the patient’s BMD with that of adults of the same age and sex. It is the number of standard deviations (SD’s) of the BMD measurement above or below that of adults of the same age and sex. Z-score is a useful indicator of possible secondary osteoporosis. Whereas Primary osteoporosis is considered directly related to aging and accelerated at menopause, Secondary osteoporosis has a direct cause. This type of osteoporosis is ‘secondary to’ or caused by, something else. For example, osteoporosis caused by the use of prednisone is a very common form of secondary osteoporosis.

A Z-score of -2.0 or below should trigger investigations for underlying disease to exclude other causes of bone mineral loss. Medications such as anti-depressants and anti-coagulants such as warfarin can also predispose to secondary osteoporosis.

Do medications help?

Do Medications Help Certain medications such as bisphosphonates (Fosomax, Boniva, Actone) inhibit the activity of the osteoclasts, which clean out old bone. They are believed to help reduce fragility fractures in up to 30 to 50% of those who have already experienced one fragility fracture. The results vary according to each study and have more recently been challenged.

There are side effects of these drugs – informed decision is always required when deciding the best option for you. A ‘load management’ approach is a more proactive and less invasive approach.

It may be worthwhile considering a change in lifestyle and taking up osteogenic exercise for a year. You should of course discuss this with your doctor. The more informed you are the better you can make the right decision for you.

Exercise for bone health

We know from research that two types of exercise are ‘Osteogenic’ – meaning important for building and maintaining bone density:

• Weight bearing or exercises on land against the resistance of gravity (anti-gravity) that help build stronger bones; tennis, power walking, jogging or running, stair climbing, dancing and team sports such as netball (high impact weight bearing exercise).
• Muscle strengthening or resistance exercise such as weight or resistance band training, functional exercises that lift your own body weight are also osteogenic and provide the stimulus of both ‘compression’ on the bone from gravity and ‘traction’ on the bone from the attached muscles to promote stronger and healthier bones; heel lifts, lunge squats, weight bearing yoga, resistance based Pilates.

These exercises also improve overall quality of life as we get older by making the normal activities of daily living – such as getting in and out of bed or a chair or car, climbing stairs, vacuuming and cleaning – easier and with a reduced risk of injury.

Poor bone and muscle condition as well as poor balance are associated with increased risk of falls. If you are unable to stand on one leg for greater than 10 seconds you have a very high risk of falling. Test yourself!

Some kinds of exercise DO NOT help bone health

It may surprise you to learn that low impact weight bearing exercise such as walking, while better than no exercise, has minimal effect in maintaining bone density. When high impact exercises are contraindicated for any reason (for example sub optimal pelvic floor strength, illness etc) low impact exercises combined with some resistance work is recommended.

Swimming and cycling, while good for cardio-vascular health, are not osteogenic and swimming, due to it being ‘weightless’ may have a detrimental affect on bone density – astronauts return from time in space with significant bone loss due to a prolonged period of weightlessness.

How much exercise do you actually need?

The current Australian Guidelines (see link below) regarding exercise to promote bone health is that it must be regular, progressive and varied. The following tips are also recommended;

• Regular smaller bursts of exercise each day are better than one long session a day.
• Lifting heavier weights are better – if you can lift a weight for 10 repetitions comfortably then the weight is too light to be osteogenic.
• Lifting weights quickly may be more beneficial than slowly (there is some controversy about this).
• Rapid short bursts of movement such as jumping or skipping are more beneficial than slow ones. You may need to address any pelvic floor issues before taking up these higher impact activities.
• Variety is important – change of direction, altering sequencing, avoiding routine is important and maximizes the physiological effects of exercise.
• For those with suboptimal pelvic floor strength or those who have had a fragility fracture – you will need to be guided by your doctor or physio as high impact exercise may be contraindicated and you will need a graduated resistance training program.

The Age Factor

When we are young we tend to be more physically active and this level of activity declines as we age. Knee and hip pain in older individuals will often inhibit exercise and it becomes a real struggle to maintain bone density and independence.

Did you know that more than 80% of joint stability comes from the surrounding muscles?

Yet the usual response to pain is to avoid using these muscles with the outcome being further instability, uncontrolled shearing forces and further damage to the joint.

Exercise is of vital importance as we age to reduce loss of muscle function and bone and reduce overall loss of function and risk of injury from falls etc. In 2012 the estimated incidence of osteoporosis (most likely underestimated and didn’t include osteopenia) was 25% of women over 50 and 6% of men over 50.

The Osteoporotic Spine

With low bone mass we need to think about precautions when exercising. Forced movements into flexion (bending forward), side bending and rotation can place excessive anterior loads on the fragile vertebrae resulting in ‘squashing the bone’ or a ‘wedge fracture’. Wedge fractures tend to occur at the front of the spine. Compression fractures can occur when lifting heavy weights, even carrying a lot of body fat. The downward pressure causes the fragile vertebrae to flatten.

The Vertebral bodies most at risk are T6, 7 and 8 – right between the shoulder blades. These vertebra are most at risk with flexion such as toe touches, crunches etc. Such exercises can be very dangerous if not done in a very careful way. That’s where Clinical Pilates can help. In clinical Pilates exercises are modified and varied according to pathology. Touching toes forcefully is not a good idea without good muscular control and lengthening the spine in the process. Clinical Pilates emphasizes controlled extension activities.

Osteoporosis is often called the silent disease because fragility fractures can happen over time in the spine and may not be detected – or detected incidentally when a more serious fracture such as a hip fracture occurs.

Once one vertebrae changes shape into a wedge – the following cascade effect occurs.

• Progression of a kyphotic (rounded) spine.
• Reduced height, stiffer rib cage and reduced volume of breath.
• Reduced appetite and discomfort in the abdomen.
• Poor elimination – constipation.
• Poor neck posture resulting in neck tension and headaches.
• Shoulder problems due the change in position of the bones that form the shoulder joint and abnormal loading of the supportive muscles all resulting in shoulder pain and impingement.

Good balance reduces the risk of falls

Apart from appropriate strength training for healthy bones it is also important to improve your balance to minimize your risk of falling and sustaining a fracture.

If you are unable to stand on one leg for 10 seconds or more – lightly touch a wall or bench and gradually withdraw this assistance as able.

Once you can balance unsupported for 30 seconds or more close your eyes and repeat the exercise until you can balance for over 10 seconds.

Gradually progress to more challenging balancing exercises with guidance from your physiotherapist. Balance exercises can be done incidentally throughout the day for example, when cleaning your teeth, waiting for the kettle to boil, or while talking on the telephone.

