Symptom​ Checker

Migraine

Migraine is a complex condition with a wide variety of symptoms. For many people the main feature is a painful headache. Other symptoms include disturbed vision, sensitivity to light, sound and smells, feeling sick and vomiting. Migraine attacks can be very frightening and may result in you having to lie still for several hours.

The symptoms will vary from person to person and individuals may have different symptoms during different attacks. Your attacks may differ in length and frequency. Migraine attacks usually last from 4 to 72 hours and most people are free from symptoms between attacks. Migraine can have an enormous impact on your work, family and social lives.(1)

The most common symptoms of a migraine attack include throbbing headache, sensitivity to light and noise, nausea (feeling sick), vomiting (being sick) and lethargy (lack of energy).(1)

Medical treatment involves pharmaceutical medication of which there are many to help with migraine. These approach migraine in different ways and can be extremely useful in the acute and prophylactic treatment of migraine attacks.(1)

If this route is not effective for you or you would like to supplement its effectiveness or look for an alternative long term solution, we offer number of options. Current RCT’s suggest that massage therapy, physiotherapy, relaxation and chiropractic spinal manipulation might be equally efficient as propranolol and topiramate.(2,3) Acupuncture is also an option having been shown to reduce headache days and medication use and is therefore recommended in the NICE Guidelines 2012.(4,5,6,7)

Our practitioners will look at a number of different factors that may be impacting your symptoms including posture, biomechanics, muscle patterning, sleep, exercise and diet. There are many factors that can impact migraine and so your treatment will be individual to you. Whilst going through your history we will discuss particularly which triggers you have and in detail what your symptoms are. Many migraine sufferers we see present with migraines and “normal” headaches which are not migraines. We will enquire in depth about both as this is relevant for appropriate treatment.

If you have any questions or would like to make an appointment then please call us today at our Liverpool Clinic on 0151 4275000 or our Wirral Clinic on 0151 6485000. Alternatively you can email enquiries@chiroandphysioclinic.co.uk and find out how we can help you.

Tension Headache

Symptoms

A tension-type headache is the most common type of headache and the one most people would consider a normal, everyday headache.  It may feel like a constant ache that affects both sides of the head. You may also feel the neck muscles tighten and a feeling of pressure behind the eyes.

A tension headache normally won't be severe enough to prevent you doing everyday activities. It lasts for 30 minutes to several hours, but can last for several days. About 2 or 3 in every 100 adults experience tension-type headaches more than 15 times a month for at least three months in a row. This is known as having chronic tension-type headaches. (1)

Introduction

In the twenty-first century, headaches are very common and cause substantial pain and disability. So if you are suffering from headaches you are not alone!. Headache is probably the most common problem seen in clinical practice by health care professionals, with tension type, cervicogenic headache, and migraine as the most common forms.2 These headaches are associated with a high burden of suffering and considerable socioeconomic costs.

Who suffers from tension headaches?

Most people are likely to have experienced a tension headache at some point. They can develop at any age, but are more common in teenagers and adults. Women tend to suffer from them more commonly than men.(1)

It's estimated that about half the adults in the UK experience tension-type headaches once or twice a month, and about 1 in 3 get them up to 15 times a month.(1)

What treatment can help?

Several therapeutic approaches have been proposed for the management of headaches though the most common are medication, physical therapy, and relaxation/cognitive therapies the most 4 The European Federation of Neurological Societies concluded that conservative non-drug management, i.e. physical therapy and acupuncture, should always be considered. 5 A national study conducted in the USA revealed that alternative medicine therapies are the most utilized treatments requested by individuals with headaches. 6 In fact, manual therapies are the treatment approach most requested by patients with tension type headache.

How can we help?

At the Chiro and Physio clinic we can help with tension headaches. There are indications within the literature that tension headaches can have a mechanical component, whether this is from the neck, posture or from the jaw. 8 Where this is the case, treatment to these areas via a combination of hands on therapy, specific advice and exercises have have a significant impact on your symptoms.

Cervicogenic Headache

Cervicogenic headache is a relatively common cause of chronic headache that is often misdiagnosed or unrecognized.  Early diagnosis and management by way of a comprehensive, multidisciplinary pain treatment program can significantly decrease the protracted course of costly treatment and disability that is often associated with this challenging pain disorder. (1)

Cervicogenic headaches most commonly appear at the base of the skull but they can radiate to the top of the head and behind the eye on either or both sides. The headaches can be accompanied by neck pain and stiffness. Sometimes the neck symptoms start before the headache manifests itself. With chronic or recurrent headaches, you may start to experience shoulder or arm symptoms including aching, heaviness or diffuse pain.(2) Pain is often associated with neck movement or sustained neck postures such as driving or desk work.(3) Overhead work is most likely to aggravate symptoms. In addition to the pain you may experience lightheadedness, dizziness, nausea or tinnitus (ringing or dullness in the ears). If you experience any of these symptoms you should seek the care and guidance of a healthcare professional.

Manual therapy has been shown to help cervicogenic headaches.(4,5) Research indicates that a combination of treatment and addressing the cause by such methods as strengthening will achieve the best results.(6,7) This is why at The Chiro & Physio clinic we are not just interested in the treatment to improve you we also want to address the underlying causes to prevent recurrence.

If you are struggling with cervicogenic headaches, call us today at our Liverpool Clinic on 0151 4275000 or our Wirral Clinic on 0151 6485000 or email enquiries@chiroandphysioclinic.co.uk and find out how we can help you.

When to seek medical help (8)

There's usually no need to see your GP if you only get occasional headaches. However, see your GP if you get headaches several times a week or your headaches are severe.

Your GP will ask questions about your headaches, family history, diet and lifestyle to help diagnose the type of headache you have.

You should seek immediate medical advice for headaches that:

• come on suddenly and are unlike anything you've had before
• are accompanied by a very stiff neck, fever, nausea, vomiting and confusion
• follow an accident, especially if it involved a blow to your head
• are accompanied by weakness, numbness, slurred speech or confusion

These symptoms suggest there could be a more serious problem, which may require further investigation and emergency treatment.

Painkillers (8)

Painkillers such as paracetamol or ibuprofen can be used to help relieve pain. Aspirin may also sometimes be recommended.

If you're taking these medications, you should always follow the instructions on the packet. Pregnant women shouldn't take ibuprofen during the third trimester, as it could risk harming the baby, and children under 16 shouldn't be given aspirin.

Medication shouldn't be taken for more than a few days at a time and medication containing codeine, such as co-codamol, should be avoided unless recommended by a GP.

Painkiller headaches (8)

Taking painkillers over a long period (usually 10 days or more) may lead to medication-overuse headaches developing. Your body can get used to the medication and a headache can develop if you stop taking them. 

If your GP suspects your headache is caused by the persistent use of medication, they may ask you to stop taking it. However, you shouldn't stop taking your medication without first consulting your GP.

1. Cervicogenic Headache: A Review of Diagnostic and Treatment Strategies. David M. Biondi, DOThe Journal of the American Osteopathic Association, April 2005, Vol. 105, 16S-22S.
2. Cervicogenic headache: too important to be left un-diagnosed Torbjørn A Fredriksen, Fabio Antonaci, Ottar Sjaastad J Headache Pain. 2015; 16: 6. Published online 2015 January 20.
3. Diagnosing cervicogenic headache. F. Antonaci, G. Bono, P. Chimento. J Headache Pain. 2006 June; 7(3): 145–148
4. Manual therapies for cervicogenic headache: a systematic review. Aleksander Chaibi, Michael Bjørn Russell. J Headache Pain. 2012 July; 13(5): 351–359
5. Mobilization and Manipulation of the Cervical Spine in Patients with Cervicogenic Headache: Any Scientific Evidence? Garcia JD, Arnold S, Tetley K, Voight K, Frank RA. Front Neurol. 2016 Mar 21;7:40
6. Int J Sports Phys Ther. 2011 Sep; 6(3): 254–266. CERVICOGENIC HEADACHES: AN EVIDENCE-LED APPROACH TO CLINICAL MANAGEMENT
7. Conservative physical therapy management for the treatment of cervicogenic headache: a systematic review. Stephanie Racicki, Sarah Gerwin, Stacy DiClaudio, Samuel Reinmann, Megan Donaldson. J Man Manip Ther. 2013 May; 21(2): 113–124
8. NHS Direct.

Cervicoegenic Dizziness

Cervicogenic Dizziness means dizziness coming from the neck/cervical spine. This is classically described as experiencing a dizziness with unsteadiness in balance. Patients often describe feeling “muzzy headed” and it can be accompanied by a lack of ability to concentrate and/or nausea. There are often neck symptoms too such as stiff, achey, restricted, uncomfortable or in more severe cases sharp or catching pain. Patients can also experience headaches. (1)

When diagnosed correctly, cervicogenic dizziness can be successfully treated using a combination of manual therapy and vestibular rehabilitation. (2) We also look at posture and strength which can contribute to symptoms (3)

Dizziness is different from vertigo. Vertigo is a sensation that you, or the environment around you, is moving or spinning.(4) Vertigo can be very severe and is usually linked with either conditions affecting the ear such as labyrinthitis, BPPV or vestibular neuronitis. It is also associated with migraines. (4)

In the clinic we commonly see cervicogenic dizziness in conjunction with neck stiffness and/or pain and headaches. This is something that we find responds well to treatment a combination of treatments specific to the individual and we always look to address the underlying cause and address this too. This may involve some strengthening or home exercises, postural end ergonomic advice and sleep advice is often very important too. If you are struggling with cervicogenic dizziness or you would like to ask more, please contact our Liverpool Clinic on 0151 4275000 or the Wirral Clinic on 0151 6485000 or contact us at enquiries@thechiroandphysioclinic.co.uk

1. Disabil Rehabil. 2007 Aug 15;29(15):1193-205. Cervicogenic dizziness - musculoskeletal findings before and after treatment and long-term outcome. Malmström EM1, Karlberg M, Melander A, Magnusson M, Moritz U.J Chiropr Med.
2. 2011 Sep; 10(3): 194–198. Chiropractic spinal manipulative treatment of cervicogenic dizziness using Gonstead method: a case study Aleksander Chaibia,⁎ and Peter J. Tuchinb
3. Arch Phys Med Rehabil. 1996 Sep;77(9):874-82. Postural and symptomatic improvement after physiotherapy in patients with dizziness of suspected cervical origin. Karlberg M1, Magnusson M, Malmström EM, Melander A, Moritz U.
4. www.NHS.uk

TMJ Dysfunction (Temperomandibular Joint Dysfunction)

Symptoms:

• Pain or discomfort on biting or chewing
• Clicking, popping, or grinding noises when opening or closing the mouth
• Dull, achey pain in the face or jaw
• Earache
• Headache
• Neck pain or restriction
• Tenderness of the jaw
• Locking or restriction of the jaw
• Difficulty opening or closing the mouth (1)

Characterised by pain, ache or discomfort around the TMJ/jaw joint.(2) TMJ disorders are problems that affect the chewing muscles and joints that connect your lower jaw to your skull. The TMJ is located adjacent to the ear so this can fee l like ear ache. It is associated with jaw clicking, locking and teeth grinding/bruxism.(3) You may also experience neck pain, ache and stiffness or headaches with this condition.(4)

TMJ Dysfunction can be cause by:

• Bad bite or orthodontic braces,
• Stress and tooth grinding. Many people with TMJ problems do not grind their teeth, and many who have been grinding their teeth for a long time do not have problems with their TMJ joint. For some people, the stress associated with this disorder may be caused by the pain, as opposed to being the cause of the problem.
• Poor posture can also be an important factor in TMJ symptoms. For example, holding the head forward while looking at a computer all day strains the muscles of the face and neck.
• Many people end up having "trigger points." These are contracted muscles in your jaw, head, and neck. Trigger points can refer pain to other areas, causing a headache, earache, or toothache.
• Other possible causes of TMJ-related symptoms include arthritis, fractures, dislocations, and structural problems present since birth. (5)

Treatment at the clinic involves a thorough history and examination. There TMJD is diagnosed, treatment may include soft tissue therapy and treatment of the joint itself. Treatment can be given from outside or inside the mouth (intra-oral). Where this occurs we use latex and powder free single use gloves. Your practitioner will always discuss treatment with you and talk you through the treatment they are administering. Where there is a concomitant neck problem, treatment will importantly include the neck. We have found exercises to be an important component of successfully treating TMJD and these will be included in your therapy as and when appropriate. Your practitioner will only undertake treatment that you are happy with.

