RSI- Repetitive Strain Injury or overuse injury

Most people realise the human body is only subject to withstand a certain amount of force. When the force exceeds what a particular body part can withstand a break or tear will occur. This is straight forward and easy to comprehend (cause and effect). When dealing with RSI or overuse injuries it is more complicated, as there is more components involved. The three main components that will influence RSI are:

• Load: The weight of the object being lifted (might be internal i.e weight of your arm)
• Repetition: How often the load is being lifted
• Rest: Time between repetitions

Other factors such as biomechanics, nutrition, current fitness, training/exercise history and genetics will play an important role as to why some people get RSI and others don't even thought the 3 main components are the same. 

Treatment of RSI

• Education: Tell the client why they are getting pain. as explained above may not be a straight forward.
• Rest: Cease provocative movement. 
• Modify: If rest from provocative movement is not achievable reduce load or repetition and/or increase rest time.
• Physiotherapy: Release tight muscles, mobilise stiff joints, strengthen weak muscles and secure unstable joints.
• Acupuncture: Similar effect to massage. 
• Anti-inflamatories: Only an adjunct to other treatment.
• Plan: Gradual introduction to big three components.
• Braces and taping: Can be used to unload damaged tissue. 
• Ice and heat: Ice tendons and joints, heat muscles.

In the real world treatment of RSI is really challenging because people need to work or train. However the above treatment modalities are used to control the aggravating factors. The most effective treatment is combining all treatments. If components cannot be changed it will take longer. 

The most important aspect of any treatment plan is getting improvements every session. A good therapist isn't necessarily at fault if improvements aren't observed from session to session. The reason I say this is because the patient's symptoms may have been getting worse from week to week and if physiotherapy stopped the symptoms progressing, then this is still effective treatment. However if the patient is prepared to rest or modify the provocative activity then the therapist should get improvements in symptoms.

Selecting the right health practitioner

What should I expect to get out of visiting a Health Practitioner?

Most people that visit a health practitioner such as a Physiotherapist, Chiropractor, Acupuncturist etc do so because they are in pain or have a restricted range of movement. As a patient you shouldn't be placed in a situation where you are unsure whether the treatment performed is effective or not.

An exceptional practitioner should be transparent and demonstrate that what he or she has done in that session has reduced your pain or increased your range of motion. Don't be over awed by fancy language and excuses as to why your pain has not reduced, if a change can not be observed from the start of the session to the end of the session, then it would be fair to say that the practitioner has been ineffective in resolving your issue - It's that simple. Due to the complex nature and individual variance of the human anatomy ineffective treatment sessions are very common even with exceptional practitioners, however this is not a wasted session the practitioner has simply discovered what structures are not affected by your injury.

Insanity: Doing the same thing over and over and expecting different results.

DO NOT GO BACK TO THE SAME HEALTH PRACTITIONER IF THEY KEEP DOING THE SAME TREATMENT SESSIONS AND YOU ARE NOT GETTING ANY RESULTS!!

Any health practitioner that genuinely cares about you will want to get the results and will get frustrated with the lack of progress made. Practitioners should give advice and exercises to correct any imbalances so you can take control of and best manage your condition outside the treatment room, this will promote healing and allow the quickest possible recovery for yourself. At the end of the day a half hour treatment session is going to have limited impact if your condition is constantly aggravated outside the treatment room, therefore the advise and exercises given will benefit each person and will allow both yourself and the Practitioner to see your improved results.

An exceptional therapist will find the cause of the problem and not just treat the symptoms, however it is to be noted that often what gives you pain is not the cause of the problem. Pain usually results from excessive load causing structural anatomical strain. The structure that is damaged is usually not the cause of the problem and therefore a symptom. Finding the reason why that anatomical structure failed due to excessive load is extremely important to complete rehabilitation.

In summary, you want:

• Effective Treatment
• A practitioner who will treat the cause and not the symptom
• A practitioner that legitimately cares 

Shoulder Pain

Anatomy of the shoulder

The shoulder is designed to allow large movements in all directions (ball and socket joint), this is great functionally as we can manipulate objects with our hands in lots of various positions. Unfortunately there is a strong correlation between large range of motion and instability, as such it is important to understand what mechanisms provide stability to the shoulder.