Maintain the Correct Posture

Good erect posture can minimise the effect of gravity on your spine.

We all tend to slouch at times particularly with a more sedentary lifestyle. This leads to postural changes such as; rounded shoulders, poke chin, sway back and rounding of the spine. These changes cause our centre of gravity to move forward resulting in more compressive loads on the spine, shoulders and head due to gravity. This increased compressive load can be enough to cause wedge fractures of the thoracic spine. There are many exercises that, over time, can realign your spine and restore healthy posture.

Exercises that work your spine in extension should be a part of your healthy bones routine.

Common ankle and foot injuries include:

Lateral Ligament Sprain

Lateral ligament sprains are one of the most common ankle injuries, occurring when the ankle rolls inwards. Symptoms commonly include significant swelling, bruising and pain with weight-bearing. Patients will also commonly experience a deficit in strength, control, balance and proprioception.

Lateral ligament sprains generally have good functional outcomes, even in the presence of a complete tear. Following the initial inflammatory phase, treatment may consist of range of motion and strengthening exercises, balance work and eventually rehabilitation for return to sport if required.

Chronic Ankle Instability

Chronic ankle instability refers to repeated ankle sprains, most commonly of the lateral ligaments. Patients often develop chronic ankle instability when the deficits in strength, control, balance and proprioception associated with an ankle sprain are not treated effectively. As such, treatment for chronic ankle instability is focused on addressing these deficits. Taping or soft braces may also be used to provide external support to the ankle.

Achilles Tendinopathy

Achilles tendinopathy is a common overuse injury that can affect either the midportion of the Achilles, or the insertion of the Achilles onto the calcaneus (heel bone). Commonly, Achilles tendinopathy develops following a sudden increase in training load or intensity. Symptoms may include pain that is worse in the mornings and that eases with exercise, as well as tightness and weakness in the calf. Pronated feet, or “flat feet”, are also a risk factor for developing Achilles tendinopathy.

The treatment for Achilles tendinopathy varies, depending on whether the tendinopathy is in the middle of the tendon or where the tendon inserts into the heel bone. However, with a well-planned and appropriate exercise protocol, patients with Achilles tendinopathy can return to full function and, if desired, high-level sport.

Plantar Fasciitis

The plantar fascia is a band of fibrous, connective tissue on the sole of the foot that supports that provides arch support and shock absorption. Plantar fasciitis refers to inflammation or pain in the plantar fascia and may be associated with a sudden increase in load or activity. Common symptoms of plantar fasciitis include heel pain (particularly with the first few steps in the morning), pain with ascending stairs, limited ankle range of motion and calf tightness.

Treatment of plantar fasciitis may include avoiding aggravating activities, release of the plantar fascia, taping, stretching and strengthening of supporting muscles.

Fractures

Ankle fractures most commonly occur during sport or as the result of a fall. Common locations of ankle fractures can include the base of the fifth metatarsal, above the lateral and medial malleoli and across the tibial plafond (at the end of the fibula or tibia). Following a fracture, significant swelling and bruising may occur and patients will often experience pain with weight-bearing. Suspected ankle fractures should be confirmed with imaging as soon as possible. Treatment often consists of immobilisation while the fracture heals, then progressive range of motion, strengthening and balance or proprioception exercises. Fractures of the foot are less common than ankle fractures, however, treatment principles are often similar.

Osteoarthritis

Osteoarthritis in the ankle or foot occurs less frequently than in other joints of the body. Up to 70% of cases of ankle and foot osteoarthritis are secondary to a trauma, such as a fracture or a severe ankle sprain. Symptoms of osteoarthritis are generally similar across all joints of the body, including morning stiffness, pain with weight-bearing, muscle weakness, stiffness and “clicking” or “crunching” noises.

Physiotherapy treatment for ankle and foot osteoarthritis may include targeted strengthening exercises, range of motion exercises, balance or proprioception training and hydrotherapy. Massage, heat and passive mobilisation may also be used, however, these should only be used as short-term, adjunct treatments.

Post-surgical Pain & Stiffness

Following ankle or foot surgery, patients will often experience pain and stiffness, particularly if the joint has been immobilised. Treatment for post-surgical pain and stiffness may include passive joint mobilisation, range of motion exercises, strengthening exercises and balance or proprioception training. Treatment can also include gait re-training and specific rehabilitation for return to sport or pre-injury activities.

Knee injuries can occur across all ages and can be either acute or gradual in onset. The knee is heavily influenced by the biomechanics of the hip and ankle, so consideration of the whole lower limb chain is essential to long-term treatment and injury prevention.

Common knee injuries include:

Ligament Injury (ACL, PCL, MCL, LCL)

Ligament injuries most commonly involve the anterior or posterior cruciate ligaments and the medial or lateral collateral ligaments. In more severe injuries, more than one ligament may be affected. The most common mechanisms of injury for each ligament are outlined as follows:

• Anterior Cruciate Ligament (ACL)Sports involving rapid changes in direction, jumping or sudden deceleration, e.g. landing from a jump then turning on a planted foot
• Posterior Cruciate Ligament (PCL)Direct blow to the front of the tibia while the knee is bent, e.g. dashboard injury during a motor vehicle accident
• Medial Collateral Ligament (MCL)Impact to the outside of the knee when the foot is fixed on the ground
• Lateral Collateral Ligament (LCL)Impact to the inside of the knee, or lateral rotation during weight-bearing, e.g. during sports with rapid changes in direction

On assessment, ligament injuries are graded according to their severity;

• Grade I injury: Indicates the ligament has limited damage (sprain) but is still able to stabilise the knee
• Grade II injury: Indicates the ligament has been partially torn, with a resulting decrease in joint stability
• Grade III injury: Indicates a complete tear or rupture of the ligament

Following a ligament injury, patients will often report immediate pain, swelling and bruising. A popping sound may also be reported at the time of the injury.

Treatment can vary, depending on which ligament was injured and the severity of the injury. Initial management generally involves managing swelling and inflammation and reducing pain. Crutches may also be recommended depending on the level of pain and the patient’s ability to weight bear. For MCL injuries, patients will often be required to wear a limited range of motion brace for several weeks to protect the ligament from further damage. Treatment of ligament injuries generally involves extensive rehabilitation for a safe return to sport and prevention of future injury. In some instances, surgery may also be required.

Meniscus Injury

Acute meniscal injuries often occur as a result of a combined compression and rotation force. For example, twisting while the foot is anchored on the ground. Symptoms can vary depending on the severity of the injury but typically swelling and pain may not develop until 24-48 hours after the injury. In more severe cases, restricted knee movement and locking of the knee may be experienced.

