• Home
• Spinal Conditions
• Peripheral Joint
• Sports Injury
• Workplace Health
• FAQ
• About MCR

Subscribe

Is the Outcome of ACL Surgery really better than Conservative Management?

If you have sustained an ACL ( Anterior Cruciate Ligament of  the knee) tear and is considering an ACL surgery, you would find it useful to know more about the latest research discussion on ACL surgery versus Physical therapy management.

Knock Knees – Can I reverse it? (Part 2)

In the previous entry for Knock Knees, we discuss about the different types of knock knees and the contributing factors of it. Now, we will talk about the problems of this condition and ways we could get rid of it.

The Problems of this condition

The alignment of the knee joint in someone with knock knees is such that there is an increased force on the medial (inner) part of the knee joint. This can predispose the knee joint to osteoarthritis because of the increased loading on the medial compartment.
Symptoms from this may not even present within the knee joint, you may have ankle problems or hip problems as a result of having knock knees.

How do I get rid of it?

External aids:

1. Orthotics

The knee joint may appear to be misaligned if the foot is not biomechanically sound. This means that someone with a very pronated/inverted/flat feet may be at risk of developing a symptoms similar to someone with knock knees. Placing an insole or orthotics device may help correct the foot position, and indirectly the alignment of the knee joint.

2. Knee braces

These can help prompt correct alignment of the knee joint, but may create a degree of dependency.

3. Strengthening

A physiotherapist can design an exercise program to help strengthen weak muscles. By focussing on the specific muscles that require strengthening, you will put your body is a safe healthy direction, and will be able to train for all types of sporting challenges and limit your risk of injury.

4. Stretching

Stretching is an important component of knock knee reversal. When a joint has spent all it’s time in a misaligned position, certain structures will shorten and become stiff. Stiffness in the joints and muscles will make it very difficult to train and strengthen the area. A physiotherapist can assess the position of your knee, ascertain which structures are tight, and give you an appropriate stretching program.

 

Maybe it’s not Plantarfasciitis but Heel Fat Pad Syndrome

Do you have heel pain? And think it is Plantar Fasciitis?

Maybe not, it might be another type of heel pain called the Heel Fat Pad Syndrome.

What´s the difference between the Plantar Fasciitis and Heel Fat Pad Syndrome?

As shown in the illustration, both structures are in the same area of the heel whereas the plantar fascia (illustrated as plantar apponeurosis) is covered by the fat pad. The plantar fascia attaches at the toes and forms the medial (longitudinal) arch of the foot. It provides static support of the medial arch and dynamic shock absorption. The main functions of the fad pad is shock absorption of stress during heel strike (heel contact during walking).

While both the heel fat pad and plantar fascia can be a source for heel pain, the contributing factors, clinical signs and symptoms and management for them differ.

Plantar Fasciitis

Plantar fasciitis is an overuse condition of the plantar fascia.

Contributing factors: It is often seen in people with foot deformities e.g. flat feet (low arches) or pes cavus (high arches). This deformities can lead to an excessive strain at the fascia during walking and hence cause pain. Other risk factors which can lead to increased stress in the fascia are inappropriate or non-supportive footwear, reduced ankle mobility, obesity and work related weight bearing.

Clinical signs and symptoms: A typical clinical sign is swelling of the plantar fascia and can be confirmed by ultrasound investigations. People with plantar fasciitis classically have a gradual onset of symptoms and feel their pain more on the inner side of the heel. Further symptoms are acute tenderness of the inner side of the heel, a tight plantar fascia and pain during stretching of the fascia. Especially the first steps in the morning or after rest are painful. The pain seems to decrease after a few minutes, and returns as the day proceeds and time on the feet increases.

Management: Due to the tightness of the plantar fascia that leads to pain, treatments involve stretching and massaging to release the tight fascia and calf muscles. Other management include avoiding aggravating activities (e.g. wearing heels), cold therapy (R.I.C.E), anti-inflammatory drugs, taping to to relief pain and lastly it is crucial to strengthen calf muscles that have weakened during the pain process. Some patients who are still symptomatic after conservative treatment might need surgery.

Heel Fat Pad Syndrome

Heel fat pad syndrome is often caused by a decreased elasticity of the fat pad. A fall onto the heel from a height or chronically excessive heel strike with poor footwear can also lead to heel pain.