There are a number of structures used to stabilise the shoulder:

• Glenoid Labrum: Deepens the surface area the humeral head sits in.
• Shoulder capsule: Holds the shoulder in place
• Ligaments: restricts end of range movements
• Scapular: A direct barrier to prevent movement
• Muscles: create and prevent movement at the shoulder.

Shoulder pain from trauma

Following a collision or fall it is very common to sustain a shoulder injury. Any of the above structures can be damaged depending on the direction of force. Depending on how your injury presents will determine whether a scan in necessary and surgical intervention is needed. As the shoulder has a large range of movement available the brain will restrict movement to structures that are damaged to prevent pain and aid healing. However other structures will move excessively and create abnormal movement patterns. After the original structure has healed secondary problems will result if correct movement patterns aren't restored to normal.

Shoulder pain referred from the neck

The most common type of shoulder pain is commonly received from the neck region. Nerves exiting the neck (Cervical Spine) provide sensory and motor innovation to the shoulder, the muscles attached from the neck to the shoulder can also tighten causing secondary issues,  therefore any dysfunction in the neck will effect the shoulder in one way or another. Neck mobility or stability issues need to addressed to fix 95% of shoulder issues.

Poor shoulder biomechanics

Optimal shoulder mechanics involve smooth rhythmic control between the arm (Humerus) and shoulder blade (Scapulae). Muscles around the shoulder and neck contract and relax in correct sequence to ensure the Humerus doesn't impinge on the Scapulae. Any imbalance will result in compensatory or abnormal movements that will eventually lead to pain. This condition is very common in gym goers, especially those who focus on bench press and other related chest exercises.

Postural related pain

For those who find themselves sitting at a desk all day and have a slouched (flexed) posture will most likely find they have postural related pain. If you are finding that you are unable to stand up straight (lacking thoracic extension) you will find this places huge stress on the shoulders. This is exacerbated   when attempting to do anything at or above shoulder height. Office workers that attend boxing classes are a classic example of this.

Miscellaneous

• Frozen shoulder (Adhesive capsulitis): synovial folds stick together limiting movement in all directions, (insidious onset).
• Polymyalgia Rheumatica: inflammatory condition effecting multiple joints
• Osteoarthritis: degenerative bone condition
• Thoracic Outlet Syndrome: Condition where the nerves travelling between the collar bone and first rib get compressed.

Postural back pain

Postural Back Pain

The most important concept to understand about postural back pain is that a sustained position for a lengthy period of time is not ideal, even if you are maintaining the best posture. The body is designed to move and relies on movement for correct function. Moving the body results in:

• Muscle contractions: Returning blood to the heart and organs for filtration, cleansing the muscles of chemical substrate build up and aids in recovery.
• Joint positional change: Alters the distribution of load, which in turn will reduce the force at a particular part of the joint, therefore reducing chance of injury.
• Psychological factors: Stimulating the brain and improving productivity.

Should you find that a sustained position needs to be maintained, optimal biomechanics that shares force equally through most joints need to be adopted.

Below are two different postures that can be applied:

Sitting posture

Place both feet firmly on ground, shoulder width apart with equal weight distribution. Ensure your bottom  is firmly against back rest and you have a neutral spine (lower back slightly off back rest, back of shoulders against back rest). Tuck your chin in (giving the impression of a double chin) ensuring your ear lobes are in line with your shoulders which should be relaxed and slightly squeezed back, elbows should be by your side and the keyboard is slightly below elbow level with the top of  the computer at eye level and keeping your chair in close to the desk.

Standing posture

Placing equal weight through both feet, with your knees slightly bent, ensure that you squeeze your shoulders back slightly, pushing your chest out and tucking your chin in (giving the impression of a double chin). For a person of slender builds, you should tuck your tail bone under slightly, and for those that find themselves to be overweight it is recommended that you stick your bottom out slightly due to the different weight distribution around the centre of mass of your body.

Injury will occur when excessive force exits the body at a certain point. The above postures limit excessive force exiting the body at a certain point. By moving the body consistently you will be changing the amount of force at a particular joint at any given time. However repetitive movements can be detrimental as they can lead to the same joints and muscle been loaded in the same way. This can lead to an overuse injury as not enough recovery is given to working muscles.