Treatment of meniscal injuries varies depending on the severity and in some cases, surgery may be indicated. Initially, treatment involves the management of pain and swelling. Following this, specific strengthening, stabilisation and range of motion exercises will be included. Physiotherapy management should always be considered for meniscal injuries, even when surgery is indicated, because patients will often have better postoperative results if they have performed preoperative rehabilitation (or “prehab”).

Degenerative meniscal injuries commonly occur in older adults often without any trauma or any resulting symptoms. Conservative physiotherapy treatment, again involving strengthening, stabilisation and range of motion exercises, is often successful for degenerative meniscal injuries.

Patellar Dislocation

Patellar dislocation is often associated with a traumatic force to the knee and may occur in sports involving twisting or jumping. Although the patella may relocate spontaneously soon after the dislocation, severe pain and swelling will often be experienced immediately. Locking of the knee and instability may also be experienced. Following a patellar dislocation, imaging is often recommended to exclude an osteochondral or avulsion fracture.

For a first-time patellar dislocation, treatment often involves immobilisation in a brace for six weeks, followed by physiotherapy treatment to improve stability, range of motion and strength. In some cases, surgery may be indicated.

Patellar Tendinopathy (Jumper’s Knee)

The patellar tendon is located below the patella (knee cap) and works with the quadriceps muscles and quadriceps tendon to straighten the knee. Patellar tendinopathy can occur following a sudden increase in load or as a result of overuse and is often associated with biomechanical abnormalities, muscle weakness or poor motor control. Patellar tendinopathy is a common cause of knee pain in jumping sports. It may also occur in sports involving rapid and frequent directional changes. Patients may report knee pain aggravated by jumping or walking downstairs.

Treatment of patellar tendinopathy is individualised to the patient but often includes initial load reduction, soft tissue therapy, targeted strengthening exercises, correction of biomechanical abnormalities and specific motor control exercises. An important part of patellar tendinopathy rehabilitation is a graduated and structured return to sport, as increasing load too quickly can delay rehabilitation and cause the tendon to become symptomatic again.

Quadriceps Tendinopathy

The quadriceps tendon is a single tendon for all four quadriceps muscles, located above the patella (kneecap). Quadriceps tendinopathy is an overuse injury, associated with overloading of the quadriceps tendon. Weightlifters may be more prone to developing a quadriceps tendinopathy, due to the increased loading of the tendon in deep squats. Symptoms will often include pain above the patella and pain with resisted contraction of the quadriceps. Treatment of quadriceps tendinopathy is often similar to the treatment of patellar tendinopathy, including load reduction, targeted strengthening and motor control exercises and correction of biomechanical abnormalities.

Patellofemoral Pain Syndrome (PFPS)

Patellofemoral pain syndrome (PFPS) refers to pain around the patellofemoral joint and surrounding soft tissues, which is commonly related to increased or unaccustomed loading of the joint. PFPS may be caused by either intrinsic or extrinsic factors, however, a combination of both will often be present. Intrinsic factors contributing to PFPS may include rotation of the femur or tibia, the angle of the knee or ankle joint, muscle flexibility, muscle strength and movement of the patella. Extrinsic factors may include training load, volume or intensity; the type of training (e.g. hill running, long-distance running, cycling); training surfaces (e.g. concrete, grass, trails) and training technique.

Consideration of both intrinsic and extrinsic factors contributing to PFPS is essential for treatment and long-term recovery. Initially, taping or stabilisation braces may be recommended, combined with a decrease in training load or intensity. Following this, rehabilitation often involves targeted strengthening exercises, soft tissue release, correction of technique and biomechanical abnormalities and a graduated return to the patient’s former training load.

Iliotibial Band Friction Syndrome (ITBFS)

The iliotibial band (ITB) is a band of fascia running from the hip to the knee along the lateral aspect of the thigh. Iliotibial band friction syndrome (ITBFS) is an overuse injury caused by friction between the ITB and structures around the lateral knee, commonly occurring in runners, cyclists and endurance athletes. The main symptom of ITBFS is aching in the lateral knee aggravated by running, cycling or walking downhill. There may also be tightness of the ITB and weakness of the hip muscles.

Treatment of ITBFS often focuses on initially reducing the patient’s training load, correcting biomechanical abnormalities and strengthening muscles around the hip, before gradually returning to a high training load.

Osteoarthritis

Knee osteoarthritis is a common degenerative condition. It mostly affects the articular cartilage which allows the bones to glide smoothly and painlessly over each other, while also helping to absorb shock. Knee OA is characterised by the degeneration of this articular cartilage, causing the cortical bone below to become exposed. OA is diagnosed with x-ray, which will show a loss of joint space and changes to the bony surfaces of the joint.

In July 2018, the Royal Australian College of General Practitioners published new guidelines for the management of hip and knee OA. These guidelines confirm that exercise and weight management are the best treatments for OA. Specifically, land-based exercises such as walking, strength training and tai chi, are recommended. Treatments such as heat, massage, hydrotherapy and medication can also be used for OA but should only be used as adjunct treatments to exercise and weight management. Before commencing an exercise program for OA it is important to consult a physiotherapist. A thorough physiotherapy assessment will allow for the development of an appropriate exercise program, based on symptoms, functional limitations, personal preference and goals.

Total Knee Replacement

A total knee replacement (TKR) is a common surgery for end-stage osteoarthritis (OA). Following TKR surgery, patients will be treated by a hospital-based physiotherapist until discharge. Initially, physiotherapy is focused on mobilisation out of bed within the first 12-24 hours of surgery. This may begin with just sitting on the edge of the bed, standing at the bedside or taking a few steps with a forearm support frame. Over the next few days, physiotherapy involves regular walking with a walking aid, range of motion exercises and gentle strengthening exercises. Often patients will need to demonstrate at least 90 degrees of knee flexion on the operated knee and be able to walk independently with crutches or a walking frame before being discharged from hospital.

Following discharge, a strict exercise program of range of motion and strengthening exercises should be followed, both at home and under the guidance of a physiotherapist. These exercises are often required to be performed multiple times daily to avoid post-surgical stiffness and allow a full return to normal daily activities and hobbies. At Hawker Place Physiotherapy and Pilates, we provide individualised exercise programs for patients who have had a TKR, regardless of the length of time since surgery. Prior to TKR surgery, undergoing a pre-operative rehabilitation (“prehab”) program of strengthening and mobility exercises may also improve early post-operative pain and function.