Contributing factors: Increased age and weight decreases the elasticity of the fat pad.

Clinical signs and symptoms: Compared to plantar fascitis, fat pad related heel pain is felt more at the outer side of the heel especially when the heel gets loaded (heel strike). MRI investigations will reveal changes in the fat pad showing signs of swelling.

Management: Treatments aimed at unloading the heel by avoiding aggravating activities. In an acute situation the R.I.C.E. rule (Rest Ice Compression Elevation) should be applied and anti inflammatory drugs are given. Further treatment includes taping, the use of a silicone gel heel pad and use of appropriate footwear.

References:

1. Brukner, P & Khan, K 2007, Clinical Sports Medicine, 3^rd edition, Tata McGraw Hill, Australia .
2. Cole, C, Seto, G & Gazewood, J 2005, 'Plantar Fasciitis: Evidence-Based Review of Diagnosis and Therapy`, American Family Physician, vol. 72, no. 11, pp. 2237-42.
3. Thomas, JL, Christensen,, JC, Kravitz,, SR, Mendicino, RW,  Schuberth, JM, Vanore, JV, Weil, LS, Zlotoff, HJ, Bouche, R & Baker, J 2010, ´ The Diagnosis and Treatment of Heel Pain: A Clinical Practice Guideline–Revision 2010`,The Journal of Foot & Ankle Surgery, vol. 49, pp. 1-19.

For Swimmers : Common Injuries, Treatment and Prevention tips

Do you swim leisurely or competitively? If yes, continue to read on.

Recently, one of our physiotherapists, Chng Chye Tuan was interviewed by Style:Men on the common musculoskeletal injuries face by swimmers in the July's issue. Do read on to find out what he has to share.

What are the common problems competitive/regular swimmers face?

The most common swimming injury is the rotator cuff impingement / tendonitis.

• Ball joint of the shoulder compress the tendon against the roof of the socket (acromion) in 2 phases of freestyle – the pullthrough and recovery phase.
• Pull-through phase in the freestyle stroke involves the arm pulling against the resistance of the water. The outstretched arm with internal rotation of the shoulder stresses the tendon and pinched it against the acromion. The pinching can irritate the tendons and give a sudden catching kind of pain.
• The recovery phase involves a body roll and raising the elbow up and out to allow the upper limb to recover out of water efficiently otherwise the shoulder will be working harder at an awkward position to pull the hand out of water.
• Repeated pinching will give rise to inflammation and fraying of the soft tissues.

What are the usual causes?

The usual contributing factors are mainly due to over training, poor technique, poor core muscles and unilateral breathing.

• Over training – when muscles are fatigued, the stabilising component from the rotator cuff muscles becomes compromised thus increasing the chances of the humeral head translating upwards and impinging the rotator cuff tendons. The ball component has to be centralised within the socket of the shoulder to optimise stability and muscle function.
• Technique – the freestyle and backstroke requires the swimmer to roll their trunk such that the drag is minimise and the propulsion force can be maximised. Too much drag will increase the resistence, tiring out the shoulder muscles sooner.
• Strong core muscles and truck control enable the swimmer to do a body roll along the longitudinal axis so that it is easier for the shoulder to pull the upper limb out of water.
• Unilateral breathing can develop a muscle imbalance leading to improper muscle activation and overuse.

What kind of treatments do you recommend?

An assessment of the shoulder girdle, spine and core strength will be performed to be able to properly manage a swimmer’s shoulder.

A key treatment to approach the swimming shoulder is to rehabilitate the rotator cuff muscles to be able to centralise the humerus at different shoulder positions.

Exercises will be prescribed to specifically target these rotator cuff muscles, correcting any imbalances. These exercises include strengthening the weak muscles to improve dynamic support and also stretching exercises to the tight muscles pulling the joint out of position.

As most competitive swimmers will not be able to cease training completely, kinesiotaping complements the rehabilitation therapy by improving the rotator cuff’s ability to stabilise the shoulder joint via better joint awareness from the corrective

Are there preventive measures that swimmers can take to minimise such problems?