Prevention is better than cure

In order to prevent postural pain, the following tips outlined above will assist in preventing injury before it actually happens. If you find static postures or repetitive movements needs to be maintained in any work situation come and see us for a consultation at Bondi Platinum Physio or discuss your issues with a medically trained professional to ergonomically assess your work place.

Remember, equal weight and load distribution with adequate recovery will help prevent most injuries.

Have a lovely day at work!!

  

Understanding Pain

Understanding the Pain :

Pain is a protection mechanism to preserve the body. If a stimulus is damaging to the body, your neurological system will relay information to the brain which will evoke a response. This is the common response to a painful stimulus, for example, place your hand on a hot plate, you will withdraw your hand quickly without consciously thinking about it. This makes sense, we understand it, there are very few problems associated with this.

Problems arise when we don't understand pain. Accepting it, gaining help to manage it and finally knowing why we are getting pain in the first place are the most important stage's in the recovery process.

Below are some examples where and why you may be getting pain and what may be needed to be done to resolve the issue:

The Muscle

Acute muscle tear or strain will cause a sharp "knife like" pain if you try to stretch or activate that area. Additionally there maybe a dull ache when you are at rest, this may imply a significant tear or strain. RICE (Rest Ice Compression Elevation) and gentle pain free stretches are important at this stage. 

Chronic muscle pain usually involves muscle cramping, tightness and an associated dull ache. Correcting any biomechanical issues, breaking down scar tissue and strengthening the region is important at this stage. Usually a complete tear will be visible, as the muscle will roll back on itself. If this is apparent we and/or your doctor will recommend surgery at this stage. 

The Bone

Acute fractures will cause a sharp "knife like" pain if any load is placed through the fracture site. Often night pain and a dull to severe ache is associated with this injury. In this instance surgery and or immobilisation will be key.

Post fracture pain will be dull in quality, it is important to gradually load the bone in this phase without any sharp "knife like" pain and mobilise joints above and below. Stress fractures are usually sharp in quality but can eleviate with exercise, however post exercise a dull ache or throb will be evident. A severe stress fracture will intensify with exercise. Reduction in training load and correcting biomechanics is key at the stage. 

The Ligament 

A partial tear will result in sharp "knife life" pain when the ligament is stretched. There will be no pain associated when the joint is compressed as the ligament is not being stressed. Stabilisation of the joint at this stage is important to prevent further injury and surgery.

A ligament that has completely torn will not result in a sharp pain when the joint is stretched as the fibres are not attached and therefore can't be stretched. A severe dull ache, joint instability and extensive odema is associated with this condition. The type of ligament torn will determine whether surgery or conservative treatment is needed.

The Tendon

A micro tear (Tendonopathy) will result in a sharp pain whilst loading the tendon, such as stretching or activating its associated muscle. As the tendon is used and the muscle warms up the pain will subside, however upon rest the area of aggravation will result in a dull stiff ache and an increased sharp pain with movement. At this stage muscle relaxation is essential to reduce tendon stress and aid recovery. Gradually loading the tendon once pain free is ideal to prevent scar tissue from forming and return to pre injury status. 

Complete tendon rupture will result in extreme sharp pain initially followed by an intense dull ache. In addition to this there will be an inability to move the joint that tendon is designed to move or extreme weakness if multiple joints are responsible for moving that joint.

The Nerve

Without nerves it is impossible to detect and experience pain. Nerves like to glide freely through their interface. A nerve gets irritated when a muscle or joint restricts the nerves available movement. This is extremely uncomfortable and is usually sharp or burning in quality. To differentiate nerve pain from other injuries you have to stretch the nerve at a remote place and reproduce the same specific pain without stressing the injured site. Mobilising tight muscles and joints, correcting biomechanics and moving the nerve pain free through its interface is important at this stage.

When a Nerve gets so irritated one will experience numbness, pins and needles, muscle weakness and  loss of sensation. If the symptoms persist or get worse and conservative physiotherapy treatment doesn't work, consult with your GP or neurosurgeon. Surgery might be indicated to release the trapped nerve. 

Severed or a complete nerve block will result in the inability to activate its supplied muscle or sensory area depending on whether it is a motor or sensory nerve.