Post-surgical Pain & Stiffness

Following knee surgery, patients will often experience pain and stiffness, particularly if the joint has been immobilised. Treatment for post-surgical pain and stiffness may include passive joint mobilisation, range of motion exercises, strengthening exercises and stabilisation or proprioception training. Treatment can also include gait re-training and specific rehabilitation for return to sport or pre-injury activities.

Pain around the hip is common for all age groups. The hip joint’s integration with the pelvis, sacroiliac joint (SIJ) and lumbar spine (lower back) makes it a complex region to correctly analyse and assess any dysfunction.

Hip function can also be affected by low back and lower limb biomechanics involving the knee, foot and ankle, as well as the thigh and calf muscles.

Common hip conditions include:

Hip Osteoarthritis

Hip osteoarthritis is a common degenerative condition. It mostly affects the articular cartilage which allows the bones to glide smoothly and painlessly over each other, while also helping to absorb shock. Hip OA is characterised by the degeneration of this articular cartilage, causing the cortical bone below to become exposed.

OA is diagnosed with x-ray, which will show a loss of joint space and changes to the bony surfaces of the joint.

In July 2018, the Royal Australian College of General Practitioners published new guidelines for the management of hip and knee OA. These guidelines confirm that exercise and weight management are the best treatments for OA. Specifically, land-based exercises such as walking, strength training and tai chi, are recommended. Treatments such as heat, massage, hydrotherapy and medication can also be used for OA but should only be used as adjunct treatments to exercise and weight management. For hip OA specifically, it has been found that patients who participate in a regular strength program are less likely to have a hip replacement, or are able to prevent the need for a hip replacement for a longer period of time (Sverge et al, 2013).

Before commencing an exercise program for OA it is important to consult a physiotherapist. A thorough physiotherapy assessment will allow for the development of an appropriate exercise program, based on symptoms, functional limitations, personal preference and goals.

Svege, Ida, et al. “Exercise Therapy May Postpone Total Hip Replacement Surgery in Patients with Hip Osteoarthritis: a Long-Term Follow-up of a Randomised Trial.” Annals of the Rheumatic Diseases, vol. 74, no. 1, 2013, pp. 164–169., doi:10.1136/annrheumdis-2013-203628.

Total Hip Replacement

A total hip replacement is a common surgical procedure, where the head of the femur and the hip socket are replaced with artificial substitutes. The hip is a ball and socket joint, where the head of the femur is the ball that fits into the hip socket. Most commonly, total hip replacements are a treatment option for hip osteoarthritis once physiotherapy management is no longer enough to minimise pain.

Another common reason for a total hip replacement is to fix a broken hip following a fall. In this case, it is an emergency procedure and there is no option to trial physiotherapy prior to surgery.

Following THR surgery, patients will be treated by a hospital-based physiotherapist until discharge. Initially, physiotherapy is focused on mobilisation out of bed within the first 12-24 hours of surgery. This may begin with just sitting on the edge of the bed, standing at the bedside or taking a few steps with a forearm support frame. Over the next few days, physiotherapy involves regular walking with a walking aid, range of motion exercises and gentle strengthening exercises.

Following discharge, a strict exercise program of range of motion and strengthening exercises should be followed, both at home and under the guidance of a physiotherapist. These exercises are often required to be performed multiple times daily to avoid post-surgical stiffness and allow a full return to normal daily activities and hobbies.

At Hawker Place Physiotherapy and Pilates, we provide individualised exercise programs for patients who have had a THR, regardless of the length of time since surgery. Prior to THR surgery, undergoing a pre-operative rehabilitation (“prehab”) program of strengthening and mobility exercises may also improve early post-operative pain and function.

Gluteal Tendinopathy & Trochanteric Bursitis

Gluteal tendinopathy and greater trochanteric bursitis are often grouped under the term greater trochanteric pain syndrome (GTPS) despite being different conditions. Symptoms of both gluteal tendinopathy and greater trochanteric bursitis are very similar. There will generally be pain and tenderness over the lateral hip bone as well as pain when lying on that side.

A gluteal tendinopathy is a common cause of lateral hip pain. Tendons are tough fibrous structures that connect the muscles to bones. Gluteal tendinopathy is a degeneration of the tendon caused by repetitive overloading. It is a common condition both in athletes and in the older population. Treatment involves modification of activity to reduce the load on the tendon and a gradual strengthening program guided by your physiotherapist.

Greater trochanteric bursitis is an inflammation of the bursa that sits on the hip bone. A bursa is a fluid-filled sac that acts to absorb shock and minimise friction between the soft tissues and bone. Greater trochanteric bursitis has a gradual onset and progresses over time due to overuse, increased friction, too much pressure or direct trauma. In most cases treatment consists of reducing aggravating activities and a strengthening and stretching program with a physiotherapist. Ice and anti-inflammatory medications can also be used to help reduce inflammation and pain.

Stress Fracture

Stress fractures occur in bones when they cannot tolerate the amount of mechanical load being placed through them.

Bones are constantly in a cycle of breakdown and repair (known as bone resorption and bone formation). Stress fractures occur when repetitive loads placed through bones lead to an imbalance between the two processes – with a higher rate of breakdown than repair.

Stress fractures will usually begin as a microscopic crack in areas of greatest stress, if the bone continues to be loaded and not heal, this can lead the crack to enlarge.

Many factors can contribute to bone stress fractures including; high repetitive activity levels, osteoporosis, radiation therapy, hormone imbalances, poor nutritional status, and bone quality.

Stress fractures of the hip most commonly occur in runners at the femoral neck. Symptoms include pain at the front of the hip or groin. Pain will initially be present during running, however, in more severe cases, pain can become more constant.

Hip Labral Tear

The labrum of the hip is a cartilaginous ring that lines and deepens the socket and improves hip joint stability. Tears to the labrum can occur in sports involving repetitive activities such as kicking and dancing. People with other hip conditions, such as femoroacetabular impingement or hip dysplasia, have a higher risk of labral tears.

Labral tears are often characterised by deep pain towards the front of the hip or groin, aggravation of pain with movement and clicking, catching or giving way of the limb. Your physiotherapist or doctor may refer you for further imaging in order to assist in diagnosis of a labral tear.

Pelvic Girdle Pain during Pregnancy

Low back and pelvic girdle pain are common side effects of pregnancy. Pelvic girdle pain can occur at any stage of pregnancy, however, it is more common in the third trimester. It is important to know that pelvic girdle pain will not harm your baby, though it can result in a lot of pain for you.