Regular stretching exercises, core stability training and work on the techniques. During the early stage of feeling the impingement (catching or pinching) pain, seek help from a sports physician or physiotherapist as soon as possible.

Management for ITB friction syndrome

 

Training methods

Biomechanical Gait issues

More Essential Stretches for Swimmers

Stretching is an important part of any warm up and cool down. Sport specific stretching allows you to warm up the specific muscles required for the sport. In swimming, the four competitive strokes are:

• Butterfly
• Backstroke
• Breastroke
• Freestyle

These strokes encompass the use of practically all the muscles in the body, the main muscles that are responsible for the movements that make up a stroke are called the primary muscles. Primary muscles used for all strokes are:

Other muscles that allow for controlled smooth movements are secondary muscles these are:

Anterior deltoid Posterior deltoid Pectorals Serratus anterior Latissimus Dorsi Triceps Hip stabilisers Hamstrings Quadriceps Gluteals

click for larger view

Trapezius Biceps Upper abdominals Lower abdominals Calf

click for larger view

There are many different types of stretches that a swimmer can use. The main types of stretching are:

• Static Stretching – Holding a position that stretches the muscle for ~ 30 seconds.
• Passive Stretching – Similar to static, but someone else holds the position for you.
• Dynamic Stretching – Controlled leg and arm swings that gently take you to the limits of your range of motion. It mimics the action of the muscles during the event. Often used in warm ups or in preparation for an event.
• Ballistic Stretching – Forcing a joint beyond its normal range of motion by bouncing into a stretched position. Unpopular these days due to the high risk of injury associated with it.
• Active Isolated (AI) Stretching – Using a muscle to stretch the opposite muscle by contracting one muscle and moving the opposite muscle in a stretched position.
• Isometric Stretching – Alternatively stretching a muscle and contracting it to facilitate its relaxation.
• Proprioceptive Neuromuscular Facilitation (PNF) – Combination of passive and isometric stretching.

A combination of these stretches is appropriate for swimmers. Try them out and see which ones help you most. Regular stretching improves force, and speed. One bout of stretching won’t make a difference.

---

Here are some examples of stretches that are particular the primary muscles used in swimming.

click to view	Anterior deltoid, serratus anterior and pectorals stretch – Rotate your body so that you can feel a stretching sensation over the front of the shoulder and chest.
click to view	Triceps stretch – With your opposite hand, pull your elbow downwards and towards your head so that you feel the stretch over your upper arm
click to view click to view click to view	Posterior shoulder stretch 1 – Pull the arm towards the chest Posterior shoulder stretch 2 – Some traction can be applied by leaning the body away from the hand. Posterior shoulder stretch 3 – All your body weight should be positioned over your shoulder; your opposite hands helps to push the arm down towards the floor. The shoulder angle is kept at 90 degree, and so is the elbow joint. This stretch is felt at the back of the shoulder.
click to view click to view click to view	Latissimus dorsi stretch 1 – Accompany this stretch with breathing exercises. As you exhale, lean a little further over the side. Latissimus dorsi stretch 1:1 – Starting in a forward position, crawl your fingers towards to maximise the stretch, hold this position, then change your direction to one side to feel the stretch over the opposite side. Latissimus dorsi stretch 1:2 – Starting in a forward position, crawl your fingers towards to maximise the stretch, hold this position, then change your direction to one side to feel the stretch over the opposite side.
click to view click to view click to view click to view	Hip stabilisers stretch 1 – To stretch your right hip, put the right leg diagonally behind the left, lean over to the left side, so as to increase the length and stretch over the right side. Hip stabilisers stretch 2 – Cross your right leg over a straightened left leg, and rotate to your right. You will feel this stretch through your lower back, but predominantly through your right hip. Hip stabilisers stretch 3 – This will stretch your right side, holding onto your left knee, gently pull it in towards your chest to feel the stretch on the outside and back of your right hip. Hip stabilisers stretch 4 – This will stretch your right side, holding onto your left knee, gently pull it in towards your chest to feel the stretch on the outside and back of your right hip.
click to view	Quadriceps stretch – Keeping your knees and thighs together, stretch the front of your thigh by standing up straight and pushing your hip forwards.
click to view	Hamstrings stretch – You don't need to flex your foot to stretch your hamstrings, let it relax and lean forwards from your hips, your back should not be overly arched.

