Achilles Tendon Injury
What are the symptoms?
What causes Achilles Tendinopathy?
There are certain risk factors that may lead some people to developing Achilles tendinopathy, many of which relate to changes in load through the tendon rather than to a person’s biomechanics.
There are three questions that should be considered:
The key areas that physiotherapy focuses on are as follows:
There is good evidence that slow, heavy load-strength training can improve a tendon’s tolerance to load and this is one of the gold standards for treatment. It is important, though, to avoid overload through other aspects of training while strength training, otherwise it may fail.
While there may also be specific biomechanical factors feeding into the tendinopathy.
Your Physiotherapist will consider the whole chain when assessing, including looking at the hips and knees any spinal involvement.
More common than biomechanical problems are training errors. Most people we see present with Achilles tendon problems when they have radically changed their training load. All the evidence points towards load management as the best way to treat Achilles tendinopathy. And it is important to give it time before considering other options – we suggest three to six months.
A Myofascial Trigger Point (MTrP) is a discrete, hard, hyper-irritable nodule or ‘knot’ in a taut band of muscle, which is exquisitely tender on palpation. The inclusion of “myofascial” in the name has developed from the view that both muscle and fascia (connective tissue) are likely to be involved in the symptoms. MTrP are often seen as part of Myofascial Pain Syndrome, which is a term used to describe a pain condition that involves the muscle and it’s surrounding fascia. This can be acute or chronic.
Active trigger points are associated with spontaneous pain in the immediate surrounding tissue and/or to distant sites in specific referred pain patterns. Strong palpation of the active trigger point can exacerbate a person’s pain complaint and mimics their familiar pain experience. MTrPs can also be classified as latent, in which case the MTrP is physically present but not associated with a spontaneous pain complaint. However, pressure on the latent MTrP elicits local pain at the site of the nodule. Both latent and active MTrPs can be associated with muscle dysfunction, muscle weakness, increased tension and a limited range of motion/reduced flexibility.
Muscle pain disorders were first written about in the 1500s. In the 1900s, researchers injected hypertonic saline into various anatomical structures such as fascia, tendon, and muscle in healthy volunteers in order to chart zones of referred pain in local and distant tissue.
In the 1950s, Janet Travell and Shannon Rinzler coined the term “myofascial trigger point”, reflecting their finding that the nodules can be present and refer pain to both muscle and overlying fascia. Myofascial Pain and Dysfunction: The Trigger Point Manual is the most comprehensive collection of information on trigger point referral patterns and is used by a wide range of clinicians. However, research is still on-going in this area with the view to further develop our understanding of MPS and the true mechanisms behind MTrP development.
There is general agreement that any kind of muscle overuse or direct trauma/injury to the muscle can lead to the development of MTrPs due to changes in blood flow and the release of chemicals in the body. Muscle overload is thought to be the result of sustained or repetitive low-level muscle contractions, eccentric muscle contractions, and maximal or submaximal concentric muscle contractions, hence causes of MTrP can range from sports training injuries to muscle weakness from lack of exercise; slips/trips/falls/accidents to general muscle strains; and sustained poor postures, including computer use.
Generally, myofascial pain resolves in a few weeks with or without treatment. In some cases, however, muscle pain persists long after resolution of the injury; it may even refer to other parts of the body. This heralds the ‘sensitised state’, which is one of the features of a chronic pain disorder, in which the pain itself is the pathology and requires medical intervention for its resolution. I find this fascinating and it is certainly something we see a lot of in clinic, especially given that chronic pain is defined as ‘a pain lasting more than 12 weeks’, which for a lot of people is just a mere drop in the ocean compared to how long they have had their pain.
Because of this, MPS has also been associated with other pain conditions such as referred pain from spinal discs and nerves, joint dysfunction like arthritis, tendonitis, migraines, tension headaches, carpal tunnel syndrome, whiplash-associated disorders, pelvic pain and back/neck pain. Interestingly, low mood and sleep disruptions have also been associated with MPS.