Pelvic pain can occur at the front or back of the pelvis and can occasionally refer into your hips or thighs. The cause of pelvic girdle pain during pregnancy is believed to have multiple contributing factors including; hormonal, physiological and postural changes. As your baby grows the increased weight can change your posture when you sit or stand, increasing stress on the pelvis. Your physiotherapist can provide you a range of exercises, strategies, and therapies to help you to manage your pelvic girdle pain during pregnancy.

Osteitis Pubis

Osteitis pubis is an inflammation of the pubic symphysis. The pubic symphysis is a cartilage joint that joins your left and right pubic bones together. Its role is to keep the two bones of the pelvis steady and together during movement and activity. Symptoms include pain over the pubic bone which can also refer into the groin region. Often pain will also be reproduced with coughing, sneezing and during sit ups. Osteitis pubis is a common cause of groin pain in athletes in the football codes. Your physiotherapist will recommend a period of rest, alongside a rehabilitation program consisting of specific stabilisation exercises of the pelvis. Once symptoms start to improve, your physiotherapist will recommend a graded return to your sport or activity

Sciatica

Sciatica is a term used to describe pain along the distribution of the sciatic nerve, which runs from the lower back, through the buttock and down through the back of the leg. Sciatic pain is caused by irritation or pinching of the sciatic nerve.

Irritation or pinching of the sciatic nerve can be the result of many different pathologies. These can include entrapment from a herniated disc in the lumbar spine, spinal canal stenosis, arthritic conditions, fractures, spondylolisthesis (a slipping of the vertebra) or even just stiffness of the lumbar spine or tightness of muscles surrounding the sciatic nerve.

Patients with sciatica may experience radiating pain or altered sensation such as pins and needles or numbness. In more severe cases, muscles throughout the leg may also become weak.

Your physiotherapist will perform a comprehensive assessment of your range of motion, movement patterns, neurological structures and strength. Treatment will often include manual therapy, soft tissue massage and gentle strengthening and mobility exercises.

According to the Australian Bureau of Statistics (2014-15 report), 70-90% of all Australians will experience low back pain at some point in their life.

Approximately 95% of all cases of low back pain are diagnosed as “non-specific low back pain”. This means that multiple structures could be contributing to the pain, including intervertebral discs, facet joints, ligaments, muscles, fascial tissue and dural connective tissue.

For the remaining 5% of cases of low back pain, only 4% are diagnosed as a spinal nerve root compression and only 1% as a more serious spinal pathology, such as a fracture or a tumour.

Spinal imaging methods, such as x-ray, MRI and CT scans also have a limited capacity to accurately diagnose the cause of low back pain. Common imaging findings, such as bulging discs, degeneration and spondylolisthesis, are actually normal age-related changes. In fact, a large 2015 study found that 60% of 50-year-olds with no back pain had a disc bulge on imaging!

Despite the difficulty of identifying the source of low back pain, a variety of physiotherapy treatments are effective at reducing pain and stiffness, improving functional outcomes and preventing recurrence of pain. Low back pain is a very recoverable condition, with approximately 90% of cases recovering completely within 6 weeks.

Physiotherapy treatment for low back pain will vary depending on how acute the pain is. For acute flare-ups, treatment may include gentle manual therapy, massage and mobility exercises. Your physiotherapist will also be able to provide advice about the best strategies to manage pain and movement during acute episodes of low back pain.

Following the acute stage, physiotherapy treatment often includes more targeted soft tissue massage, manual therapy and exercises. As pain decreases, physiotherapy treatments will become increasingly focused on exercise to promote self-management and decrease the risk of future flare-ups. While some of these exercises may be based on increasing core strength and control, recent studies have found general strengthening exercises are equally as effective in preventing low back pain as core exercises.

If you have recently experienced an acute episode of low back pain, or if low back pain is something that bothers you on a regular basis, physiotherapy can be highly beneficial. At Hawker Place Physiotherapy and Pilates, our physiotherapists also run private and group Clinical Pilates classes designed specifically for people with acute or chronic low back pain.

Pain and stiffness caused by thoracic spine injuries are generally located in the upper to mid back region. Thoracic pain is most commonly associated with poor posture, occupations and hobbies. Pain and stiffness will commonly present gradually, or after a period of increased computer time such as during exam periods or busy periods at work. However pain can also occur suddenly, such as following an awkward lift or reach.

Thoracic pain is often associated with muscle tension of the shoulders, the neck and low back. Physiotherapy treatment involves mobilisation and soft tissue techniques, alongside specific exercises which aim to decrease pain and restore mobility and normal function.

Pain caused by rib injuries most commonly present in the chest or upper to mid back regions. Rib injuries often occur following a cold or flu and will often be painful when taking a deep breath, during coughing, and whilst laughing. Direct trauma to the chest and back can also be a cause of rib fractures and sprains.

Common causes of thoracic spine or rib pain include:

Posture-related Pain or Tension

This is a common issue seen at Hawker Place Physiotherapy and Pilates, due to the high number of office workers and public servants in Canberra. Posture-related pain is commonly found in the mid to upper back, neck and around the shoulder blades. This may involve tense muscles, intervertebral joints or the rib joints.

Pain in this area typically worsens over time especially with stationary tasks such as computer work, driving and reading. Physiotherapy will involve a comprehensive assessment of neck, thoracic and shoulder joints and muscles as well as assessing the way you move, sit, stand.

Treatment may involve techniques to reduce muscle tension such as massage, dry needling, stretching or joint mobilisations. You will undoubtedly have some home work after physiotherapy to optimise posture and to strengthen the postural muscles to help prevent pain recurrence.

Rib Fractures

Rib fractures can result acutely from trauma such as severe coughing or a direct blow, as well as over time from repetitive loading activities such as rowing.

Rib stress fractures are different from traumatic fractures in that they appear as a weakened area of the bone rather than a crack or break. Stress fractures most commonly occur in athletes, particularly rowers.

Typically with a rib fracture you will experience pain when taking deep breaths or coughing. There may also be pain locally over one or more ribs when pressed. Traumatic rib fractures are characterised by a sudden onset of pain, whereas stress fractures will often be associated with a gradual onset of pain, first in the general chest or back regions, then becoming more localised.

A period of rest combined with physiotherapy will help you to return to your usual sports and activities.

Costochondritis

Chostochondritis is the inflammation of the cartilage located within the joints that connect the ribs to the sternum (breastbone). Patients with chostochondritis commonly experience chest pain on either side of the sternum. The joint will be tender to the touch and the pain will often be aggravated by a slouching posture and exercise.

Chostochondritis is a self-limiting condition, which means that it should resolve over time. It can appear in both children and adults.