If you are suffering from TMJD call our clinics today at Wirral 0151 6485000 or Liverpool on 0151 4275000 to speak to someone directly. If you would rather email, contact us on enquiries@chiroandphysioclinic.co.uk

1. Rotter BE. Temporomandibular joint disorders. In: Flint PW, Haughey BH, Lund LJ, et al, eds. Cummings Otolaryngology: Head & Neck Surgery. 5th ed. Philadelphia, PA: Elsevier Mosby; 2010:chap 94.
2. TMJ Disorders. National Institute of Dental and Craniofacial Research
3. Mujakperuo HR, Watson M, Morrison R, Macfarlane TV (2010 “Pharmacological interventions for pain in patients with temporomandibular disorders". The Cochrane Database of Systematic Reviews (10): CD004715. doi:10.1002/14651858.CD004715.pub2. PMID 20927737.
4. Shi Z, Guo C, Awad M (2003). "Hyaluronate for temporomandibular joint disorders". The Cochrane Database of Systematic Reviews (1): CD002970. doi:10.1002/14651858.CD002970. PMID 12535445.
5. Uyanik J.M., Murphy E. Evaluation and management of TMDs, Part 1. History, epidemiology, classification, anatomy, and patient evaluation. Dent Today. Oct 2003;22(10):140-5. [Medline].

Neck Pain

Introduction:

Neck pain and stiffness are very common and can have a huge impact on your life. Symptoms can include the following;

Symptoms;

• Pain at the neck radiating to the shoulders or into the arm
• Pain or aching at the top of the neck/base of the skull
• Stiffness or restriction
• You may experience sharp twinges with turning or with unguarded movements
• Associated headaches are common

When to seek help;

• If your symptoms are significant and impacting on everyday activities including sleep then you should seek help. This is an indication that your symptoms are severe enough that they may not settle by themselves and you may require treatment to experience relief.
• If you are experiencing pain into the arm accompanied by numbness, tingling and paraesthesias (pins and needles) then you should seek help. This is an indication that the nerves coming from the neck are being aggravated and you need to have this assessed to determine if there is any nerve damage occurring. If so, you will require MRI scans and if non-responsive to treatment you will require further referral to a consultant. All our patients presenting with these symptoms will undergo an upper limb neurology assessment to ascertain if there is nerve damage. Referral where appropriate will be undertaken by your practitioner and it will be explained to you exactly what is going on.
• If you are experiencing dizzyness, nausea or visual blurring you should seek help. These symptoms can be signs that the neck is irritated to a greater extent than simple “mechanical” aggravation and you may take longer to recover and require very specific care.

How can we help?

Neck pain is the most common complaint we see after low back pain. Neck an arm pain or neck pain and headaches are more common that neck pain alone. At The Chiro & Physio Clinic we utilise a number of techniques in line with best evidence to provide you with relief. We undertake a great deal of hands on treatment - this may be soft tissue release, joint mobilisation or manipulation. We have specialist equipment which provides drop technique, flexion distraction and toggle technique. We also utilise acupuncture, activator, IASTM (Instrument Assisted Soft Tissue Manipulation) and Taping techniques. For full symptomatic resolution and long term relief we work very closely with Rehabilitation Coaches - intact we even have one in clinic! - to get you the best results both short and long term.

If you are struggling with neck pain, call us today at our Liverpool Clinic on 0151 4275000 or our Wirral Clinic on 0151 6485000 or email enquiries@chiroandphysioclinic.co.uk and find out how we can help you.

Neck and Arm Pain

Here at The Chiro & Physio Clinic we see neck and arm pain more commonly than we see arm pain alone.

Symptoms;

• Pain in the neck radiating to the top of the shoulder and into the upper arm
• Pain on neck movement especially rotation (turning movements) and extension (looking overhead)
• Pain can be nagging, achey & dull, interspersed with sharp, shooting pain on certain movements or unguarded movements
• May be accompanied by numbness, tingling or paraesthesias (pins & needles)
• The arm may feel or be heavy and weak
• If you have unremitting pain shooting into the arm with numbness and paraesthesias it is likely that you have radiculopathy and it is important that you have this assessed

Patterns of Neck Pain

Neck and arm pain is a very common problem that we assess and treat at The Chiro & Physio Clinic. Symptoms have often been building for a while and they can start as less of a problem but they become more frequent, more painful and extend or radiate more over time. If you have symptoms that are doing this and are progressing overall it is important to seek advice and have your neck assessed. Episodes can also be recurrent and chronic which means that you periodically experience them over time. Again this is an indication there is an underlying problem that needs to be addressed before this can be resolved.

What can cause this?

Neck problems are very commonly associated with poor posture or weakness of the muscles of the upper back. This can be exacerbated further by bad desk or work ergonomics, stress and poor sleep i.e. sleeping with the wrong pillow or sleeping on your front. Sleeping position is so important that we have a short video tutorial on the do’s and don’ts which you may fine useful. Identifying causative factors is very important. If we don’t know what caused the neck issues how do we stop them from coming back? One thing we can always do is increase your strength. Being stronger makes you more robust and this is a great way to safeguard your neck longterm.

Treatment

At The Chiro & Physio Clinic we employ a number of different techniques in order to provide you with relief. This is in line with best evidence practice. The predominant feature in all our techniques is a very hands on approach. This may be soft tissue release, joint mobilisation or manipulation. We use specialised benches to provide drop technique, flexion distraction and toggle technique. We are also qualified in acupuncture, activator, IASTM (Instrument Assisted Soft Tissue Manipulation) and Taping techniques. For full symptomatic resolution and long term relief we work very closely with Rehabilitation Coaches; infact we even have one in clinic! This gets you the best results both short and long term.

How can we help?

If you are struggling with neck and arm pain, call us today at our Liverpool Clinic on 0151 4275000 or our Wirral Clinic on 0151 6485000 or email enquiries@chiroandphysioclinic.co.uk and find out how we can help you.

Neck and Shoulder Pain

Here at The Chiro & Physio Clinic we see neck and arm pain more commonly than we see arm pain alone.

Symptoms;

• Pain in the neck radiating to the top of the shoulder and into the upper arm
• Pain on neck movement especially rotation (turning movements) and extension (looking overhead)
• Pain can be nagging, achey & dull, interspersed with sharp, shooting pain on certain movements or unguarded movements
• May be accompanied by numbness, tingling or paraesthesias (pins & needles)
• The arm may feel or be heavy and weak
• If you have unremitting pain shooting into the arm with numbness and paraesthesias it is likely that you have radiculopathy and it is important that you have this assessed

Patterns of Neck Pain

Neck and arm pain is a very common problem that we assess and treat at The Chiro & Physio Clinic. Symptoms have often been building for a while and they can start as less of a problem but they become more frequent, more painful and extend or radiate more over time. If you have symptoms that are doing this and are progressing overall it is important to seek advice and have your neck assessed. Episodes can also be recurrent and chronic which means that you periodically experience them over time. Again this is an indication there is an underlying problem that needs to be addressed before this can be resolved.

What can cause this?

Neck problems are very commonly associated with poor posture or weakness of the muscles of the upper back. This can be exacerbated further by bad desk or work ergonomics, stress and poor sleep i.e. sleeping with the wrong pillow or sleeping on your front. Sleeping position is so important that we have a short video tutorial on the do’s and don’ts which you may fine useful. Identifying causative factors is very important. If we don’t know what caused the neck issues how do we stop them from coming back? One thing we can always do is increase your strength. Being stronger makes you more robust and this is a great way to safeguard your neck longterm.

Treatment

At The Chiro & Physio Clinic we employ a number of different techniques in order to provide you with relief. This is in line with best evidence practice. The predominant feature in all our techniques is a very hands on approach. This may be soft tissue release, joint mobilisation or manipulation. We use specialised benches to provide drop technique, flexion distraction and toggle technique. We are also qualified in acupuncture, activator, IASTM (Instrument Assisted Soft Tissue Manipulation) and Taping techniques. For full symptomatic resolution and long term relief we work very closely with Rehabilitation Coaches; infact we even have one in clinic! This gets you the best results both short and long term.

How can we help?

If you are struggling with neck and arm pain, call us today at our Liverpool Clinic on 0151 4275000 or our Wirral Clinic on 0151 6485000 or email enquiries@chiroandphysioclinic.co.uk and find out how we can help you.

Whiplash - WAD

Symptoms

Include neck and upper back aching and pain which may radiate to the shoulders. You may also experience upper limb symptoms including numbness, pins and needles and also headaches. Symptoms can appear immediately after the injury, but often are not felt until days afterwards.1 Whiplash is usually confined to the spine. The most common areas of the spine affected by whiplash are the neck and thoracic spine (between the shoulder blades). You may also experience some dizziness, nausea and, lack of ability to concentrate and irritability.2

Overview

"Whiplash" is actually a slang word or colloquialism. The official diagnosis would be a "whiplash associated disorder" (WAD). This describes the injury sequelae and symptoms.

Whiplash is commonly associated with road accidents most commonly with rear impact collisions however, the injury can be sustained in other ways, including head banging3 bungee jumping and falls.4 Given the wide variety of symptoms associated with whiplash injuries, the Quebec Task Force on Whiplash-Associated Disorders coined the phrase 'Whiplash-Associated Disorders’.5

Treatment

At The Chiro & Physio Clinic we will assess you thoroughly to ascertain if there is any associated neurology, central sensitisation, thoracic dysfunction or TMJ Disorders in addition to your WAD. Research has shown that treating the neck alone frequently does not give lasting relief.6,7,8,9,10 Having a full picture of your clinical symptoms is essential to gaining the best results with treatment. Research has shown chiropractic treatment to have positive effects for WAD - it was associated with a 93% improvement rate for chronic pain sufferers of WD.11 Exercise rehabilitation is also a key part of recovery as recommended by the Bone and Joint Decade Task Force on Neck Pain and its Associated Disorders12

1. Krafft, M; Kullgren A; Lie A; Tingval C (2005-04-01). "Assessment of Whiplash Protection in Rear Impacts" (PDF). Swedish National Road Administration & Folksam. Archived from the original (pdf) on August 8, 2007. Retrieved 2008-01-18.
2. Borenstein, P.; Rosenfeld, M.; Gunnarsson, R. (2010). "Cognitive symptoms, cervical range of motion and pain as prognostic factors after whiplash trauma.". Acta Neurol Scand 122 (4): 278–85 1
3. http://www.nhs.uk/conditions/whiplash/Pages/Introduction.aspx
4. (2010). Retrieved January 16, 2013 from http://www.njpcc.com/conditions-of-the-spine/neck-paininjury.html
5. Desapriya, Ediriweera (2010). Head restraints and whiplash : the past, present, and future. New York: Nova Science Publishers. ISBN 978-1-61668-150-0. 1
6. Bismil QM, Bismil MS (2012). "Myofascial-entheseal dysfunction in chronic whiplash injury". J R Soc Med Sh Rep 3 (8): 57. doi:10.1258/shorts.2012.012052.
7. Gorski JM and Schwartz LH, Shoulder Impingement Presenting as Neck Pain. The Journal of Bone & Joint Surgery Vol 85-A · Number 4 · April 2003 p635-638
8. Chauhan SK, Peckham T, Turner R (2003). "Impingement Syndrome Associated with Whiplash Injury". J Bone J Surg 3: 408–410.
9. Umaar W. Yew KIM; Zenios M.; Brett I.; Sharma Y. (2005). "Whiplash Injury of the Shoulder: Is it a Distinct Clinical Entity?". Acta Orthop. Belg. 71: 385–387.
10. Abbassian A.; Giddins G. (2008). "Subacromial Impingement in Patients with Whiplash Injury to the Cervical Spine". Journal of Orthopaedic Surgery and Research 3 (25): 1749.
11. Injury. 1996 Nov;27(9):643-5.Chiropractic treatment of chronic 'whiplash' injuries. Woodward MN1, Cook JC, Gargan MF, Bannister GC
12. Eur Spine J. 2016 Feb 6. [Epub ahead of print] Are non-invasive interventions effective for the management of headaches associated with neck pain? An update of the Bone and Joint Decade Task Force on Neck Pain and Its Associated Disorders by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration. Varatharajan S1,2,3, Ferguson B4, Chrobak K4, Shergill Y5, Côté P6,7,8, Wong JJ1,2, Yu H1,2, Shearer HM1,2, Southerst D1,9, Sutton D1,2, Randhawa K1,2,3, Jacobs C1,10, Abdulla S4, Woitzik E4, Marchand AA11, van der Velde G12,13,14, Carroll LJ15, Nordin M16, Ammendolia C17,14,18, Mior S2,17, Ameis A19, Stupar M1, Taylor-Vaisey A1.