Trigger points may be relieved through non-invasive measures, such as manual therapies, which include post-isometric relaxation, trigger point compression, muscle energy techniques, myofascial release, massage, heat and cold, and stretching. Invasive treatments in our clinics would include dry needling and acupuncture. Invasive medical interventions include injections with local anesthetics, corticosteroids, or botulism toxin.
Postural re-training (including pilates), stretching and strengthening exercises, stress management, and mindfulness can also help to address the underlying causes of a person’s MTrPs. This is particularly important in chronic conditions where the chance of recurrence might be more likely due to on-going aggravating factors. Self-myofascial release techniques using a foam roller or spiky ball can be a beneficial part of this self-management.
A point regarding referred pain:
Referred pain is where a person perceives pain at a location that is different from the site of where the pain originates. Spinal nerves, joints and organs are example of parts of our anatomy that can refer pain. MTrP have specific patterns of pain referral. These charts are easily accessible on the internet and can prove very useful in self-diagnosis. If your pain persists beyond self-help, then it is important to seek professional advice as either not enough is being done to address the underlying aggravating factors that are perpetuating your symptoms, or you may require ‘hands-on specialist treatment’, or it may be that your pain may not be myofascial in origin.
If you feel this is something you would like to discuss further, then please get in touch or book in for an assessment with one of our clinicians.
Costco-vertebral joint irritation
Costco-vertebral joint irritation is pain originating from where your ribs attach on to the spine in the centre of your back. It’s a common place to suffer with pain, in particular for desk workers who are hunched forward for the majority of the day. It will be the area which you can never reach, between the shoulder and the neck but slightly too far down to show someone the exact point which is causing the pain.
Bath Chiropractor 01225 683007
The most common presentation with someone suffering from this injury is pain between the shoulder blades, which doesn’t seem to improve with massage or stretching. If left for longer than a few weeks, the pain can start to travel into the neck and head, in addition to shoulder pain and restriction. This joint where the rib attaches to the spine needs to move when we breathe, so when the costo-vertebral joint can’t move freely it can be painful during deep breaths or lying on the painful area at night. In unusual circumstances this can present as chest pain, where the ribs can’t move properly and the pain wraps around to the front of the chest.
By assessing and detecting the painful region, Chiropractic treatment including spinal manipulation can relieve the symptoms and increase the movement to the affected joint and the surrounding area, relieving the pin-point tenderness and any associated head, neck or shoulder symptoms. By addressing the primary cause, the muscles sitting on top or surrounding the irritable joint will overtime desensitise and stop tensing to protect the injured area. Like with most injuries, icing the area will reduce excess inflammation to a muscle, and specific exercises can help prevent future recurrences. If this sounds like something you suffer with, don’t hesitate to contact us and book in with our Chiropractor Mike
Osteoarthritis: Exercise as Medicine
For people with hip and knee osteoarthritis (OA), high-quality research shows that exercise therapy is very helpful in decreasing pain and improving movement in these joints. The phrase, Exercise as Medicine, has been used for some time – but not just for OA, for some twenty five other long term health conditions too.
OA is the most common cause of arthritis and a major public health problem. It was first thought of as simply ‘wear and tear’ affecting cartilage within joints. Common misbeliefs focused solely on mechanical (load-related) or occupation-related reasons for these joint changes. However, our knowledge of this condition has advanced considerably.
OA is a condition mediated by and affecting the entire ‘synovial joint organ’, which means it affects much more than just cartilage. It includes not only fibrocartilage and hyaline cartilage, but also the bone below this area (subchondral bone) and the soft tissue which lines the joint (synovium). More recently, a central theory of the cause of OA is that of chronic, low-grade inflammatory processes not only promoting OA symptoms, but also accelerating OA progression.
Many risk factors come into play when considering the cause of OA, as outlined in the Arthritis Research UK information leaflet.
Exercise as Medicine
It is widely known that exercise should be an integral part of standard care for people with knee and hip OA. Raising your physical activity levels is effective in achieving good outcomes.
Exercise should consist of:
There are also many other important non-surgical treatment options available to those who suffer with OA.