It is important that if you are experiencing chest pain you consult a medical professional to distinguish chostochondritis from cardiac causes of chest pain.

Physiotherapy can be helpful to address any postural changes and stiffness in related areas of the body.

Scoliosis

Scoliosis is an abnormal curvature of the spine and is the most common spinal disorder in children and adolescents. It is characterised by a sideways curvature of the spine, often in combination with abnormal rotation of the spinal vertebrae.

Common characteristics of patients with scoliosis include;

• Sideways curves of the spine (may look like an ‘S’)
• Significant differences in shoulder height
• Side lean body posture
• Clothes may not hang properly
• Some patients can experience muscle and joint pain
• In severe cases, breathing may be affected due to secondary deformation of the rib cage

Scoliosis can be structural and non-structural. Structural scoliosis has deviations that are unable to be, or can only partially be, corrected. Non-structural scoliosis results from posture, or muscle compensations around the spine and can be corrected with physiotherapy and exercise.

The wrists, hands and fingers are areas commonly injured during sport. Acute injuries may involve tendons, ligaments, joints or muscles and should be treated promptly. The wrists, hands and fingers are also commonly affected by osteoarthritis, particularly in older adults.

Carpal Tunnel Syndrome

Carpal tunnel syndrome refers to compression of the median nerve (one of the nerves in your arm) as it passes through the carpal tunnel in the wrist. The carpal tunnel is a small space on the palmar side of the wrist made up of small carpal bones and ligaments. For various reasons the median nerve can get compressed through this tunnel and cause symptoms like wrist pain, pins and needles, numbness and weakness of the hand.

Physiotherapy can help to manage symptoms of carpal tunnel syndrome with advice on activity modification, bracing or taping, mobilising stiff carpal bones or helping to release tight tissue in the hand. Your physiotherapist will be able to provide education on personal factors that may be affecting your carpal tunnel, for example inflammatory arthritis or pregnancy. Your physiotherapist can also help to establish an ongoing plan to help prevent a recurrence of carpal tunnel syndrome.

De Quervain’s Tenosynovitis

De Quervain’s tenosynovitis is a common condition causing pain usually around the thumb side of the wrist or even up the forearm. It is the result of inflammation or irritation to two tendons, abductor pollicis longus and extensor pollicis brevis as they pass through the wrist up to the thumb. This is often caused by repetitive hand or thumb movements over time or due to a variety of other factors such as disease, scar tissue build up or weakness. Often people will experience swelling around the painful area or may even feel the tendon creaking as it slides around during hand and wrist movements.

Physiotherapy treatment will include adjusting biomechanics of activities involving the hand, advice on managing inflammation and exercises to strengthen the involved tendons to help prevent future recurrences.

Fractures & Dislocations

Fractures and dislocations of the hand and fingers are commonly caused by traumatic injuries such as falls onto an outstretched hand. They are very common in older adults as well as people who play ball sports. If you are ever unsure whether you have sustained a fracture or dislocation you should always go to ER for medical attention. There are many different joints in the wrist and hand that can be fractured or dislocated and due to their location become very frustrating to manage, especially if they occur on the dominant hand.

Often these injuries will need a period of immobilisation and can leave the hand and wrist feeling very stiff, sore or weak afterwards. Your physiotherapist can help to restore your hand function back to normal after immobilisation using a combination of exercises and manual therapy to loosen joints and scar tissue.

Ligament Sprains

Ligament sprains of the fingers or wrists are also common in people who play high impact sports or have had falls. Often a ligament sprain will be accompanied with bruising, swelling, pain and stiffness of the area. Your physiotherapist is able to help you through the rehabilitation process right from the initial management where braces/tape and inflammation reduction is necessary, all the way through to giving you exercises and making sure your hand or wrist is back to full function before you return to sports and daily activities.

Triangular Fibrocartilage Complex Tear

The triangular fibrocartilage complex (TFCC) is a triangular shaped piece of cartilage at the base of your wrist on the little finger side of your hand. It’s role is to assist in keeping your wrist joint nice and stable. TFCC tears can be painful when compressed or when lifting and twisting. Your physiotherapist can help determine if bracing will be helpful as well as strengthening exercises to improve the stability of the wrist joint.

Mallet Finger

Mallet finger is an acute injury to the finger which occurs as the finger is forced to bend at the same time the finger is trying to straighten. This can result in the muscle which helps to straighten the finger being torn and the consequence is that the end of the finger can’t actively be straightened.

Mallet finger injuries are common in ball catching sports. If untreated this injury can be permanent. Your physio can help pick up this injury early and splinting of the finger is commonly required.

Jersey Finger

Jersey finger is an acute injury the the finger which occurs as the finger is forced to straighten at the same time the finger is trying to bend. Imagine grabbing an opponent’s jersey as they run away from you, the fabric rips out of your grasp and the fingers are forced to straighten. This can tear the muscle which bends the finger off the bone and results in the inability to bend that finger actively.

Partial tears can be treated with conservative management. Complete tears may require surgical intervention.

Osteoarthritis

Osteoarthritis can occur in any joints in the hand and wrist but is most commonly seen around the thumb area and in the fingers. Symptoms can include pain, stiffness, aching and sometimes swelling around the affected area. While arthritis itself cannot be reversed, physiotherapists are able to educate you on how to best manage the symptoms. Treatment often includes education about activity modification, pain management strategies and exercises to help with the range of motion, pain and strength in the wrist and hand.

Elbow injuries are most often classified as repetitive strain or overuse injuries. Various activities and sports can cause an overuse elbow injury, such as typing at a keyboard, tennis and golf. Symptoms that may be associated with elbow pain include difficulty lifting, opening jars, turning door handles and carrying and gripping objects.

Lateral Epicondylalgia (Tennis Elbow)

Lateral epicondylalgia (or epicondylitis) refers to pain on the outside of the elbow. It is often due to tendinopathy of the extensor tendons and more commonly referred to as tennis elbow. The most common cause is repetitive strain through actions that involve the elbow and wrist, for example tennis, typing, painting, cutting, digging or other activities that involve gripping. Pain is often associated with weakness of the arm and wrist. Other causes of lateral elbow pain may include referred pain from the cervical or upper thoracic spine.

Resting from aggravating activities can often ease the pain. Adjusting gripping technique and fixing the wrist, arm and upper body posture can also reduce the load placed through the elbow. Seeking help from your physiotherapist to modify your techniques with problem activities and having a workstation assessment can be beneficial.

Your physiotherapist can implement a specific exercise program targeted to your function and goals. It is important to thoroughly rehabilitate this injury to prevent recurrence.