Impingement Syndromes

Symptoms;

With Impingement Syndrome you will most commonly experience pain, weakness and restriction of the affected shoulder. Overhead movement and sleeping on the side of your affected shoulder will typically aggravate symptoms. If you injured the shoulder the onset of pain may be acute, if your symptoms started gradually they are more likely to be from posture or “wear and tear” such as an osteoarthritic spur. You may also experience grinding or popping sensations during movement of the shoulder. A classic sign of Impingement Syndrome is a painful arc of movement during forward elevation of the arm from 60° to 120°.

What is Impingement Syndrome

It is also known as subacromial impingement, painful arc syndrome, supraspinatus syndrome, swimmer's shoulder, and thrower's shoulder. It is a clinical syndrome which occurs when the tendons of the rotator cuff muscles become irritated and inflamed as they pass through the subacromial space, the passage beneath the acromion.

How does it happen

When you lift your arm, the subacromial space (between the front edge of the acromion and the head of the humerus) narrows. The tendon of the supraspinatus muscle passes through this space.Anything that narrows this space further can impinge the tendon and cause an inflammatory response, resulting in impingement syndrome. Narrowing can be caused by bony projections from under the acromion (subacromial spurs), osteoarthritic spurs on the acromioclavicular joint, and variations in the shape of the acromion. Thickening or calcification of the coracoacromial ligament can also cause narrowing. Weakness or injured to the rotator cuff can cause the humerus to elevate resulting in impingement. Inflammation and subsequent thickening of the subacromial bursa can also cause impingement.

Scapular mechanics (the motion and control of the shoulder blade) play a huge role in shoulder impingement syndrome. Scapular mechanics are governed by the intrinsic muscles of the scapula including the subscapularis, infraspinatus, teres minor and supraspinatus .§ Each of these muscles has their own role in proper shoulder function and must be in balance with each other in order to avoid shoulder pathology. Abnormal scapular motion is called scapular dyskinesis. The position and motion of the scapula influences the position of the acromion which can impact impingement. If you are suffering from Impingement Syndrome, it is very important to have your scapular mechanics assessed.

At The Chiro & Physio Clinic we will assess the movement of your whole shoulder girdle, your glenohumeral joint, scapular motion, thoracic and cervical spine movements. We then use a recognised series of testing that repositions each area to look at how this impacts upon your pain. This way we can identify specifically to you which structures are contributing to your problems. We work with specialist consultants and know when you are responding and when you require further imaging or assessment. So you can rest assured you will always be in the right hands.

How can we help?

If you are suffering from Impingement Syndrome, call us today at our Liverpool Clinic on 0151 4275000 or our Wirral Clinic on 0151 6485000 or email enquiries@chiroandphysioclinic.co.uk and find out how we can help you.

Rotator Cuff Injury

Symptoms

A rotator cuff injury will cause dull aching deep in the shoulder socket joint which can increase if you sleep on the side of that shoulder. Symptoms will be aggravated with overhead activities i.e. drying your hair, hanging out washing or serving in tennis.(1) These injuries are more common if you repeatedly perform overhead motions within your job or sports. For example if you are a painters, carpenters, or you play baseball or tennis. Your risk injuring your rotator cuff also increases with age (2)

What is a Rotator Cuff Injury?

The rotator cuff is a group of muscles and tendons that surround your shoulder joint, keeping the head of your humerus (upper arm bone) firmly located in the shallow socket of the shoulder. The cuff is comprised of four muscles and their tendons. These are the;

• Supraspinatus,
• Infraspinatus,
• Teres Minor
• Subscapularis.

Sometimes known as the “SITS” muscles. Injury, Fatigue or Atrophy (wasting) of any of these muscles or their tendons is a Rotator Cuff Injury(3). Injury occurs either as the result of a single injury - i.e. a fall or gradually over a period of time with repetitive activities as descried above. Tears are graded and may be Minor (Grade 1 or Fascial Tear) or Major (Grade 4 or Rupture). Minor and moderate tears respond well to conservative treatment with exercise rehabilitation.(1,4,5) It is also essential that your shoulder mechanics and assessed to avoid recurrence of issues. Without addressing aberrant muscular patterning, full recovery is unlikely and re-injury is common. Extensive rotator cuff tears may require surgical repair, transfer of alternative tendons or joint replacement. However it is important that after surgery you receive treatment to reduce pain, increase movement and strengthen the shoulder muscles in order to restore correct function (6)

If you are looking for full assessment and treatment of your Rotator Cuff Injury, call the Wirral Clinic on 0151 6485000 or our Liverpool Clinic on 0151 4275000. If you would prefer, email us at enquiries@chiroandphysioclinic.co.uk

1. www.mayoclinic.com
2. www.nhs.co.uk
3. Jobe FW, Moynes DR (1982). "Delineation of diagnostic criteria and a rehabilitation program for rotator cuff injuries". Am J Sports Med 10 (6): 336–9
4. JESS, Jan-Feb 2009Volume 18, Issue 1, Pages 138–160Exercise in the treatment of rotator cuff impingement: A systematic review and a synthesized evidence-based rehabilitation protocol. John E Kuhn MD
5. Escamilla RF, Yamashiro K, Paulos L, Andrews JR (2009). "Shoulder muscle activity and function in common shoulder rehabilitation exercises". Sports Med 39 (8): 663–85
6. Brewster C, Schwab DR (1993). "Rehabilitation of the shoulder following rotator cuff injury or surgery". J Orthop Sports Phys Ther 18 (2): 422–6

Scapular Dyskinesis (SD)/Scapulothoracic Dysfunction

Symptoms

Signs and symptoms of SD may include pain in the shoulder or arm, especially with arm elevation, overhead or throwing activities. You could notice popping or clicking or be aware that your shoulder blade does not move correctly, it may “wing” (stick out). You might have no pain at all. However SD has been heavily implicated as an important factor in most shoulder injuries. may also contribute towards Impingement Syndromes, Bicipital Tendonopathy, Rotator Cuff Injury, Shoulder or Trapezius Pain, Neck pain or Upper Back Pain and stiffness. (1,2,3,4)

Scapular Summit 2013 Major Conclusions;(1)

• Scapular dyskinesis is present in a high percentage of most shoulder injuries
• The exact role of the dyskinesis in creating or exacerbating shoulder dysfunction is not clearly defined
• Shoulder impingement symptoms are particularly affected by scapular dyskinesia
• Scapular dyskinesis is most aptly viewed as a potential impairment to shoulder function
• Treatment strategies for shoulder injury can be more effectively implemented by evaluation of the dyskinesis
• A reliable observational clinical evaluation method for dyskinesis is available and
• Rehabilitation programmes to restore scapular position and motion can be effective within a more comprehensive shoulder rehabilitation programme.

Our Treatment

At The Chiro & Physio Clinic we fully assess and rehabilitate SD as recommended by the best experts in the field. We will look at your scapular motion but also assess this in relation to the cervical spine (neck), thoracic spine (upper back) and glenohumeral motion (shoulder joint). Where appropriate we also look further afield to identify and address the cause of your dysfunction. We also have in-house Exercise Rehabilitation and local gyms to ensure your appropriate and comprehensive rehabilitation programme. We also work with shoulder specialists, both surgical and non-surgical so that where appropriate we can refer you to the best person to help you gain relief. This way you know you will always be in good hands. If you are suffering from Scapular Dyskinesis, contact our Wirral Clinic on 0151 6485000 or Liverpool Clinic on 0151 4275000 so speak to a practitioner or book an appointment. If you would like to email, contact us on enquiries@chiroandphysioclinic.co.uk

Tendonitis vs Tendonopathy

What is Tendonitis?

Tendonitis is inflammation of a tendon. Just as in appendicitis and tonsillitis the suffix “-itis” refers to an inflammatory process. Inflammation occurs when the musculotendinous unit is suddenly overloaded with a force that it trying to lengthen the tendon that is too heavy and/or too sudden. Tendinitis is still given very commonly as a diagnosis, despite research increasingly indicating that the process involved is far more commonly tendonosis (1,2,3)

That is Tendonosis?

Tendinosis is the degeneration of the collagen component of a tendon in response to chronic overuse. This occurs when the overuse is continued without giving the tendon recovery time allowing healing. This fundamentally alters the makeup of the tendon and this can be seen at a cellular level in tendons. (1,2,3,4)

Symptoms

Think tendinitis and you think pain and burning in the affected area, decreased strength and flexibility, and pain caused by everyday activities. As it turns out, tendinosis causes the same symptoms and is far more commonly the underlying cause. (1,2,3)

Confused?

The confusion about the difference between tendinitis and tendinosis is widespread. Many injuries commonly presumed to be tendinitis are actually tendinosis. Tennis elbow is an example of this. It is usually described as tendinitis of the extensor carpi radialis brevistendon. However, on examining any surgical pathologic specimens of patients clinically diagnosed with lateral tennis elbow syndrome, no signs of acute or chronic inflammation were found. This proves that tennis elbow is not tendinitis, it is actually tendinosis. (1,2,3,4,5)

Why does it matter?

The difference is critical. Because if you don't know what is happening you cant treat it effectively These syndromes have different healing times, different treatments and most importantly some treatments used for one are actively contraindicated in the other.(6)

Do you really have tendonitis?

So if you have been suffering with tendonitis, if you have been treated and not responded it is very possible that you have been diagnosed and are being treated for the wrong thing which is why you are not responding. Find out your actual diagnosis and get treated appropriately to achieve results at The Chiro & Physio Clinic. Call us at Liverpool 0151 4275000 or our Wirral Clinic on 0151 6485000 or email us at enquiries@chiroandphysioclinic.co.uk

1. Khan KM, Cook JL, Kannus P, et al. Time to abandon the “tendinitis” myth: Painful, overuse tendon conditions have a non-inflammatory pathology [editorial] BMJ. [Accessed 16 September 2011]. http://www.bmj.com/content/324/7338/626.full. Published March 16, 2002.
2. Heber M. Tendinosis vs. Tendinitis. Elite Sports Therapy. [Accessed 16 September 2011]. http://www.elitesportstherapy.com/tendinosis-vs--tendonitis.
3. Khan KM, Cook JL, Taunton JE, et al. Overuse tendinosis, not tendinitis—Part 1: A new paradigm for a difficult clinical problem. [Accessed 13 February 2012];Physician Sportsmed. 2000 28(5) http://www.massagebyjoel.com/downloads/OveruseTendinosis-PhysSptsmed.pdf. [PubMed]
4. Boyer MI, Hastings H. Lateral tennis elbow: Is there any science out there? J Shoulder Elbow Surg. 1999;8(5):481–491. doi: 10.1016/S1058-2746(99)90081-2. [PubMed] [Cross Ref]
5. Kraushaar B, Hirschl RP. Current concepts review - tendinosis of the elbow (Tennis Elbow). Clinical features and findings of histological, immunohistochemical, and electron microscopy studies. [Accessed 28 January 2012];J Bone & Joint Surg. 1999 81(2):259–278. http://www.jbjs.org/article.aspx?Volume=81&page=259. [PubMed] Int J Ther Massage Bodywork. 2012; 5(1): 14–17. PMCID: PMC3312643 Published online 2012 Mar 31. Tendinopathy: Why the Difference Between Tendinitis and Tendinosis Matters Evelyn Bass, LMT

Bicipital Tendonitis vs Tendonopathy

Symptoms

Biceps Tendonosis can be very painful. If you are suffering from Bicipital Tendonopathy, you will experience dull and achey pain at the front of the shoulder radiating to the front of the arm. This can increase to sharp or stabbing pain with overhead activities, lifting in front of the body or overhead or with repetitive activities.(1) Often your pain will be worse at night. Your tendon can often be felt at the front of the shoulder and can be very tender to touch or press.