The Brain

Without the brain is it impossible to interpret or perceive pain. Centrally dominant pain occurs when the brain misinterprets a non painful stimulus as painful or becomes hypersensitive. This pain is very real and is extremely difficult to treat, as there is nothing structurally wrong. There is a high risk of this pain turning chronic, as the mechanism and nature of the injury doesn't reflect the pain. Most people find this hard to comprehend. 

The best way to treat this pain is through education, identifying painful stimulus, gradual introduction of more challenging or painful stimulus and exercise. Every body part represented in the sensory and motor cortex of the brain, is constantly changing based on supply and demand. For example over the last 20 years the area in the brain that represents the thumb has tripled in size due to an increase in demand of activities such as phone texting. This is relevant to centrally driven pain as the area in the brain that has constant painful stimulus associated with it will increase in size and become more sensitive.    

The Blood Vessel

Certain blood vessel diseases such as peripheral vascular disease will cause claudication (intermittent pain with an increase in the demand of blood vessels such as during exercise). This pain will usually be associated with cramping, feelings of heaviness, pins and needles, numbness. Pain eases as soon as exercise stops. Building up tolerance to exercise is important with these conditions.

It is uncommon for blood vessels to be the cause of pain in young healthy individuals besides rare blood diseases. However during trauma blood vessels can tear causing odema. This swelling can compress nerves causing a intense sharp irritation with movement. Best treatment at this stage is RICE. During the repair of blood vessels excessive load placed on them prior to healing can lead to a dull aching throb.

The Joint (articular cartilage)

Excessive load of joints without adequate recovery leads to degradation of the joint surface. Loss of articular cartilage will cause pain as cartilage is somewhat smoother than bone. Increase in friction leads to irritation inflammation and swelling. This will cause a dull ache with associated stiffness when loading the joint. Increase in load will result in an increase in pain. Treatment at this stage involves assessing biomechanics to unload the damaged joint and preventing further damage.

If too much load is placed through the joint at a particular point in time a tear may result. This is usually very painful initially (sharp stabbing pain) and involves locking or restricted movement of the joint, as the cannot bend past the torn cartilage. Treatment at this stage usually requires surgical intervention or extensive physiotherapy involving muscle relation techniques, joint mobilisations and strengthening exercises surrounding the joint.

In conclusion

Pain is very complex and can come from a number of structures. To make it even more complex pain can be referred from another structure entirely. It is vital to understand the cause of the problem and have a clear resolution pathway. Everyone is different and therefore two people with the same cause of pain will respond differently to the same treatment. Find something that works for you.

Due to the complex nature of the pain a number of pathways can be taken to get someone pain free. The best pathway will depend on the person in pain. For most people it is the quickest and most cost effective pathway. To ensure this happens it is vital you find an objective measure that reproduces your specific pain. This is important to show effectiveness of someones treatment. For example if you can reproduce your shoulder pain (8/10) when you lift your arm up to 80 degrees, then by the end of the session you want either the pain to be less (<8/10) or the same pain but more movement (>80 degrees). CAUSE AND EFFECT.

"Runners knee"

There are a variety of reasons why a person will get knee pain during or post running. The most common of these is a tracking issue involving the patella (knee cap). This condition is known as patella femoral pain syndrome (PFPS).

Poor biomechanics will result in the patella not tracking correctly against the femur (leg bone). To address this problem completely you need to correct the cause of the problem which is usually poor biomechanics, not just correct the symptoms such as a tight Iliotibial band (ITB).

Any weakness or poor dynamic control of the following muscles need to be addressed to minimise PFPS.

• Gluteus maximus
• Gluteus medius
• Vastus medialis obliquus (VMO)
• Transverse abdominals
• Peroneal longus
• Gastrocnemious    

In addition to the strengthening program, deep tissue massage, acupuncture or any muscle relaxation technique such as foam rolling should be used on the above muscle groups to ensure ideal muscle length tension is restored. It's also not uncommon for other muscles such as hip flexors, groin, quads, ITB and lower back to tighten up to compensate for poor biomechanics. 