Medial Epicondylalgia (Golfer’s Elbow)

Medial epicondylalgia (or epicondylitis) refers to pain on the inside of the elbow. It is more commonly referred to as golfer’s elbow or thrower’s elbow. Golfer’s elbow is similar to tennis elbow, except it involves the flexor muscles of the forearm. It is often a result of overuse or overloading of these muscles during activities such as a golf swing or tennis forehand involving a lot of topspin. Those involved in throwing sports may also experience medial elbow pain, often as a result of straining the ligaments in the elbow joint.

As with many overuse injuries, rest is required to reduce the pain and symptoms. Improving technique and gradually increasing your load with specific exercises as guided by your physiotherapist can help to return you to your normal level of activity.

Radial Tunnel Syndrome

Radial tunnel syndrome refers to a compression of the posterior interosseous nerve below the elbow. Compression of the posterior interosseous nerve is commonly associated with repetitive gripping and activities that involve repeated supination of the forearm. Symptoms of radial tunnel syndrome include altered sensation in the hand and forearm, such as pins and needles or numbness, and vague forearm and wrist pain. In more severe cases there may be weakness of the wrist and fingers. Your physiotherapist can assist you with a range of exercises and manual treatment to help improve your symptoms.

Fractures & Dislocations

Fractures of the elbow are most often caused by an acute injury, such as a fall onto an outstretched hand or direct trauma in contact sports. The fracture may be to either or both bones of the forearm (ulnar and radius) or to the upper arm bone (humerus). Often a period of immobilisation is required in either a sling, splint or cast.

Following this period of immobilisation, the elbow joint may be stiff with limited range of motion, and the arm will be weak. Your physiotherapist can help guide you through the appropriate exercises and provide you with manual therapy to help regain your range of motion and strength. Your physiotherapist can also assist you with a safe and gradual return to sport or high level activity.

Bursitis

Bursae are small sacs of fluid that are found around areas of friction, such as where a tendon runs over a bone. They provide cushioning around a joint and allow for smooth movement of the muscles and tendons. Olecranon bursitis (inflammation of the bursa), is the most common bursitis in the elbow joint and is found at the back of the elbow. It is often caused by repetitive trauma to the triceps tendon as occurs when throwing/pitching or from frequent leaning on your elbow. It can also occur secondarily to an acute injury, such as a fall onto the elbow or during contact sports.

Symptoms of olecranon bursitis include pain and swelling at the back of the elbow, pain with leaning on your elbow or pain when fully straightening or bending your elbow.

Ice can help reduce pain and swelling and refraining from aggravating activities is important. Physiotherapy treatment often involves soft tissue massage, strengthening and alteration of biomechanics.

Ligament Sprains

Elbow ligament sprains are normally a result of high force being applied sideways though the joint. The ligaments can be sprained, meaning they are overstretched or overloaded. Tears to part of the ligaments or acute rupture may be the result of a very high stress injury of the elbow. Your physio will be able to help determine the extent of ligament injury during an assessment and implement a treatment program.

The shoulder is the most mobile joint in the body and so shoulder pain and injuries are common. The surrounding shoulder muscles, such as the rotator cuff muscles, are vital in providing dynamic stability, particularly in weak or unstable shoulders. In many cases, shoulder pain is associated with muscles that are weak or that are not working in a coordinated and controlled manner.

A thorough physiotherapy assessment of a painful or stiff shoulder includes examination of the shoulder joint itself, the neck and surrounding soft tissues, which can refer pain to the shoulder. This allows a comprehensive treatment plan to be developed, for both short and long-term improvements in pain and/or stiffness. Research shows that managing shoulder injuries conservatively with physiotherapy is very successful.

Common shoulder conditions include:

Bursitis

Shoulder bursitis is a condition involving inflammation or irritation of the bursa in the subacromial space. This can occur as a result of repetitive activities, poor shoulder positioning or traumatic events, such as a fall onto the shoulder causing injury to the bursa and pain in the shoulder or upper arm area. Typically, pain will be associated with movements involving reaching forwards or sideways, such as putting a jacket on, washing hair, reaching to high cupboards or lifting weight.

Physiotherapy is important to assist in correct diagnosis as well as identification of additional factors contributing to the problem. Treatment may involve exercises to strengthen postural and rotator cuff muscles, shoulder mobilisation and stretching.

Impingement

Shoulder impingement, or subacromial impingement, refers to the biomechanical pinching of soft tissue within the shoulder joint. This may include pinching of the subacromial bursa and/or the rotator cuff tendons. Rather than being a diagnosis itself, impingement is a symptom that occurs secondarily to another injury of the shoulder, such as bursitis or a rotator cuff tendinopathy or tear.

Physiotherapy is important in order to help recovery by assisting in identifying the physical and biomechanical factors that may contribute to shoulder impingement.

Rotator Cuff Tears or Tendinopathy

The rotator cuff is the group of shoulder muscles that help support and provide mobility to the shoulder joint. The rotator cuff muscles include the supraspinatus, infraspinatus, teres minor and subscapularis. These muscles all work together to keep the humerus centred in the shoulder joint as the arm moves in different directions.

Rotator cuff tendinopathy describes an acute or chronic condition involving painful irritation of a rotator cuff tendon, whereas a rotator cuff tear refers to a partial or complete tear of the muscle or tendon. Both conditions can result in pain associated with moving the arm or sleeping on the affected side and difficulty lifting or carrying heavy items.

Treatment may involve a period of rest from aggravating activities then gradual loading and strengthening of the affected rotator cuff and surrounding postural muscles.

Acromioclavicular (AC) Joint Injury

The acromioclavicular (AC) joint is located at the point of the shoulder where the end of the collar bone meets the acromion (part of the shoulder blade). This joint helps create a strut where forces from the arm can be transferred to the rest of the trunk through the collar bone. The AC joint also allows for overhead movement of the arm as the collar bone rotates.

The AC joint is typically injured by a fall onto the point of the shoulder (for example in a rugby tackle, or upon landing after flying over the handlebars of a push bike). Some of the strong ligaments surrounding the AC joint can tear causing pain and instability. The shoulder can feel like it is dragging and heavy and sometimes a gap will be apparent.

Treatment may initially involve stabilisation with tape, a sling, or even surgery, followed by graduated exercises to regain normal range of motion and control as the joint recovers.