At Physioimpulse we have a Gait analysis and Biomechanic assessment service which enables us to assess your foot mechanics and create custom made insoles to reduce the pain of OA affected joints and enable more effective rehabilitation.
Some people struggle to exercise efficiently due to high pain levels so we also provide Ostenil injections which"lubricate" the joint and can provide up to 9 months of pain relief.
Other Non-Surgical Treatment Options
Here at PhysioImpulse, we want to support you to keep active and manage your OA as best able.
Take home Message:
Stay active and exercise!
Arthritis Research UK (2018) https://www.arthritisresearchuk.org/arthritis-information/conditions/osteoarthritis.aspx [Accessed online 2nd September 2018]
Exercise Is Essential for Osteoarthritis: The Many Benefits of Physical Activity Journal of Orthopaedic & Sports Physical Therapy, 2018 Volume:48 Issue:6 Pages:448–448.
Liu-Bryan, R. and Terkeltaub, R., 2015. Emerging regulators of the inflammatory process in osteoarthritis. Nature Reviews Rheumatology, 11(1), p.35.
Osthoff, A.K.R., Niedermann, K., Braun, J., Adams, J., Brodin, N., Dagfinrud, H., Duruoz, T., Esbensen, B.A., Günther, K.P., Hurkmans, E. and Juhl, C.B., 2018. 2018 EULAR recommendations for physical activity in people with inflammatory arthritis and osteoarthritis. Annals of the rheumatic diseases, 77(9), pp.1251-1260.
Pedersen, B.K. and Saltin, B., 2015. Exercise as medicine–evidence for prescribing exercise as therapy in 26 different chronic diseases. Scandinavian journal of medicine & science in sports, 25, pp.1-72.
NICE guidelines support physiotherapy for patients with Parkinson’s
Recently updated NICE (National Institute for Clinical Excellence) guidelines have suggested that individuals with a diagnosis of Parkinson’s should have an assessment from a specialist neurological physiotherapist and on-going access to physiotherapy. NICE advocates that physiotherapy can help to manage symptoms and maintain an independent lifestyle. It can also reduce the number of admissions into hospital.
NICE quality statement (updated February 2018)
Adults with Parkinson's disease are referred to physiotherapy, occupational therapy or speech and language therapy if they have problems with balance, motor function, activities of daily living, communication, swallowing or saliva.
NICE also advises early input after a diagnosis of Parkinson’s from a specialist physiotherapist in this field. This can help people to keep in control of their condition and symptoms and allow them to live well and independently with Parkinson’s. This recommendation was updated in 2017 and highlights the benefit that physiotherapy can contribute to in the management of Parkinson’s short and long-term.
Parkinson’s is a progressive neurological condition, which affects an area of the brain known as the substantia nigra. This area normally produces a chemical known as dopamine, which helps to control the coordination of movement. In Parkinson’s, the nerve cells in the substantia nigra become damaged meaning that dopamine production is reduced. This can cause symptoms such as tremors (shaky movements), slowness of walking and rigidity (stiffness in muscles and joints). Other common symptoms are freezing (feet feel ‘stuck’ to the ground), falls, speech and swallowing difficulties and pain.
Bath Neuro Physio 01225 683007
How can physiotherapy help?
There are many different treatment options for people with Parkinson’s depending on the specific symptoms and goals of the individual. These include:
Peak ACL force during jump landing in downhill skiing is less sensitive to landing height than landing position
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Handoll, H.H., Hanchard, N.C., Goodchild, L.M. and Feary, J., 2006. Conservative management following closed reduction of traumatic anterior dislocation of the shoulder. Cochrane Database of Systematic Reviews.
Khiami, F., Gérometta, A. and Loriaut, P., 2015. Management of recent first-time anterior shoulder dislocations. Orthopaedics & Traumatology: Surgery & Research, 101(1), pp.S51-S57.