What is Bicipital Tendonitis vs Tendonopathy?

Biceps tendonitis is an inflammation of the Long Head of Biceps tendon, however according to latest research it is a much overused term as more often than not the cause is Tendonopathy. It is important to differentiate between the 2 so that you can receive the appropriate treatment as they are 2 very different processes.(2,3,4)

Tendinitis is the inflammation of the tendon and results from micro-tears that happen when the musculotendinous unit is acutely overloaded with a tensile force that is too heavy and/or too sudden such as weightlifting above your limit or falling onto the arm.

Tendinosis is the degeneration of the tendon’s collagen in response to chronic overuse. When overuse is continued without giving the tendon time to heal and rest (such as with repetitive strain injury) tendinosis results. Even tiny movements, such as clicking a mouse, can cause tendinosis, when performed repeatedly. The latter of the processes is far more common.(2,3,4,5,6)

Getting it right

The treatment for both processes is markedly different and actually some treatments recommended fro bicipital Tendonitis are actually contraindicated in Tendonosis. Ibuprofen which is an NSAID (Non-Steroidal Anti-Inflammatory Drug) is associated with inhibited collagen repair (7) Corticosteroids which are used with tendonitis are known to inhibit collagen repair and have been shown to be a predictor of later tendon tears.(4,5,8)

How to Treat?

With the far more common tendonopathy, as it is a chronic overuse injury posture, muscle balance and shoulder mechanics are key issues that require thorough assessment and treatment. Correcting these not only treats your current symptoms but assists in future prevention. It is important that the muscles in the shoulder are balanced and strong. Posture also plays a key role as does scapular mechanics and thoracic mobility. These are elements that are all assessed, treated and strengthened where appropriate at The Chiro & Physio Clinic. We know that treatment is only part of the solution. Full resolution and future prevention are only achieved with correct strengthening and patterning which is why we have in-house specialists to achieve this for you.

Contact Us

So if you are suffering from Bicipital Tendonopathy or Tendonitis call us at the Liverpool Clinic on 0151 4275000 or our Wirral Clinic on 0151 6485000 and see how we can help you. Alternatively you can email us at enquiries@chiroandphysioclinic.co.uk

1. www.shoudlerdoc.com
2. Khan KM, Cook JL, Kannus P, et al. Time to abandon the “tendinitis” myth: Painful, overuse tendon conditions have a non-inflammatory pathology [editorial] BMJ. [Accessed 16 September 2011]. http://www.bmj.com/content/324/7338/626.full. Published March 16, 2002. [Ref list]
3. Heber M. Tendinosis vs. Tendinitis. Elite Sports Therapy. [Accessed 16 September 2011]. http://www.elitesportstherapy.com/tendinosis-vs--tendonitis. [Ref list]
4. Overuse tendinosis, not tendinitis part 1: a new paradigm for a difficult clinical problem. Khan KM, Cook JL, Taunton JE, Bonar F Phys Sportsmed. 2000 May; 28(5):38-48.
5. Lateral tennis elbow: "Is there any science out there?”. Boyer MI, Hastings H 2nd J Shoulder Elbow Surg. 1999 Sep-Oct; 8(5):481-91.
6. Tendinosis of the elbow (tennis elbow). Clinical features and findings of histological, immunohistochemical, and electron microscopy studies. Kraushaar BS, Nirschl RP J Bone Joint Surg Am. 1999 Feb; 81(2):259-78.
7. Ibuprofen inhibition of tendon cell proliferation and upregulation of the cyclin kinase inhibitor p21CIP1. Tsai WC, Tang FT, Hsu CC, Hsu YH, Pang JH, Shiue CC J Orthop Res. 2004 May; 22(3):586-91. Rattray F, Ludwig L. Clinical Massage Therapy: Understanding, Assessing and Treating Over 70 Conditions. Elora, Ontario: Talus Inc; 2001. [Ref list]

Nerve Pain - Radicular Pain

Symptoms;

• Severe pain in the neck and arm
• Pain will be easily aggravated and sharp/stabbing when irritated
• Constant background dragging, nagging, horrible pain
• Pins and needles and tingling in the arm - this will be in specific fingers. If it’s in the whole hand then this is nerve involvement but it indicates a Brachial Plexus irritation rather than a specific nerve root

What causes Radicular Pain?

Radicular pain from the neck is caused when one of the nerves from the neck is being irritated to a significant amount. Nerves have a huge ability to cause pain as they themselves are the communication and pain pathways of the body. The nerves from the neck supply the sensation, reflexes and muscle strength to the upper arm. The most important differentiation when you experience symptoms like this is whether the nerve is being irritated alone or if it has been irritated enough to affect it’s ability to function. This will lead to sensory deficit (loss of touch sensation), weakness and reflex loss. Therefore it is extremely important that you have your upper limb neurology assessed if you are experiencing these symptoms. This has a huge impact on how likely you are to respond to treatment and whether or not you would require surgery. Conservative treatment is the first approach utilised in these cases. If you are suffering from this condition, when we see you at The Chiro & Physio clinic we will undertake treatment whilst simultaneously referring you for MRI scans which inevitably will take a few weeks to come through. This way we waste no time in having treatment.

Can Radicular Pain be treated?

Yes. The first option should always be conservative care. Surgery in the neck is a significant procedure with significant risks and would only be undertaken in non-responsive cases. Conservative care must be specific and appropriate. When you are in so much pain, our initial goal is to relieve any irritation to the nerves and reduce your pain. This means addressing the arm pain first. We have a number of techniques that are gentle and specific in conjunction with a lot of home advice and specific, gentle exercises at regular intervals.

VERY IMPORTANT

If you experience lower limb or body symptoms in addition to the above then you need to contact your GP immediately. Should you experience leg or foot numbness or loss of control of your bowels or bladder then you need to call an ambulance.

How to treat?

With the far more common tendonopathy, as it is a chronic overuse injury posture, muscle balance and shoulder mechanics are key issues that require thorough assessment and treatment. Correcting these not only treats your current symptoms but assists in future prevention. It is important that the muscles in the shoulder are balanced and strong. Posture also plays a key role as does scapular mechanics and thoracic mobility. These are elements that are all assessed, treated and strengthened where appropriate at The Chiro & Physio Clinic. We know that treatment is only part of the solution. Full resolution and future prevention are only achieved with correct strengthening and patterning which is why we have in-house specialists to achieve this for you.

Treatment

So if you are suffering from Radicular Pain call us at the Liverpool Clinic, if you have been treated and not responded it is very possible that you have been diagnosed and are being treated for the wrong thing which is why you are not responding. Find out your actual diagnosis and get treated appropriately to achieve results at The Chiro & Physio Clinic. call us today at our Liverpool Clinic on 0151 4275000 or our Wirral Clinic on 0151 6485000 or email enquiries@chiroandphysioclinic.co.uk and find out how we can help you.

Nerve Pain - Radicular Pain

Symptoms;

• Severe pain in the neck and arm
• Pain will be easily aggravated and sharp/stabbing when irritated
• Constant background dragging, nagging, horrible pain
• Pins and needles and tingling in the arm - this will be in specific fingers. If it’s in the whole hand then this is nerve involvement but it indicates a Brachial Plexus irritation rather than a specific nerve root

What causes Radicular Pain?

Radicular pain from the neck is caused when one of the nerves from the neck is being irritated to a significant amount. Nerves have a huge ability to cause pain as they themselves are the communication and pain pathways of the body. The nerves from the neck supply the sensation, reflexes and muscle strength to the upper arm. The most important differentiation when you experience symptoms like this is whether the nerve is being irritated alone or if it has been irritated enough to affect it’s ability to function. This will lead to sensory deficit (loss of touch sensation), weakness and reflex loss. Therefore it is extremely important that you have your upper limb neurology assessed if you are experiencing these symptoms. This has a huge impact on how likely you are to respond to treatment and whether or not you would require surgery. Conservative treatment is the first approach utilised in these cases. If you are suffering from this condition, when we see you at The Chiro & Physio clinic we will undertake treatment whilst simultaneously referring you for MRI scans which inevitably will take a few weeks to come through. This way we waste no time in having treatment.

Can Radicular Pain be treated?

Yes. The first option should always be conservative care. Surgery in the neck is a significant procedure with significant risks and would only be undertaken in non-responsive cases. Conservative care must be specific and appropriate. When you are in so much pain, our initial goal is to relieve any irritation to the nerves and reduce your pain. This means addressing the arm pain first. We have a number of techniques that are gentle and specific in conjunction with a lot of home advice and specific, gentle exercises at regular intervals.

VERY IMPORTANT

If you experience lower limb or body symptoms in addition to the above then you need to contact your GP immediately. Should you experience leg or foot numbness or loss of control of your bowels or bladder then you need to call an ambulance.

How to treat?

With the far more common tendonopathy, as it is a chronic overuse injury posture, muscle balance and shoulder mechanics are key issues that require thorough assessment and treatment. Correcting these not only treats your current symptoms but assists in future prevention. It is important that the muscles in the shoulder are balanced and strong. Posture also plays a key role as does scapular mechanics and thoracic mobility. These are elements that are all assessed, treated and strengthened where appropriate at The Chiro & Physio Clinic. We know that treatment is only part of the solution. Full resolution and future prevention are only achieved with correct strengthening and patterning which is why we have in-house specialists to achieve this for you.

Treatment

So if you are suffering from Radicular Pain call us at the Liverpool Clinic, if you have been treated and not responded it is very possible that you have been diagnosed and are being treated for the wrong thing which is why you are not responding. Find out your actual diagnosis and get treated appropriately to achieve results at The Chiro & Physio Clinic. call us today at our Liverpool Clinic on 0151 4275000 or our Wirral Clinic on 0151 6485000 or email enquiries@chiroandphysioclinic.co.uk and find out how we can help you.

AC Joint Sprain

When you put your hand on someone’s shoulder you will cover the AC joint. The joint can be strained with trauma - most commonly a blow to the joint or a fall onto an outstretched hand. This causes local pain and may cause swelling. When damaged, the ligaments of the AC joint are graded;

• Grade 1 - Involves a sprain of the acromioclavicular ligament only. This is the most common sprain type.
• Grade 2 - This affects the AC ligament and the joint capsule with a vertical subluxation of the clavicle.
• Grade 3 - This is where the AC & Coracoclavicular ligament and capsule are disrupted and AC joint dislocation occurs.

These pains can be more problematic than initially thought with with up to 9% of grade 1 and 42% of grade 2 sprains causing severe pain and instability. Therefore it is very important to have your injury assessed and treated appropriately to gain the best short and long term results.

Labral Tears

The labrum of the shoulder is a fibrous cartilage ring which creates a “cuff” around the “socket” of the scapula of the ball and socket joint of the shoulder. This allows better congruency and stability of the shoulder joint. A number of different tears can occur from trauma or repetitive overuse injuries. These are given different names. The most common are Bankart and SLAP tears. Tears cause pain and catching or weakness/giving way sensations in the shoulder.

Having the correct diagnosis and appropriate treatment is essential for achieving the best recovery. Whether your tear is appropriate for conservative management or not depends on the size of the tear and it’s location. It also depends on how strong your shoulder muscles are and if you have good muscle patterning. Where appropriate we work closely with shoulder consultants and local experts to achieve the best result for you.

Adhesive Capsulitis/Frozen Shoulder

Adhesive Capsulitis can be extremely painful and debilitating. It is generally divided into 3 distinct stages;

• Stage 1 - “Freezing” Stage which is the Painful Stage. This is very painful and associated with progressive loss of range of the shoulder. This stage usually lasts 3-9 months. It occurs due to an acute synovitis of the glenohumeral joint.
• Stage 2 - “Frozen” In this stage symptoms do not tend to get worse but they plateau. Do to lack of use, muscular disuse of the arm can occur in this stage. This lasts anywhere from 4-12 months.
• Stage 3 - “Thawing” lasts anywhere from 12-42 months and ROM and pain levels begin to improve.