Labral Injuries

The socket of the shoulder joint is very shallow. The labrum is a rim of cartilage that helps deepen the socket, making it more stable. The labrum is also the attachment site of some tendons and ligaments and despite being a sturdy structure, it can be injured. Common modes of injury include mishaps during throwing, suddenly catching at a heavy load and shoulder dislocation. SLAP lesions (Superior Labrum Anterior to Posterior) are the most common, and involve the labrum peeling off the socket near the insertion of the biceps tendon. Another type of labral injury is a Bankart lesion, which can happen during a shoulder dislocation.

Instability, Subluxation or Dislocation

The shoulder joint is often described as similar to a golf ball (the humerus) resting on the golf tee (the glenoid). The difference between the small surface area of the glenoid and the large area of the head of the humerus allows for the full range of shoulder movements. Shoulder stability is achieved from the cohesive working of the rotator cuff muscles, ligaments and the labrum. Shoulder instability is the result of a defect with one (or more) of these structures.

A subluxation is the name given to an injury, usually traumatic, where the humerus comes partially out of the socket before relocating back into normal position on its own. A dislocation means that the humerus comes out of the socket and stays out. Dislocations usually require a hospital visit to relocate the bones to the normal position and to xray to determine if any damage was done. Physiotherapy can be a helpful part of recovery as soft tissues can be overstretched, muscles weakened and range of motion restricted. Physiotherapists are trained to rehabilitate all of these conditions.

Hypomobility, or Frozen Shoulder

Hypomobility can mean something different to frozen shoulder. Hypomobility means restricted range of shoulder motion. This often presents as stiffness and restriction of one or more movements, such as reaching over head or to the side. This can occur after a period of disuse or immobilisation, such as following a fracture or surgery. Physiotherapy is helpful in reducing stiffness, improving movement and strengthening associated muscles.

In comparison, frozen shoulder, or adhesive capsulitis, is a clinical condition involving pain and a gradual loss of range of motion. This is due to a thickening of the shoulder joint capsule itself without a known cause. Frozen shoulder tends to follow a predictable course of three stages as follows:

1. “Freezing” stage: Pain can be significant and movement of the shoulder joint is gradually reduced
2. “Frozen” stage: Pain gradually improves, however movement is still reduced
3. “Thawing” stage: Movement gradually returns to the shoulder joint

As the shoulder thaws, exercise is also very helpful in restoring normal function.

Physiotherapy can be helpful in correctly identifying this condition and providing education on the current stage and expected outcomes.

Fractures

A fracture to the shoulder may involve the humerus, collarbone or even shoulder blade. Generally fractures are the result of a traumatic incident (stress fractures in the shoulder are very rare). Once the bone is healed it can be difficult to regain full and normal movement of the shoulder as well as regain normal arm strength. Physiotherapy can be helpful in regaining normal shoulder range of motion with manual therapy, stretches and range of motion exercises. Physiotherapy can also assist in regaining strength throughout the shoulder and arm to stabilise the joint and prevent future injuries.

The neck, or cervical spine, is the most mobile segment of the spine and is stabilised by many layers of surrounding soft tissue. Neck pain and stiffness can develop gradually over time, particularly in people who spend prolonged periods of time in a fixed posture. Neck conditions can also develop acutely, for example following a bad night’s sleep or a rear-end car accident.

In many cases, the pain and stiffness being experienced is often associated with significant tension throughout the muscles of the neck, shoulder and thoracic spine. With appropriate massage, manual therapy and strengthening exercises, many neck conditions can recover quickly.

See below for common neck conditions.

Posture-related Pain or Tension

Poor posture can have a significant influence on strength, pain, mobility and function throughout the body. Due to their close proximity to the neck, the position of the shoulders and thoracic spine often contribute to neck pain and stiffness.

For example, people who tend to slouch will often demonstrate increased curvature of the thoracic spine and shoulders that are rolled forward. This position places more load on the structures surrounding the neck and may cause them to become painful. Poor posture can also lead to weakness and deactivation of particular muscles, increasing the likelihood of developing neck pain.

Posture-related neck pain is common in occupations requiring prolonged periods of sitting or standing. Office workers are often prone to developing neck pain and stiffness, especially when they have a poor workstation setup. Postural abnormalities associated with sports and hobbies can also lead to neck pain and stiffness.

Posture-related neck pain can be prevented and treated effectively with physiotherapy. While treatment may vary between patients, it often involves a combination of manual therapy, massage, strengthening exercises and posture correction.

Acute Wry Neck

Acute wry neck involves a sudden onset of sharp neck pain and stiffness, typically following a sudden, quick movement or after sleeping in an abnormal position. Often, patients will have pre-existing abnormal postures or muscle deconditioning prior to the onset of pain. Acute wry neck can affect joints and discs in the cervical spine and may result in a protective tension response in surrounding soft tissues, further exacerbating pain.

Treatment of acute wry neck often involves the use of heat, passive mobilisation of the cervical spine, gentle range of motion exercises, release of surrounding soft tissues and strengthening exercises for muscles that support the neck. Education about the importance of movement in treating acute wry neck is also essential to successful and timely recovery.

Whiplash

A whiplash injury occurs after a sudden acceleration-deceleration incident, such as a rear-end collision or a tackle in football. A whiplash injury can affect multiple structures in the cervical spine, including muscles, ligaments, joints and neural tissue. Common symptoms of whiplash include neck pain, headaches and neck stiffness. In more severe cases, neurological symptoms or a cervical spine fracture may be present.

Early treatment of a whiplash injury is very important for recovery and should include education about the condition and gentle neck movements within a comfortable range. Following this, treatment should include a combination of specific exercises, manual therapy and ongoing education.

Cervical Radiculopathy

Cervical radiculopathy, more commonly known as a pinched nerve, arises as a result of compression on a nerve root in the neck. This compression can be caused by osteophytes, disc changes, spondylosis or inflammation of a nearby structure. Symptoms may include pain, pins and needles, numbness or sensation changes in the shoulder and arm.

Initial treatment may include use of heat, traction, neural tissue mobilisation and passive mobilisation of the cervical spine. Following the acute phase, treatment is aimed at preventing recurrences and may include posture correction and muscle strengthening.

Cervicogenic Headaches

Cervicogenic headaches, or cervical headaches, are caused by tension or abnormalities in the structures of the neck. These structures can include joints, muscles, fascia and neural structures. Symptoms of a cervicogenic headache can also be influenced by posture, poor upper body biomechanics and emotional stress.

Typically, cervicogenic headaches are described as a dull ache on one side of the head, however they can also be bilateral. Physiotherapy treatment for cervicogenic headaches varies between patients, but may involve soft tissue therapy, passive mobilisation of the cervical spine, correction of any postural or biomechanical abnormalities and strengthening of the deep neck muscles.