 

What kind of taping do I need?

Taping or strapping is commonly used in the sporting community and the effects and roles are widely understood and accepted. In recent years, taping has evolved beyond restricting the range of motion of a joint to prevent a recurring injury by stabilizing the structure with an external support. There are now techniques like Kinesio Taping and Functional Fascial Taping, which has become more popular and more well-accepted in the sports scene.

A commonality in all three taping techniques is that taping in itself is thought to enhance the proprioception or kinaesthetic feedback. This improved feedback enables the muscles to “fire” more appropriately as postulated in the earlier activation of VMO when a lateral tracking patella in clients with patello-femoral joint pain, is taped in a more neutral position. Another benefit of improved feedback can also enhance the awareness of the joint position so that a feed forward action of muscle contraction can occur prior to a re-injury. An example would be placing a simple piece of rigid tape on the outer side of an ankle while getting them to balance on a wobble board. The strip of tape would provide the information that inversion is occurring, hence the peroneal muscles would be activated to prevent this movement, averting a re-injury.

Restrictive taping: What and When

Restrictive taping as the name suggest, is to restrict range of motion of a particular joint. This can be for one direction or multi direction, depending on the direction and degree of instability. This type of taping is used to protect unstable joints, where repeated or severe ligament damage has resulted in the stretching of the ligaments and/or joint capsule, thus leading to joint laxity. In such cases, an elastic brace will not provide enough support as the brace “gives” and will not limit the joint from moving into the unstable range.

Restrictive taping is most commonly used when the athlete is recovering from a ligament or muscle strain. The tape acts as an external support to prevent the joint from going into the end range of the movement that would cause pain. The most common areas that this form of taping is used are ankle, shoulder and knees.

Kinesio Taping

Kinesio taping was popularized in the 2008 Olympics where a lot of the swimmers, runners and jumpers were having these colorful and fancy looking tapes pasted on them. Some even thought that it was a fashion statement. However, the real history of Kinesio taping started in Japan, some 25years ago by Dr Kenzo Kase. The method of taping uses a uniquely designed and patented tape for the treatment of muscular disorders and lymphedema reduction. The use of the tape was to assist and give support to prevent over contraction of the muscle or to help decrease swelling. This enables the tape to help speed up the rate of healing for injured muscles.

Functional fascial taping (FFT)

Functional fascial taping was developed by Ron Alexander, an Australian remdial massage therapist who worked with the Australian ballet. Whilst he found the restrictive taping useful in preventing the recurrence in injury, it was not functional for his ballerinas as they required a full range of movement of their injured joints/muscles to perform their dance. Hence, FFT was created to allow the continuation of functional range and activity without pain. Most musculoskeletal conditions are multifactorial in nature, and pain can be a hurdle in a successful rehabilitation. FFT provides physiotherapists with another tool to manage their clients’ pain and increase compliance.

Essentially, FFT affects the connective tissues. When tape is applied, it applies a sustained load on to the fascia in a direction that allows the muscles under the fascia to glide better. This has been observed on ultrasound. The direction of tape applied is guided by the direction of load that reduces the pain. Anecdotally, it is also found that if the tape is applied appropriately, pain disappears and the range of motion increases with the functional activity. The latter is likely due to the increase muscle gliding with FFT. As with many techniques, the physiological reasons for their effects are still largely unknown although research is still being done.

FFT can be applied on any area of the body and does not need to be on a joint. FFT has been greatly applied in dance medicine but in recent years have migrated to be extensively used in the area of sports. However, the usage of FFT has been generally limited to rehabilitation where pain would inhibit the proper activation of muscles. Though such techniques have been employed to help athletes go about their sport with no pain, it is not recommended for frequent use as it doesn’t solve the problem.

Conclusion

Taping is a great adjunct to getting us back to sports if applied properly. However, please discuss with your therapist whether you are ready to get back to sports following your injury. It’s always safer to complete your rehabilitation and taping can be used to slowly give you the confidence to get back to sports.