Longo, U.G., Loppini, M., Rizzello, G., Ciuffreda, M., Maffulli, N. and Denaro, V., 2014. Latarjet, Bristow, and Eden-Hybinette procedures for anterior shoulder dislocation: systematic review and quantitative synthesis of the literature. Arthroscopy: The Journal of Arthroscopic & Related Surgery, 30(9), pp.1184-1211.
Hip Adduction: Often forgotten in Hip Rehabilitation?
The adductors are a group of muscles on the inside of your thigh. The adductor magnus, adductor longus, adductor brevis, pectineus and gracilis muscles all have involvement in hip adduction (bringing your thighs together). The adductor magnus muscle has a large hip extensor muscle moment arm, which in simple terms, makes it an unappreciated hip extensor, while the other adductors are also hip flexors. Therefore, the adductors play a part in many movements of the hip
The adductor magnus is a very large and heavy muscle. It is much larger and heavier than the other adductors. By some measures it is the second largest muscle in the body after the gluteus maximus. Ignoring the adductor magnus is therefore likely to lead to a failure to maximize overall muscular hypertrophy (growth and increased size of muscle) in the lower body.
Just like with the front and back of the leg, where there is a strength relationship between the quadriceps and hamstrings, there is also a relationship between the abductor and the adductor strength. For most, these relationships do not need to be assessed with a fine toothcomb, but these ratios are commonly used within high performance sport. Weakness in the hip adductors compared to the abductors has been shown to be a risk factor for developing groin pain in several sports, such as football and hockey.
‘don’t just sit on the hip adduction machine in the gym, seek advice on exercise from a physiotherapist or exercise professional to add variety to your programme’
During rehabilitation, it is important to remember that the adductors may be preferentially activated at different degrees of hip flexion. The adductor magnus is most active between 0 – 45 degrees, the adductor longus and gracilis are most active at 45 degrees, and the pectineus is most active at 90 degrees. Therefore, don’t just sit on the hip adduction machine in the gym, seek advice on exercise from a physiotherapist or exercise professional to add variety to your programme. Below is an example of an evidence-based exercise for strengthening your adductors.
‘Hands on’ treatment may be used in conjunction with exercise rehabilitation too. A large consensus paper, the DOHA agreement, stated that ‘Multimodal treatment including manual adductor manipulation can result in a faster return to play, but not a higher treatment success, than a partially supervised active physical training programme’.
Copenhagen Adduction Exercise
The Copenhagen adduction exercise (CAE) is a bodyweight, partner-assisted movement popularized by Danish researchers and sports therapists, including one of the leaders in groin injuries, Kristian Thorborg.
Thorborg and colleagues also investigated other exercises using elastic bands in adductor muscle strengthening research. Here, a hip adduction movement was performed over full range of motion with 3 seconds in, 2 seconds hold, and 3 seconds out. The participants performed 3 sets of exercise with both legs during each session.
Harøy, J., Thorborg, K., Serner, A., Bjørkheim, A., Rolstad, L.E., Hölmich, P., Bahr, R. and Andersen, T.E., 2017. Including the copenhagen adduction exercise in the FIFA 11+ provides missing eccentric hip adduction strength effect in male soccer players: A randomized controlled trial. The American journal of sports medicine, 45(13), pp.3052-3059.
Ishøi L, Sørensen CN, Kaae NM, et al. Large eccentric strength increase using the Copenhagen Adduction exercise in football: A randomized controlled trial. Scand J Med Sci Sports. 2016 Nov;26(11):1334-1342.
Jackie L Whittaker, et al. (2015) Risk factors for groin injury in sport: an updated systematic review. Br J Sports Med;49,pp.803-809
Jensen, J., Hölmich, P., Bandholm, T., Zebis, M.K., Andersen, L.L. and Thorborg, K., 2012. Eccentric strengthening effect of hip-adductor training with elastic bands in soccer players: a randomised controlled trial. Br J Sports Med, pp.bjsports-2012.
Weir, A., Brukner, P., Delahunt, E., Ekstrand, J., Griffin, D., Khan, K.M., Lovell, G., Meyers, W.C., Muschaweck, U., Orchard, J. and Paajanen, H., 2015. Doha agreement meeting on terminology and definitions in groin pain in athletes. Br J Sports Med, 49(12), pp.768-774.