AC is commonly associated with other more systemic conditions such as Diabetes, Thyroid problems and adrenal imbalance. Having the correct diagnosis is essential here.

Golfer’s Elbow/Medial Epicondylopathy

Symptoms

You will experience pain at the inside aspect of the elbow which may radiate down the forearm. The pain will be exacerbated by gripping especially if you then use the arm, i.e. pouring hot water from a kettle, using secateurs in the garden or using power tools.(1) The movement however doesn't have to be strenuous, turning the key in the lock of a door can elicit sharp pain too. Despite the name, you don’t have to be a golfers to get it, just as you don't have to play tennis to get tennis elbow.(2)

What is Medial Epicondylopathy?

As an overuse injury of the tendon, this is still often referred to as an “Epicondylitis”. However we know through recent research that there is primarily a degenerative rather than inflammatory condition of the tendon. As such it is very important to treat and manage it in this way as discussed in our “Tendonitis vs Tendonosis” section. (3,4)

Treatment

Most people respond well to conservative treatment with physical therapy and strengthening (5)

Manipulation has also been shown to be useful in pain modulation (6) These are all techniques that we would use as standard at The Chiro & Physio Clinic and in addition we use Instrument Assisted Techniques and Taping. Most importantly we will diagnose and therefore treat your epicondylosis appropriately to achieve the best results for you.

If you are suffering from Medial Epicondylopathy then call us at Liverpool on 0151 4275000 or on the Wirral on 0151 6485000 to ask more of book an appointment. Alternatively you can email us at enquiries@chiroandphysioclinic.co.uk

1. Clin Sports Med. 2004 Oct;23(4):693-705, xi.Diagnosis and treatment of medial epicondylitis of the elbow. Ciccotti MC1, Schwartz MA, Ciccotti MG.
2. J Am Acad Orthop Surg. 2015 Jun;23(6):348-55. doi: 10.5435/JAAOS-D-14-00145. Medial epicondylitis: evaluation and management. Amin NH, Kumar NS, Schickendantz MS.
3. Khan KM, Cook JL, Kannus P, et al. Time to abandon the “tendinitis” myth: Painful, overuse tendon conditions have a non-inflammatory pathology [editorial] BMJ. [Accessed 16 September 2011]. http://www.bmj.com/content/324/7338/626.full. Published March 16, 2002.
4. Heber M. Tendinosis vs. Tendinitis. Elite Sports Therapy. [Accessed 16 September 2011]. http://www.elitesportstherapy.com/tendinosis-vs--tendonitis.
5. Med Clin North Am. 2014 Jul;98(4):833-49, xiii. doi: 10.1016/j.mcna.2014.04.002. Elbow tendinopathy. Pitzer ME1, Seidenberg PH2, Bader DA1.
6. Does effectiveness of exercise therapy and mobilisation techniques offer guidance for the treatment of lateral and medial epicondylitis? A systematic review. Hoogvliet P, Randsdorp MS, Dingemanse R, Koes BW, Huisstede BM. Br J Sports Med. 2013 Nov;47(17):1112-9. doi: 10.1136/bjsports-2012-091990. Epub 2013 May 24. Review. PMID: 23709519

Tennis Elbow/Lateral Epicondylopathy

Symptoms

If you have Tennis Elbow you will experience pain at the lateral aspect (outside) of the elbow, classically with a point tenderness of pain over the bony prominence (lateral epicondyle). Your pain will increase with gripping activities, especially those that involve wrist extension (bending backwards) such as sweeping, lifting when the palm is facing down or pouring the kettle. The pain can also radiate down to the forearm even to the wrist. The pain is similar to Golfer’s Elbow but occurs at the other side of the elbow. Sometimes you may experience both Golfers and Tennis elbow if you have had symptoms for a long time.(1,2)

What is Lateral Epicondylopathy?

It is very important that you have this treated as an Epicondylosis or Epicondylopathy as we know that epicondylitis doesn’t exist. The reason this is important is because the treatment, management and prognosis is very different to an acute tear or strain. The correct approach in treatment, loading and management is key to gaining relief and it explains why many people suffer with these conditions long term and finally have to undergo surgery. These conditions respond well to conservative care when managed appropriately. With chronic cases that are non -responsive to conservative care, discuss autologous blood injections with us for more information.(3,4)

Treatment

Most people respond well to conservative treatment with physical therapy and strengthening (5,6)

Dry Needling has also shown to be useful in modulating pain. These are all techniques that we would use as standard at The Chiro & Physio Clinic and in addition we use Instrument Assisted Techniques and Taping. Most importantly we will diagnose and therefore treat your epicondylosis appropriately to achieve the best results for you.(7)

If you are suffering from Medial Epicondylopathy then call us at Liverpool on 0151 4275000 or on the Wirral on 0151 6485000 to ask more of book an appointment. Alternatively you can email us at enquiries@chiroandphysioclinic.co.uk

1. Clin Sports Med. 2001 Jul;20(3):549-63. Lateral epicondylitis. Peters T1, Baker CL Jr.
2. Clin Sports Med. 1996 Apr;15(2):283-305. Medial and lateral epicondylitis in the athlete. Plancher KD1, Halbrecht J, Lourie GM.
3. Khan KM, Cook JL, Kannus P, et al. Time to abandon the “tendinitis” myth: Painful, overuse tendon conditions have a non-inflammatory pathology [editorial] BMJ. [Accessed 16 September 2011]. http://www.bmj.com/content/324/7338/626.full. Published March 16, 2002.
4. Heber M. Tendinosis vs. Tendinitis. Elite Sports Therapy. [Accessed 16 September 2011]. http://www.elitesportstherapy.com/tendinosis-vs--tendonitis.
5. Med Clin North Am. 2014 Jul;98(4):833-49, xiii. doi: 10.1016/j.mcna.2014.04.002. Elbow tendinopathy. Pitzer ME1, Seidenberg PH2, Bader DA1.
6. Sports Health. 2012 Sep;4(5):384-93. Evaluation and management of elbow tendinopathy. Taylor SA1, Hannafin JA.
7. Phys Sportsmed. 2015 Feb;43(1):80-6. doi: 10.1080/00913847.2015.1004296. Epub 2015 Jan 22. Tendon needling for treatment of tendinopathy: A systematic review. Krey D1, Borchers J, McCamey K.

Patella Maltracking

The patella is otherwise known as the kneecap and is a "floating" bone suspended over the front of the knee by the tendon of the quadriceps muscle (at the front of the thigh). Is should glide over the front of the knee as it bends with no pain, clunking or clicking and should not pull to one side or the other. If it does any of these, this can be due to Patella Maltracking. In more severe cases, the patella can pop out of position. Most commonly it pops back in quickly, however if this happens to you, you definitely need to see someone as this movement can damage the joint.1

Maltracking can occur for a number of reasons. It can be the result of trauma, soft tissue contracture, patella alta (high patella) or if the knee is moving in a way that causes twisting or bending inwards.2

If you are experiencing Patella Maltracking then you should seek treatment. Firstly we need to establish how severe your case is and if it is "Functional" (due to biomechanics or soft tissue changes) or "Structural" (due to bony positions, damage or changes). This is very important to know for you to receive the correct treatment and the best care long term. Most cases of Patellar Maltracking are functional and respond well to conservative care.

1. Knee Surg Sports Traumatol Arthrosc. 2016 Jun 29. [Epub ahead of print] Characterization of patellar maltracking using dynamic kinematic CT imaging in patients with patellar instability. Tanaka MJ1, Elias JJ2, Williams AA3, Demehri S4, Cosgarea AJ3.
2. Arch Orthop Trauma Surg. 2016 Apr;136(4):485-97. doi: 10.1007/s00402-015-2381-9. Epub 2015 Dec 30. A new classification system of patellar instability and patellar maltracking. Frosch KH1,2, Schmeling A3,4.

Baker's Cyst

This is where fluid forms in the back of the knee. It is often a symptom of a cause elsewhere, often associated to inflammation in the knee, calf and hamstring weakness. Non surgical treatment is advocated, firstly to reduce the swelling, then to find the underlying cause for the inflammation.

Osgood Schlatters Disease

The tendon of the quadriceps inserts just below the knee cap. At this point there Is a lot of tension.

This is a condition that often affects adolescents; boys more so than girls and it is thought to be associated to the way you grow as a child. Bones grow sporadically and as they do the muscles and tendons struggle to keep up, this causes excessive stress at the point of attachment. If you then perform exercise and increase the tension further it can cause pain.

Treatment

The treatment often requires activity modification. You will need to reduce the amount of activity you do initially, gain range and strength in the affected muscles and progress to level you were previously.

Anterior Knee Pain (patellofemoral Dysfunction)

There are a number of causes for this condition, it is by far the most common knee complaint according to the research.

If you are suffering from Anterior Knee Pain then call us at Liverpool on 0151 4275000 or on the Wirral on 0151 6485000 to ask more of book an appointment. Alternatively you can email us at enquiries@chiroandphysioclinic.co.uk

ACL/PCL Sprain/Rupture

Mechanism

This type of injury is usually associated with a very definite mechanism. It often occurs as a result of you planting a foot on the floor and while the foot is fixed you twist. There is often a sudden pain and the knee swells very quickly.

Treatment

PCL – often the management is conservative, i.e. not surgical. You can often get back to the activities you were doing previously with exercise therapy alone. The first stage of the recovery is to promote swelling reduction, mobility and strength of the knee. After that the exercises are progressed to become more functional. Eventually specialisiing for the activity you want to return to.

ACL – The immediate management of this injury is predominantly surgical as the role of the ACL is different to the PCL. There are occasions when surgery is not required and for further information please contact the clinic.

Post surgery please see ACL/PCL Post-surgical Rehab section

Medial Collateral Ligament Strain

This type of injury is usually as a result of sudden trauma, often landing awkwardly unlike the Anterior cruciate ligament, this injury usually involves a collision with someone, where the collision has caused stress to the outside of the knee, stressing the ligament on the inside, causing it to become damaged.

If you are suffering from Medial Collateral Ligament Strain then call us at Liverpool on 0151 4275000 or on the Wirral on 0151 6485000 to ask more of book an appointment. Alternatively you can email us at enquiries@chiroandphysioclinic.co.uk

Cartilage Tear

Usually twisting on a leg that is fixed to the floor. There is often a known mechanism i.e. the person remembers exactly when it happened but this is not essential for it to be a cartilage tear. Often there is swelling that takes about a day to come on

If you are suffering from Cartilage Tear then call us at Liverpool on 0151 4275000 or on the Wirral on 0151 6485000 to ask more of book an appointment. Alternatively you can email us at enquiries@chiroandphysioclinic.co.uk

Meniscal Tear

The meniscus are semicircular bands of cartilage that sit in the joint of the knee. Their job is to offer shock absorption and offer better joint congruency.

Mechanism

There are 2 mechanisms here, 1 is as a result of trauma, the other is a result of degenerative changes to the joint.

Trauma – is often a result of planting the foot on the floor and the knee receives a sudden twisting motion. There can be a click or sharp pain, but often no pain is felt, the patient reports it not feeling quite right. There is often swelling but it can take up to 12 hours for it to show.

Degenerative – there is no cause but the meniscus often becomes worn down and means the knee

Treatment

Often the correct type of exercise placed through the knee helps to settle symptoms very well. If the tear is not too extensive it can be rehabilitated. You will often find that the knee symptoms can also be a result of what occurs above and below. Therefore weakness or stiffness in the hip and ankle can also be a cause of the tear and therefore the pain. Addressing the joints above and below are required to help treat this condition.

ACL/PCL Post-surgical Rehab

No Matter what it is you are trying to get back to, we have the specialist knowledge to return you as safely and quickly as possible. Both the physiotherapists and Chiropractors have worked with local knee surgeons/specialists to understand the various surgical procedures for this condition. The rehabilitation for this can be long but we have the skills to assist you through this process

Navicular Stress Reaction

The Navicular is a bone in the foot. It is often stressed when running or performing repeated activities. It is normal for stress to be applied through this bone, however, if the bones stress exceeds the remodeling a stress reaction can develop. There are 4 stages ranging from a very mild bone bruise to a stress fracture.