Given the knee is a relatively simple joint compared to the hip, the majority of individual variance and muscle imbalances will occur at the hip. Two of the best exercises to prevent PFPS would be a single leg squat and a single leg hop, using these two exercises will incorporate all the essential muscles needed for correct biomechanics in a controlled and dynamic manner.

Technique is vital in both of these exercises to activate the right muscles. If done incorrectly the pain and injury will worsen. In most cases you may find the specific muscles groups to perform a single leg squat is lacking, therefore preparatory exercises will need to be given, such as a Clam Shell, Hip Hitches and Bridging, to name a few, can be performed.

Other parameters to consider are:

• Running technique: Over striding, running too upright instead of leaning into the run, not pushing off your back toe or completing the stride, feet crossing over the midline of your body, heel running etc will contribute to PFPS.
• Foot mechanics: pronation under load will effect knee position and significantly contribute to PFPS. Correct footwear and/or orthotics may be required.
• Running surface: Running around an oval the same way every time (inside leg and outside leg will use different muscles) will create imbalance, hill/stair running especially down is more likely to develop PFPS, hard surface increases ground reaction force which is more likely to develop PFPS, treadmill changes running mechanics involving less glute activation and therefore more likely to develop PFPS.
• Overuse: Adequate rest is important in any training regime. Tissue that is loaded whilst running needs adequate rest before being used again / reloaded. Studies suggest any longer than a 2 week break from running would require a reduction in training load once you return.
• Anatomical structure of bones: Everyone is different, a persons individual bone structure may make it difficult to contract certain muscles. Surgery maybe indicated to correct abnormalities. For example, an individual with a small patella is more likely to suffer from PFPS as there is less area for force to disperse and therefore greater wear and tear may occur.
• Gender: Medically women are more likely to get PFPS then men purely due to the fact they they have wider hips, predominantly due to the female reproductive structure. 
• Previous injury: Torn ligaments will result in muscles tightening up around the knee to help with stabilisation. This additional compression may increase risk of developing PFPS.

Examples of Client Intervention:

Recently a client was referred by her doctor to Bondi Platinum Physio with PFPS. After years of riding horses and restarting her exercise training regime, it became evident that my clients key stabilising muscles supporting her knees and hips were extremely weak, thus causing her knee caps to track incorrectly and rotate inwards. In order to prevent immediate surgery and to help my client build the correct muscle structure to her hips and knees rectifying PFPS the following treatment was provided:
Stage One: Pain control - Releasing tight muscles and mobilising joints stiffness which was causing the pain, was performed using  massage techniques. Muscle activation exercises was performed to stabilise hyper mobile joints. My client was provided with education to prevent further inflammation and injury whilst maintaining exercise.
Stage Two: Maintaining correct muscle lengthening whilst providing a gradual progressive exercise regime
Stage Three: Reviewing the exercise techniques provided to the client that once caused pain and corrective action given, where required. Liaising with the clients Personal Trainer to optimise best practice during the training sessions.
Stage Four: The final stage was ensuring the patients goals were achieved and they were able to perform all exercises on a regular basis that once gave them pain.

Should you believe you have symptoms as outlined above, please contact me at admin@bondiplatimumphysio.com.au 

Hello cyberspace

It is only fitting my virgin blog requires a brief introduction.

Firstly the above sentence took me one hour to write, so this could be a little time consuming. Anyway my name is Evan Fletcher I'm a passionate physiotherapist that gets great satisfaction out of helping people. I recently partnered up (business partner that is not sexual partner) with Theo Morris a close friend of mine from Perth who is also a passionate physiotherapist. Our clinic is on the cool side of Bondi Junction (further towards Centennial Park near the health food stores on Oxford st).

Basically we both train non stop, play a ridiculous amount of sport and have suffered most injuries known to human beings. We live and breath physio and are exceptionally good at what we do (physio wise that is- we suck at everything else especially business skills).

Why write my blog? Well basically I want to inform readers about everything that can and will go wrong with the body and how to deal with these situations. This blog will help prevent common injuries and will give you better instruction on how to return to pre injury status if currently injured, or how to prevent injury in the first place.

I encourage people to email me at admin@bondiplatinumphysio.com.au if you want me to talk about a particular injury. I look forward to helping you get back to, or maintain your peak health and fitness as soon as humanly possible.