Reference:

1. Gary B Wilkerson. Biomechanical and neuromuscular effects of ankle taping and bracing. Journal of Athletic training 2002;37(4): 436-445
2. Gilleard W, Mc Connell J, Parsons D. The effect of patella taping on the onset of vastus medialis obliques and vastus lateralis muscle activity in persons with patellofemoral pain. Phys Ther 1998; 78:25-32
3. McConnell J. The management of chondromalacia patellae: a long term solution. Aust J Physio 1986; 32: 215-23
4. Bockrath K, Wooden C, Worrell, et al. Effects of patellar taping on patellar position and perceived pain. Med Sci Sports Exerc 1993; 25: 989-92
5. Abstracts accepted at the Fascia Research Congress
6. Functional Fascial Taping real time ultrasound investigation
7. Functional Fascial Taping for lower back pain: a case report
8. Efficacy of Functional Fascial Taping for the treatment of non-specific low back pain

Heat or Ice? When to use which?

When should you use heat or ice therapy? The answer is – it depends. In general, heat therapy is for chronic conditions and ice is useful in acute situations.

If you recently sustained an injury or aggravated an old injury, ice should be applied for a period of 15mins each time for the first 3 days. If you feel your muscles are feeling tight and stiff, a hot pack on the muscles will help to relieve the tightness.

This spectrum of acute to chronic looks at the duration since injury. If the injury is sustained within 36 hours, it is considered to be in the acute stage. At this stage the inflammation process is ongoing. Ice will help to bring down the inflammation and swelling so that the injury can heal better. Note that applying heat to this stage will increase the blood circulation, inflammation and hence swelling.

There are 2 common scenarios that cause pain, making you reach for that heat/ice pack.  One of them is the acute injury (for example a fall, twisting movement or direct blow that is immediately painful) and the other is the chronic injury (happened over a period of time or from an acute injury that failed to heal).  Each scenario requires a different approach to reducing your pain and speeding up your recovery.

Acute Injuries

It might be that you have just sprained your ankle playing soccer, shut your fingers in the car door or fractured your hand.  All these are examples of acute injuries and will show the following signs:

• Sharp, severe pain
• Swelling
• Redness
• Increased warmth
• Restricted joint movement
• Unable to put weight through the structure (e.g. leg, ankle, wrist etc).

For these types of injuries, we recommend managing the pain, inflammation, and swelling immediately with the use of ice.  The ice cools the tissues, reduces tissue metabolic rate and constricts the blood vessels helping reduce further damage from occurring.

There are many ways of applying ice like using an ice pack; wrapping ice cubes in a wet towel or using a bag of frozen peas (sometimes that is the only thing on hand!).  The cold agent should be in contact with the area for up to 20 minutes at a time and re-applied every 2-3 hours for around 3-5 days or until the swelling settles.

How does ice work?

1.    Decreasing the pain

There are a few proposed theories regarding how ice decreases pain and it is possible that a combination of some of them can cause pain relief.

• Decreased nerve transmission in pain fibres
• Cold reduces the activity of free nerve endings
• Cold raises the pain threshold
• Cold causes a release in endorphins
• Cold sensations over-ride the pain sensations

2.    Reducing swelling

Ice cools the surface of the skin and its underlying tissues, causing narrowing of the blood vessels.  This narrowing leads to a decrease in the amount of blood delivered to the area and subsequently reduces the amount of swelling.  After a few minutes, the blood vessels re-open allowing blood to return to the area.  The narrowing and opening repeat in cycles.

The decrease in swelling also allows more movement in the area and lessens the loss of function associated with the injury.  Pain is also reduced as pressure from the swelling lessens.  Chemicals that intensify the pain are released into the bloodstream when tissues are injured, thus the narrowing of the vessels help to minimize this release and pain.

3.    Decreasing metabolic rate

Ice reduces the metabolic rate and oxygen requirements of the cells.  Thus, even with the decreased blood flow and oxygen delivery that comes with narrowing of the vessels, the risk of cell death will be lessened.  This prevents further injury.

Sub-acute phase

A few days following an acute injury, the pain and swelling may have decreased so much that there may be no sign of the original injury.  However, the tissues are still in the process of recovery and will still benefit from modifying your activities (less vigorous) as well as using both ice and heat alternatively.  This means to apply ice for 10 minutes, followed immediately by 10 minutes of heat.

How does this work?