The main energy currency used all over the body is Adenosine triphosphate (ATP). ATP is broken down to adenosine diphosphate (ADP) which releases energy. ATP is produced along an energy continuum involving three key energy systems: the phosphocreatine (ATP-PC) system, which produces ATP during extremely high-intensity activity lasting up to 30-seconds; anaerobic glycolysis which produces ATP during high-intensity activities from 6-120-seconds; and aerobic metabolism which produces ATP during low-intensity activities, from 120 seconds onwards. Note that there is an overlap in the activation of the energy systems meaning that ATP production occurs with at least two energy systems at one time. Given that road cyclists require both anaerobic and aerobic power, all three of these systems need to be trained.
Interestingly, analysis of cycling grand tours such as The Tour de France, reveal that cyclists can spend approximately 20-minutes per day over the individual anaerobic threshold, and when on hilly stages they are riding at high intensities of between 70-90% of their VO2max (the measurement of the maximum amount of oxygen a person can utilise during intense exercise), hence this group of athletes need to be able to tolerate high workloads over long periods of time. They also need to be able to produce brief episodes of high-power outputs, for example when steep climbing or sprinting at the race finish.
The pedal cycle consists of the power phase and the recovery phase. During the pushing action of the power phase, the hip and knee joints extend at the same time powered by the hip extensors (gluteal and hamstring muscles) to initiate the movement and the knee extensors (quadriceps muscles) to move the crank forward, and then together they work to gain momentum on the crank to apply a substantial driving force onto the pedals. The plantarflexors of the foot (the calf muscles) contract for a short period following this. During the recovery (upstroke) phase the tibialis anterior engages to dorsiflex the ankle, and the knee and hip flexors contract to draw the pedal back to the top centre of the crank cycle. Overall the quadriceps contraction is almost twice that of the hamstrings. Cycling also requires core, upper back, and upper limb strength to maintain good posture on the bike for prolonged periods.
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Strength training is advocated because of potential improvements in speed, anaerobic capacity and movement economy, and in postponing the effects of fatigue. Strength training is an anaerobic training modality which can lead to improvements in both the ATP-PC and anaerobic systems. A further benefit of strength training is that it increases the size and strength of muscles fibres, particularly type II fast-twitch fibres. Type II muscle fibres use anaerobic metabolism and provide short bursts of power. These adaptations can result in higher peak power output during cycling and thus an improved power to weight ratio, which is advantageous to cycling performance. High-intensity training for 30-40 seconds followed by a recovery period can also help to influence the ATP-PC system.
The pedalling motion and power during cycling is created by the cyclists’ legs, however a strong core is important, particularly when riders are in the saddle for many hours. Many postural muscles contain type I muscle fibres as they need to have endurance capabilities, and core stability training can help to strengthen this group of muscles. Core stability has been described as three co-dependent subsystems: passive (skeleton), active (muscles), and neural control (nerves). Constant communication between all subsystems is required for the maintenance of stability, and exercise programs should aim to incorporate these different aspects.
Sports medicine literature describes core stability as the neuromuscular control required to allow the “production, transfer, and control of force and motion to distal segments of the kinetic chain”. In a cyclist, a stable core could help to prevent energy loss by reducing trunk rotation and shoulder movements. Improved core stability also increases pelvic stability and balance in the saddle, which in turn helps to ensure sound lower limb alignment and greater force transmission from the torso to the legs. Core strength and stability also allows for highly coordinated muscle activation patterns to change continually, depending on the demands of the task at hand. Core stability exercises should be aimed at strengthening the scapula-thoracic region and the abdominal, lumbar spine and hip muscles.
Our clinic can help you with core stability training, strength and conditioning training, bike fits to ensure optimum positioning on the bike, as well as assistance with any cycling musculoskeletal injuries or problems. Stay safe and happy cycling!
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Physioimpulse Chartered Physiotherapists