There is usually a very distinct point of pain over the bone, this is not something you can and should run through, if it begins as a stage one stress reaction it can progress to a stress fracture.

Symptoms

Pain over the bone, there can often be pain at night in the same area as the bone is healing. It often warms up when exercising and feels ok during the activity on low grade stress reactions, but is very sore after.

Treatment

Depending on the severity depends on the amount of time for it to recover. An MRI Scan with something called STIR sequences pick up these issues. Often there is a period of rest required for the bone to heal and during that time you will be given exercises to strengthen the area and prevent reoccurrence. If it has progressed to a stress fracture, a period of non weight bearing is required and you may have to wear a medical boot to prevent you stressing the bone further.

Calcanea Stress Reaction

The Calcaneus is a bone in the foot, it is where the Achilles inserts. It is often stressed when running or performing repeated activities. It is normal for stress to be applied through this bone, however, if the bones stress exceeds the remodeling a stress reaction can develop. There are 4 stages ranging from a very mild bone bruise to a stress fracture.

There is usually a very distinct point of pain over the bone, this is not something you can and should run through, if it begins as a stage one-stress reaction it can progress to a stress fracture.

Symptoms

Pain over the bone, there can often be pain at night in the same area as the bone is healing. It often warms up when exercising and feels ok during the activity on low grade stress reactions, but is very sore after.

Treatment

Depending on the severity depends on the amount of time for it to recover. An MRI Scan with something called STIR sequences pick up these issues. Often there is a period of rest required for the bone to heal and during that time you will be given exercises to strengthen the area and prevent reoccurrence. If it has progressed to a stress fracture, a period of non-weight bearing is required and you may have to wear a medical boot to prevent you stressing the bone further.

Plantar Fasciitis/Fasciopathy

PF is the most common cause of pain under the heel.1 Rather than achilles pain which is at the back of the heel, plantar fascia pain occurs directly under the heel. It can feel like you have a stone in your shoe but then usually increases to sharp and stabbing pain particularly first thing in the morning. The pain usually eases with movement even though it can be very stiff and sore initially.2,3

Treatment

There are different stages to the rehabilitation. If you suffer an acute injury i.e. feel something happen in the fascia as an acute episode, the best thing to do initially is rest and let the Achilles recover. Once the Achilles has settled you can begin to load the tendon. It is important to do the right exercises at the right time. To help with this process, we have put together a number of exercises in our Patient Portal. Your practitioner will advise you of the exercises best suited to you and how frequently to do them.

The other form of injury is not acute but degenerative, this means there are areas of the fascia that have reduced their capacity to deal with the loads required. This type of injury does not need a period of rest, it requires loading. You may find that you get an increase in your symptoms initially but this settles.

This type of injury can take a long time to fully recover, but it 90% respond well to conservative care.4,5 Sometimes the hardest thing to do is remain committed to the exercises for the time it takes. You may have done heel raises already for example but whilst this is a good start, running places strain of between 4-6 times your body weight through the foot. Heel raises are only 1x your body weight. So heel raises will only take you a quarter of the way you need to go. We can get you all they way!

1. Cleve Clin J Med. 1999 Apr;66(4):231-5.Diagnosing and treating plantar fasciitis: a conservative approach to plantar heel pain.Tisdel CL1, Donley BG, Sferra JJ.
2. Am Fam Physician. 2011 Sep 15;84(6):676-82. Diagnosis and treatment of plantar fasciitis. Goff JD1, Crawford R.
3. Am Fam Physician. 2005 Dec 1;72(11):2237-42. Plantar fasciitis: evidence-based review of diagnosis and therapy. Cole C1, Seto C, Gazewood J.
4. J Am Acad Orthop Surg. 2008 Jun;16(6):338-46. Plantar fasciitis: evaluation and treatment. Neufeld SK1, Cerrato R.
5. J Orthop Sports Phys Ther. 1999 Dec;29(12):756-60. Plantar fasciitis: etiology and treatment. Cornwall MW1, McPoil TG

Morton's Neuromas

This injury is classically an irritation of the plantar nerves, which pass under the foot. You usually feel pain between the 3rd and 4th toes. The pain is caused by the nerve becoming inflamed and not settling adequately so it remains slightly swollen. You then unfortunately end up in a deprecating cycle where the more you do the more inflamed the nerve becomes and eventually a neuroma is formed.

Treatment

If the neuroma becomes too big surgery is sometimes required, however, this is rare. We have found that this condition is associated to previous sciatica, as it is part of the same nerve. It is also caused by a weakness in the foot or calf. Please login to the patient portal to see what exercises could help you overcome this condition.

ATFL Sprain

The ATFL is the Anterior Talo-Fibular Ligament and it is the most common ligament affected in the “classic” ankle sprain. It is on the outside of the ankle; the lateral aspect. Lateral ankle sprains account for 85% of all ankle sprains. The ATFL is the weakest ligament in the lateral ligament complex and therefore the one most commonly injured.1 The mechanism for this is the foot twisting inwards, most commonly in a “toes down” position.

Ankle sprains commonly cause acute or sharp pain at the time of injury and afterwards. With damage to the ligaments, heat, swelling, redness and bruising are also common. Pain with weight bearing on the affected ankle is common.

Not only are Acute Lateral Ankle Ligamentous Sprains (ALALS) common, they are also commonly associated with long term problems. A large proportion of patients with ALALS experience recurrences and persistent symptoms after their initial ankle injury.2 Therefore undertaking expert examination, treatment and appropriate strengthening is key to both managing your injury short term and avoiding recurrence long term.3,4

1. Foot Ankle Clin. 2006 Sep;11(3):659-62. Epidemiology of sprains of the lateral ankle ligament complex. Ferran NA1, Maffulli N.
2. Fam Pract. 2016 Aug 17. pii: cmw076. [Epub ahead of print] Long-term prognosis of acute lateral ankle ligamentous sprains: high incidence of recurrences and residual symptoms. Kemler E1, Thijs KM2, Badenbroek I3, van de Port IG4, Hoes AW3, Backx FJ5.
3. Sports Med. 1987 Sep-Oct;4(5):364-80. Management and rehabilitation of ligamentous injuries to the ankle. Balduini FC1, Vegso JJ, Torg JS, Torg E.
4. Open Access J Sports Med. 2016 Mar 2;7:33-42. doi: 10.2147/OAJSM.S72334. eCollection 2016. Managing ankle ligament sprains and tears: current opinion. McGovern RP1, Martin RL2.

Retrocalcaneal Bursitis

Retrocalcaneal bursitis is an inflammation of the bursa that sits between your achilles tendon and your heel bone.1 Bursa's are fluid filled sacs that protect tendons and other structures like being rubbed and irritated by adjacent bones. Inflammation of this bursa can cause pain at the back of the heel.2,3

This is most commonly caused by overuse injuries such as running or from wearing shoes that are hard or tight around the heel.4 These may occur in association with Gout, Rheumatoid Arthritis or other Inflammatory Arthropathies. They may also be associated with Haglund Deformities (bony lump at the back of the heel) and cause pinching or Impingement of the Achilles tendon.5,6

Retrocalcaneal Bursitis responds well to conservative treatment including advice, hands on care and exercises.7,8 The use of steroid injections has been associated with Achilles Tendon rupture in cases and may be contraindicated.7,9

1. Knee Surg Sports Traumatol Arthrosc. 2011 May;19(5):835-41. doi: 10.1007/s00167-010-1374-z. Epub 2011 Jan 11. Terminology for Achilles tendon related disorders. van Dijk CN1, van Sterkenburg MN, Wiegerinck JI, Karlsson J, Maffulli N.
2. Teebagy AK. Leg and ankle. Steinberg GG, Akins CM, Baran DT, eds. Orthopaedics in Primary Care. 3rd ed. Baltimore, Md: Lippincott Williams & Wilkins; 1999. 241-67.
3. Young JL, Olsen NK, Press JM. Musculoskeletal disorders of the lower limbs. Braddom RL, ed. Physical Medicine and Rehabilitation. Philadelphia, Pa: WB Saunders; 1996. 783-812.
4. Med Arch. 2012;66(6):425-7. Haglund syndrome with pump bump. Kucuksen S1, Karahan AY, Erol K.
5. Foot Ankle Int. 2012 Jun;33(6):487-91. doi: 10.3113/FAI.2012.0487. Insertional Achilles tendinitis and Haglund's deformity. Kang S1, Thordarson DB, Charlton TP.
6. Clin Biomech (Bristol, Avon). 2014 Mar;29(3):283-8. doi: 10.1016/j.clinbiomech.2013.12.002. Epub 2013 Dec 9 Retrocalcaneal bursitis but not Achilles tendinopathy is characterized by increased pressure in the retrocalcaneal bursa. Lohrer H1, Nauck T2
7. Am Fam Physician. 1997 May 1;55(6):2207-12. The painful foot, Part II: Common rearfoot deformities. Van Wyngarden TM1.
8. Med Clin North Am. 2014 Mar;98(2):331-8. doi: 10.1016/j.mcna.2013.11.005. Achilles tendon disorders. Weinfeld SB1.
9. J Ultrasound. 2014 Jan 29;17(2):165-7. doi: 10.1007/s40477-014-0066-9. eCollection 2014. Complete Achilles tendon rupture after local infiltration of corticosteroids in the treatment of deep retrocalcaneal bursitis. Vallone G1, Vittorio T2.

Achilles Tendonopathy

The achilles tendon is the largest tendon in the body and is commonly affected.1 It is often worse when you wake up in the morning but often warms up and eases over a period of time. You may find that you can still perform the activities you wish but the Achilles feels very stiff and sore initially, and again warms up. This injury used to be called tendonitis, which implies the tendon is inflamed, more recently it has been proven that it is not an inflammatory condition but a degenerative one. Therefore it is now called tendonopathy. This means that you actually need to exercise the tendon and rest is not good for long-term health..2,3,4

The tendon can be affected in a number of different ways and in a number of different locations. There are also adjacent structures that can complicate the situation including the paratendon, adjacent bursae or the presence of heel spurs.5 Conservative treatment is recommended for Achilles Tendonopathy and includes advice on loading, rest, ice, heel lifts or orthotics, taping and the use of NSAID’s (Non-Steroidal Anti-inflammatory Drugs)5,6 There are different stages to the rehabilitation. If you suffer an acute injury i.e. feel something happen in the tendon as an acute episode, the best thing to do initially is rest and let the Achilles recover. Once the Achilles has settled you can begin to load the tendon.The use of Eccentric Exercises is highly recommended at the right time and we will cover this with you as soon as possible.1,7,8,9

The other form of injury is not acute but degenerative, this means there are areas of the tendon that have reduced their capacity to deal with the loads required. This type of injury does not need a period of rest, it requires loading. You may find that the Achilles reacts initially to the load but settles.

To address Achilles Tendonopathy you need 2 things. A correct diagnosis and an appropriate management programme. This will look at your footwear, your strength and mechanics and most importantly your loading. Tendonopathies are a loading issue and if you don't correct the load you can never get the right results. Also avoid putting off treatment. The longer you leave this problem to brew and progress the more difficult it is to settle, so our advice to you is get early intervention and comply with your programme. Our goal is to get you back to activity as soon as possible and keep you there!