Doing this will cause massive increases in blood flow to the area as the narrowing caused by cooling is reversed when heat is applied, resulting in an influx of blood to the damaged tissues.  The increased blood flow to the area provides proteins, nutrients and oxygen for better healing.  It also helps remove the products of inflammation and reduce residual swelling.
An important point to note is to ensure that inflammation has stopped before applying this technique.  That means that the area should not be red, and should not be warm to touch.

Chronic Injuries

These are injuries resulting usually from overuse where some tissues are tight and inflexible causing aches.  Examples include tennis elbow, golfer’s elbow, patella tendinitis and Achilles tendinopathy.  Symptoms include pain when performing activities, a dull ache at rest and swelling.  Occasionally, an acute injury is not allowed the time to heal properly and muscles spasm to protect it.

In order to treat these, heat should be used to help relax tight, aching muscles and joints, increase the extensibility of ligaments and tendons and promote blood flow to the area.  Heat can also be used before exercise in chronic injuries to warm the muscles and increase flexibility.

Heat can be applied to the area in the form of heat packs, a warm damp towel, hot water bottles or heat rubs.  If using a heat pack or hot water bottle, ensure a suitable layer of protection is placed over the skin to prevent burns.  The heat should be applied for 15-20 minutes.

How does heat work?

Heat applied on the skin increases the temperature of the skin and the underlying tissues.  This in turn opens up the blood vessels like your ateries, allowing more blood to flow into the area. This increase flow helps  to remove waste products from cells and deliver more nutrients, relaxing tissues. The increased temperature of the blood also warms up surrounding tissues. Heat also has an effect of increasing flexibility of the soft tissues.

Both heat and ice are cheap, easy to use and effective ways of speeding up recovery when used correctly.  Besides managing your injuries with these modalities, it may be a good idea to consult a physiotherapist in helping you rehabilitate and/or prevent the same injuries from occurring.

Tips to Run Pain Free

Recently our physiotherapist, Lenia, was featured in Shape magazine Jan 2010. Here is an excerpt from the article.

Shin splints are caused by weak shin muscles or faulty running biomechanics while plantar fasciitisis the result of tight calf muscles that reduce the foot's ability to absorb shock. Here are some tips to stay on track.  Read more

Train Proprioception to Prevent Sprains

Hi, I hear from my personal trainer that i need to train my proprioception because of my ankle sprains. What is proprioception and how is it relevant to my ankle problem? – John Koh

 

What is Proprioception? Read more

Next Page »

See the Therapist

For an appointment to consult with one of our physiotherapist for treatment, kindly call us at : +65 6226-3632 (4 Lines)

or SMS us at +65 9232 2661 or email us at enquiry@coreconcepts.com.

Find out more about our various divisions at group.coreconcepts.com.sg/divisions.





Ask the Specialists

Ultrasound Therapy, Imaging and Shockwaves

"Hi MCR, I keep hearing about ultrasound therapy but I get confused with the seemingly different answers I get about them. There appears to be one for healing... Read more »



If you have an question, feel free to drop us line. If the answer to the question is something more than a few people would be interested in, we will feature it.




• Popular Articles

  • Posterior Pelvic Pain (Sacroiliac Joint Pain) in Pregnant Women
  • Nerve Stretches
  • 5th Metatarsal Fractures
  • Multifidus - Smallest Yet Most Powerful Muscle
  • See a Therapist
  • Sports Taping - Knee
  • Myofascial Release
  • Pregnancy - Changes and Aches
  • Jaw Pain - What other causes besides the teeth and jaw?
  • Sports Taping - Wrist
  • Manual Therapy - Spinal Vertebra Mobilisation
  • Ankle Replacement Surgery
  • Patellar Tendinitis
  • Does Bad Posture Lead to Scoliosis?
  • Belt Up Your Unstable SIJ
  • Iliotibial Band Friction Syndrome
  • The Buckling Knee
  • Sway Back No More
  • Lumbar Spinal Stenosis
  • Simple Exercises For Plantar Fasciitis Sufferers

Musculoskeletal Consumer Review © 2007 - 2010 by Core Concepts Pte Ltd       Terms and Conditions | Policy

Musculoskeletal Consumer Review © 2007 - 2010 by Core Concepts Pte Ltd