1. Br J Sports Med. 2007 Apr; 41(4): 211–216. doi:  10.1136/bjsm.2007.035543 A treatment algorithm for managing Achilles tendinopathy: new treatment options Håkan Alfredson and J CookMed Clin North Am. 2014 Mar;98(2):331-8. doi: 10.1016/j.mcna.2013.11.005. Achilles tendon disorders. Weinfeld SB1.
2. cDNA-arrays and real-time quantitative PCR techniques in the investigation of chronic Achilles tendinosis. Alfredson H, Lorentzon M, Bäckman S, Bäckman A, Lerner UH J Orthop Res. 2003 Nov; 21(6):970-5
3. Glutamate NMDAR1 receptors localised to nerves in human Achilles tendons. Implications for treatment? Alfredson H, Forsgren S, Thorsen K, Fahlström M, Johansson H, Lorentzon R Knee Surg Sports Traumatol Arthrosc. 2001; 9(2):123-6.
4. In situ microdialysis in tendon tissue: high levels of glutamate, but not prostaglandin E2 in chronic Achilles tendon pain. Alfredson H, Thorsen K, Lorentzon R Knee Surg Sports Traumatol Arthrosc. 1999; 7(6):378-81.
5. Chin J Traumatol. 2015;18(3):164-9. Heel pain: A systematic review. Agyekum EK1, Ma K.
6. J Am Osteopath Assoc. 2015 Nov;115(11):670-6. doi: 10.7556/jaoa.2015.138. Achilles Tendon Disorders. Saini SS, Reb CW, Chapter M, Daniel JN.
7. Sports Med. 2012 Nov 1;42(11):941-67. Conservative management of midportion Achilles tendinopathy: a mixed methods study, integrating systematic review and clinical reasoning. Rowe V1, Hemmings S, Barton C, Malliaras P, Maffulli N, Morrissey D.
8. J Sports Med Phys Fitness. 2015 Nov 26. [Epub ahead of print] Efficacy of eccentric exercise for lower limb tendinopathies in athletes. Frizziero A1, Vittadini F, Fusco A, Giombini A, Gasparre G, Masiero S.
9. Sports Med. 2012 Nov 1;42(11):941-67. Conservative management of midportion Achilles tendinopathy: a mixed methods study, integrating systematic review and clinical reasoning. Rowe V1, Hemmings S, Barton C, Malliaras P, Maffulli N, Morrissey D.

Capsulitis

The capsule acts as a bag that surrounds the joint, acting like a weak ligament to give the joint stability and hold in the synovial fluid which is the bodies natural lubricant.

If you are suffering from Capsulitis then call us at Liverpool on 0151 4275000 or on the Wirral on 0151 6485000 to ask more of book an appointment. Alternatively you can email us at enquiries@chiroandphysioclinic.co.uk

High Hamstring Tendonopathy

Often confused as hip pain. This pain is present on the boney bit you feel when you are sat down. The pain often comes on with running and eases as you run more, but it will often be very sore afterwards.

Any exercises that involve the hamstrings are likely to cause some degree of pain.

This type of injury is usually resolved after identifying the cause – ie. What areas are weak and asking more of this area. Often the appropriate loading is required with exercise to assist in strengthening the area.

If you are suffering from High Hamstring Tendonopathy then call us at Liverpool on 0151 4275000 or on the Wirral on 0151 6485000 to ask more of book an appointment. Alternatively you can email us at enquiries@chiroandphysioclinic.co.uk

Trochanteric Bursitis

Symptoms

Usually pain on the outside of the hip, there can be a small amount of swelling. The pain is usually around the point of the hip. It is often made worse when the gluteal muscles contract around the bursa. I.e. in standing and when walking up and down stairs

What is Trochanteri Bursitis?

It is caused by the inflammation of the bursa which is a fluid filled bag. The bursa’s role is to reduce friction between the tendon and the bone. If it becomes irritated it is often very difficult to settle. Any compression,i.e. lying on it will increase the pain.

Treatment

This condition is often confused with Gluteal Tendonopathy and is treated in the same way. It often needs a period of rest to let it settle, during this time, hands on treatment, such as massage and fascial release on the surrounding structures can assist. Then a period of strengthening to resume normal function.

Hip Osteo Arthritis

Symptoms

Often presenting as an ache in the hip region. The pain is often caused by the reduction in range. Any time a joint is held at the limit of its range for sustained periods it will ache. In this case activities such as sitting which were within the range available previously are no longer so and it is why there is an ache.

Treatment

In this case an x ray is often taken but not always essential. The first goal is to promote range of motion and there are a number of ways this can be done with manual therapy, mobilisations, soft tissue techniques and exercises. You will be surprised how well joints can respond to specifically tailored exercises.

Labral Tear

Overview

The Labrum is also a cartilaginous disc that sits on the edge of the joint and prevents too much motion of the femur (ball) on the Acetabulum (socket).

What Can Cause This

There is often a mechanism involved whereby you feel something happen or tear at the front of the hip. This is not always the case and it is possible to have a degenerative tear that has just occurred over time. You may notice a click in the front of the hip with certain movements.

Treatment

Usually an MR Arthrogramme scan is used to diagnose the extent of the tear. If the tear is stable and small it can often be rehabilitated without the need for surgery. Even it surgery is indicated, getting the hip as strong as possible pre surgery has huge positive effects on the post surgery outcome.

Core stability and strength is also really important, please log into the patient portal to see the types of exercises you are likely to receive.

Femoral Acetabular Impingement

This is very similar to the Labral tear, it is often thought to be one of the precursors for the tear to the labral. If you can imagine the ball and socket joint but the ball has a little lump on it, this is thought to cause the impingement. There are however a number of other thoughts as to why this occurs. It could also be caused by very tight structures at the back of the hip. If these structures are tight they cause the hip to become impinged at the front.

Treatment

If the cause is tight structures at the back of the joint, the hip often responds really well to mobilisations and soft tissue manipulation at the back of the hip. You will also be placed on a stretching a strengthening programme to facilitate the increased mobility.

Gluteal Tendonopathy

Symptoms

Pain is often on the outside of the hip, at the area where there is a it can be sore to lie on the effected side. You can often get pain if walking for any length of time. It can often be sore if you stand after being sat.

Treatment

There can be a number of causes for this condition. The goal is to establish if there is something done differently in your lifestyle that could have caused it. I.e. taking up running, going for longer walks than previous. We will help by ascertaining if the pelvis, lower back and hip are moving and working correctly so that there is not undue stress placed on the Gluteal Tendon

You will be given exercises to gain strength in the tendon, as with all tendons, they respond very well to loading.

Lateral Femoral Cutaneous Nerve Entrapment

Symptoms

You will often feel a tingling/change in sensation along the outside of the thigh as that’s where the nerve supplying that area runs. This nerve is a branch of the femoral nerve so you may find you can have associated hip and knee pain with this injury too.

Treatment

The goal is to ascertain where the nerve is irritated and therefore causing the symptoms. The lower back, hip and groin can all be a cause, so they will all be assessed. Treatment will often involve the Neural Interface Technique (explained in the what we treat section)

Low Back Pain

Low back Pain is the most common complaint for chiropractic we see at the clinic. This is not surprising when you consider that 9-12% of people have back pain at any given point in time and 40% having it as some point through their lives (1,2). In the developed world this figure is estimated to be as high as 80% which is a huge lifetime prevalence (3). Although back pain most commonly starts from 20-40 years of age, it is more common at 40-80 years of age (4).

This suggests what we know, that low back pain is not usually a simple issue that settles quickly. It classically is a chronic remitting condition and this is because injury leads to poor muscle function, mechanics and control (5,6,7,8,9). As Professor McGill states “ This collection of evidence is quite powerful in documenting pathoneuromechanical changes associated with chronic Low Back Dysfunction. These changes are lasting years - not 6 to 12 weeks!” (10) In a nutshell, this means that in addition to treating pain and correcting restriction, unless you look at muscle weakness and imbalance and correct faulty movement patterning, you will be susceptible to problems with recurrent symptoms.

This is why at The Chiro & Physio Clinic we have a unique and in-house approach to your treatment. You will receive both treatment and advice to manage symptoms and also exercise and strengthening to gain the best effects long term and prevent recurrence.

1. Hoy D, Bain C, Williams G, et al. (June 2012). "A systematic review of the global prevalence of low back pain". Arthritis Rheum. 64 (6): 2028–37.
2. Vos, T (15 December 2012). "Years lived with disability (YLDs) for 1160 sequelae of 289 diseases and injuries 1990–2010: a systematic analysis for the Global Burden of Disease Study 2010.". Lancet. 380 (9859): 2163–96.
3. Vinod Malhotra; Yao, Fun-Sun F.; Fontes, Manuel da Costa (2011). Yao and Artusio's Anesthesiology: Problem-Oriented Patient Management. Hagerstwon, MD: Lippincott Williams & Wilkins. pp. Chapter 49. ISBN 1-4511-0265-8.
4. Casazza, BA (15 February 2012). "Diagnosis and treatment of acute low back pain". American family physician. 85 (4): 343–50
5. Sterling, Jull & Wright 2001
6. Hodges &Richardson 199,1999
7. Arendt-Neilson et al 1995)
8. Zed et al 1999
9. Grainer, Koh & Ghazawi 1992
10. McGill Low Back Disorders, 2007

Osteoarthritis/Osteoarthrosis (OA)

OA has many synonyms and therefore you may have been told you have it via another term. It’s not uncommon that one of our patients will present with “Wear and tear in the knee, arthritis of the low back and spondylosis at the neck.” In fact these are all the same thing. OA most commonly causes pain and restriction to the affected joints and surrounding area.

The really interesting thing about OA is that there is poor correlation with OA and pain. Some people can have notable OA changes on x-rays with no symptoms. Research done with Volvo Car Factory workers in 1995 showed that 85% of the workers imaged had Degenerative Disc Disease whilst having no symptoms! (1) Where OA is very severe on x-rays then yes, it is likely to be the cause of your pain. However we see a huge number of people in clinic who have mild or moderate OA on imaging and respond extremely well to chiropractic and physiotherapy treatment.

So if you are in pain or restricted in your movement and function and have been told “It’s your age, you will just have to learn to live with it” then don’t! Come and have a consultation at the very least. We focus on getting results and we have seen huge improvements in countless patients who have responded so well to

1) Hands on physical treatment to address pain and reduce restriction
2) Exercises and advice to maximise treatment and minimise re-aggravation
3) Strength and repatterining - there is a reason you have caused all that “wear and tear” and without addressing that you will fail to make the improvements you should!

1. Dr Norbert Boos et al 1995

Sciatica

The Sciatic nerve is the biggest nerve in the human body and it runs deep to the buttock passing dow the back of the leg and supplying the leg to the ankle and foot. If this nerve becomes compressed irritated, this is sciatica. This most commonly presents as a nagging, dull constant ache with intermittent sharp stabs down the back of the whole leg. This will radiate to the ankle and into the foot, even to the toes. You may also experience “paraesthesias” which are tingling and numbness sensations in the same places. This condition can be very painful.

The good thing about sciatica (bear with us!) is that if the nerve is being compressed deep in the buttock it is not being compressed by discs or joints. The compression is from muscles or connective tissue. This means that sciatica has a far better prognosis than radicular or nerve root pain as the causes are more likely to respond to chiropractic and/or physiotherapy manual therapy. It also means you are far less likely to suffer with nerve damage leading to permanent numbness or weakness which is a hugely positive thing.

However you do need a full examination to determine if you have sciatic pain or radicular pain and it is very important to determine if you have any compromise of nerve function. This is something our chiropractors and physiotherapists will always check with you. This is crucial in looking at appropriate treatment, prognosis and whether referral is needed. So if you are suffering with back, buttock and leg pain make sure that you get this checked!

Disc Herniation

Often referred to as “Slipped Discs” these are common in the low back. They may be described in different ways as synonyms or to describe different characteristics i.e. bulges, protrusions and sequestrations. Very interestingly, imaging findings of herniations do not mean you have pain. Actually, research has shown that 40% of the asymptomatic population have disc protrusions(1). Furthermore in “high risk” symptomatic populations research has found herniations in 76%(2). And these individuals had no symptoms!

Therefore disc herniation findings on an MRI need to correlate with your clinical findings before they are relevant to you. There is a much higher correlation if there is nerve root compression and this is what we are looking for. Also the findings are different in the cervical spine (neck) - this is for low back only.

If you have a disc herniation and you have radiating leg symptoms, you need a full assessment. This should include Lower Limb SMR (Sensory, Motor and Reflex) Testing. This is where your muscle strength, skin sensation and reflexes are tested. If we note any Objective Neurological Defecit (where we can objectively see there is a problem) then we will discuss GP referral and MRI options with you. This would indicate that the nerve is not only being irritated or aggravated but compromised in it’s ability to function. This extremely important differentiation is critical to you being treated and managed in the correct way. Therefore always ensure that when you have radiating or extending pain from the low back or buttock into the leg you have this checked.

We see patients who have disc herniations very commonly. We approach these with a combination of manual treatment techniques specific to the individual and bespoke advice and exercises to get great results.

1. Weishaupt D et al. “MRI of the lumbar spine: Prevalence of intervertebral disc extrusion and sequestration, nerve root compression and plate abnormalities, and osteoarthritis of the fact joints in Asymptomatic Volunteers.” Radiology – 1998; 209:661-666
2. Boos N, et al. “1995 Volvo Award in clinical science: The diagnostic accuracy of MRI, work perception, and psychosocial factors in identifying symptomatic disc herniations.” Spine – 1995; 20:2613-2625

Low Back and Leg Pain (LB&LP)

LB&LP is the most almost as common as Low Back Pain alone. Pain that radiates to some extent os the most common option. Sometimes it is just a nagging ache from the back to the buttock or the top of the thigh. Sometimes it is sharp and shooting pain radiating down the whole leg and to the foot. Just as these 2 sound rather different, they come from different sources. You require a thorough and expert assessment including a case history and examination to find out what is going on. There are some general rules;

• The more severe the pain, the worse the prognosis (ie it will take longer to settle)
• Lots of structures can cause pain. Paraesthesias (tingling & numbness) tend to be the hallmark of nerve involvement
• Disc herniations are less common the older you get - the discs “dry out” with time
• The more chronic the pain (ie the longer you have had it) - the longer it will take to address. Therefore don’t wait for symptoms to get worse and worse, address them sooner rather than later and prevent them becoming chronic.

It is very important that you have a full assessment including Sensation, Motor and Reflex testing of the lower limbs if you are suffering from leg pain and especially numbers or tingling. If you are, call to book an appointment or ask to speak to one of our practitioners.

Adductor Strain

Definition

The adductors are a group of three muscles, and all of them have a slightly different job, therefore knowing the exact way in which the injury occured helps to differentiate which one is injured. By far the most common is the adductor longus. This muscle attaches at the very top of the leg, into the groin and stretches to the inside of the thigh.

Most commonly the injury to the muscle is close to the top where the tendon meets the muscle, known as the myotendinous junction.

A slightly different injury but in a similar location is called osteitis pubis, this is inflammation of the joint that is located at the bone where the adductor longus attaches. It is important to differentiate the two injuries, as they are treated very differently. Don't fear we will be able to help you with this.

Treatment

Adductor longus

After you have overcome the acute stage, usually 2-3 days, you will be given advice on how to start strengthening the muscle. We will also look to ascertian the cause of the injury, was it a muscle weakness to begin with? Is it a pelvic asymmetry? Weak core? The list continues, but thats our role.....to find that out and address it to prevent reoccurrence.

Hamstring Strain

Mechanism

Often the injury is caused by a sudden change in direction or speed and a sharp pain is felt in the back of the thigh, this can occur at many places along the back of the leg. Occasionally as high up as the groin.

Symptoms

After the initial sharp pain, an ache is often left in the same area. Pain is rarely felt unless you take the leg into certain positions. Often patients try and return to sport after a rest period to find they are unable to change direction or speed.

Treatment

Rest unfortunately Is not enough – POLICE is the acronym used, referring to Protect, Optimally Load, Ice, Compress, Elevate.

Complete rest only befits rest, the key is to progressively stress the healing structure so that it returns to pre injury levels.

Sciatic Nerve Entrapment

Mechanism

The sciatic nerve originates in the lumbar spine and passes down the back of the leg, splitting into 2 more nerves before terminating in the foot. This nerve can be irritated at any point along its path.

Symptoms

Often the patient complains of a dull ache into the back of the thigh, thinking that they may have strained their hamstring. If however, there is no mechanism, sharp twinge of pain, it is unlikely to be the hamstring. More often it is the sciatic nerve which is either irritated or has become restricted in the back of thigh.

Treatment

Often this is quite extensive, you will need your lower back assessed and occasionally if required the foot and ankle too. The therapist will explain the cause and discuss various different treatment options.

Carpal Tunnel Syndrome (CTS)

Carpal Tunnel Syndrome is entrapment of the median nerve at the wrist and is the most common form of entrapment. Good rule of thumb (or pinkie) is that tingling and pain occur in the palm of the hand and all the fingers including the thumb, except the little finger - the 5th digit is always excluded. Pain with tingling and numbness occur in these areas.

Entrapment occurs with irritation of the nerve as it passes under the bone arch of the carpals (hand bones) at the wrist. This can occur with overuse or injury to the wrist or with fluid retention, for example in pregnancy.

If you have these symptoms, you should seek manual therapy treatment as a first line of action. Recent research has shown physical and manual therapies to be similarly effective to surgery in the medium and long term for improving pain and function but with better results in the short term (1) In addition to this, if you are experiencing symptoms in both hands, it is likely that there is some involvement of nerve irritation at the neck. We have seen a number of patients who have had bilateral CTS surgery and still have symptoms receive relief from their symptoms with treatment only to the neck.

If you are suffering from CTS or would find out more, call the clinic to book an appointment or speak to one of our practitioners.

1. J Pain. 2015 Nov;16(11):1087-94. doi: 10.1016/j.jpain.2015.07.012. Epub 2015 Aug 15. Manual Physical Therapy Versus Surgery for Carpal Tunnel Syndrome: A Randomized Parallel-Group Trial. Fernández-de-Las Peñas C1, Ortega-Santiago R2, de la Llave-Rincón AI2, Martínez-Perez A3, Fahandezh-Saddi Díaz H4, Martínez-Martín J4, Pareja JA3, Cuadrado-Pérez ML5.

Repetative Strain Injury/RSI

RSI’s are not a diagnosis as such, rather they are an all inclusive term for injuries sustained from repetitive tasks, most classically in the upper half of the body and often associated with work. They are characterised by pain, stiffness and restriction. High Force High Repetition (HFHR) tasks have been associated with increased fibrotic nerve and connective tissue changes (1) which may explain the underlying process of RSI.

In addition to adapting ergonomics and discussing loading and activities, manual therapy can be extremely effective for pain relief (2,3). Interestingly, research has also shown that physical activity outside work hours is also associated with less RSI symptoms. This may be due to overall fitness or motion release over the tissues. However it is another great reason to stay fit and active and help your body to stay well! (4)

1. J Neurol Sci. 2016 Feb 15;361:168-80. doi: 10.1016/j.jns.2015.12.029. Epub 2015 Dec 24. Manual therapy as an effective treatment for fibrosis in a rat model of upper extremity overuse injury. Bove GM1, Harris MY2, Zhao H3, Barbe MF4.
2. Ortop Traumatol Rehabil. 2011 Nov-Dec;13(6):555-64. Immediate and long-term effects of selected physiotherapy methods in patients with carpal tunnel syndrome. [Article in English, Polish] Kwolek A1, Zwolińska J.
3. J Pain. 2015 Nov;16(11):1087-94. doi: 10.1016/j.jpain.2015.07.012. Epub 2015 Aug 15. Manual Physical Therapy Versus Surgery for Carpal Tunnel Syndrome: A Randomized Parallel-Group Trial. Fernández-de-Las Peñas C1, Ortega-Santiago R2, de la Llave-Rincón AI2, Martínez-Perez A3, Fahandezh-Saddi Díaz H4, Martínez-Martín J4, Pareja JA3, Cuadrado-Pérez ML5.
4. Arthritis Rheum. 2007 Apr 15;57(3):495-500. Work-related repetitive strain injury and leisure-time physical activity. Ratzlaff CR1, Gillies JH, Koehoorn MW.

Stenosing Tenosynovitis

Commonly known as “trigger finger” or “trigger thumb” it is characterised by the flexor tendon becoming caught as it tries to slide through the system of pulleys that hold it in place. This can occur with a thickening of either the pulley or the tendon itself. When the tendon then manages to pull through, the finger snaps into a “trigger” position rather than moving smoothly. This can be associated with pain and a popping or snapping noise.

Trigger fingers are common with conditions such as gout, rheumatoid arthritis and diabetes. Sometimes they can occur with occupations or hobbies that involve repeated strong gripping activities. Sometimes it occurs with no obvious cause.

Treatment will usually be via your GP and includes the use of splints, ergonomic advice, anti-inflammatories and may involve injections. Physical therapy is not usually indicated with this condition.

Hip Flexor Strain

The hip flexors are a group of muscles that all have the action to bring the thigh forward, they are therefore usually injured in the same way. If you have attempted to do something different in your life/training you can injure this muscles. The pain is then felt performing these movements after the injury has occurred. Exercises such as walking can be painful here.

As these muscles lie deep in the hip it is therefore unlikely you will see any bruising or swelling when the muscles have been injured.

Treatment

After you have overcome the acute stage, usually 2-3 days, you will be given advice on how to start strengthening the muscle. We will also look to ascertain the cause of the injury, was it a muscle weakness to begin with? Is it a pelvic asymmetry? Weak core? The list continues, but thats our role.....to find that out and address it to prevent reoccurrence

Quad Strain

The quadriceps make up some of the biggest muscles in the body, this means there is usually a lot of force involved in injuring them. Often a patient will report doing something they haven't before, i.e.e a sprint session having not run for years. This puts excessive force through the muscle, it is then not strong enough to cope and suffers a tear.

There will often be pain on any movements involving these muscles. Stairs are often painful. Moving from sitting down to standing up is also sore.

Treatment

After you have overcome the acute stage, usually 2-3 days, you will be given advice on how to start strengthening the muscle. We will also look to ascertain the cause of the injury, was it a muscle weakness to begin with? Is it a pelvic asymmetry? Weak core? The list continues, but thats our role.....to find that out and address it to prevent reoccurrence

Groin Strain

This is a collective term for a number of different issues. We have included it here so that you can be steered in the right direction.

If you have pain in the top and inside of your thigh please see adductor strain

If you have pain at the front of the hip (approximately the pocket of your trousers) please see hip flexor strain

If you have pain lower than this in the front of the thigh please see quad strain

Pubic Symphysis Dysfunction

Often the area of symptoms for the patient is not also the cause. Those patients suffering with PGP can experience pain into the sacroiliac joint (two joints at the back of the hips just below your spine). The cause in our experience is often how tight the structures at the front of the hips have become. Therefore treatment is aimed at releasing tension in the front of the hips and increasing strength in the back. Addressing mismatching of function gains more sustained relief as opposed to isolated treatment to the painful structures alone.

The opposite is then often true if you are experiencing pain in the groin, specifically the symphysis pubis. This can be caused by increased tension posteriorly that then increases the tension at the front of the hips. Treatment is then aimed at releasing structures in the back of the pelvis and increasing strength in the front. Please read below as we have a real account from one of our patients who felt relief from this type of treatment;

If you are suffering from pain during pregnancy, call our Liverpool Clinic on 0151 4275000 or Wirral Clinic on 0151 6485000 to book an appointment or speak to a practitioner. Alternatively, email us at enquiries@chiroandphysio.co.uk

Treatment when Pregnant

So what are the mechanisms behind pain during pregnancy? On of the major factors is that your body releases a hormone called Relaxin. This hormone is essential in allowing the pelvis to cope with the growing baby. It causes ligaments to elongate and gain much needed space, however, this elongation then requires more help from the muscles surrounding the area to increase stability of the joints. Where your muscles are not strong enough, this can increase strain to your muscles, ligaments and joints resulting in pain. In addition to the relaxin, pregnancy will of course change the mechanics of your low back and pelvis which inherently increases stress. The combination of these factors makes this problem a common one that we see.

Buttock Pain

Buttock Pain commonly occurs with low back or Sacroiliac Joint (SIJ) pain. Pain can be deep seated in the buttock, often described as achey and nagging. It can also be accompanied by intermittent sharp or twingy pain which occurs with certain movements like sitting to standing or getting in and out of the car. Often there can also be pain radiating into the leg. This can be achey or sharp and you may also experience pins and needles or numbness sensations.

Buttock pain can be from local muscles, most commonly the Gluteal (buttock) Muscles or the Piriformis. It can also radiate from the SIJ. When it involves the “side of the hip” - the bony part of your hip that you feel if you lie on the floor on your side - then the Trochanteric Bursa can be involved too. This is common when the Gluteal Muscles and/or Piriformis become recurrently tight.

In all these circumstances, Chiropractic and Physiotherapy treatment is very helpful to reduce pain and restore function. The painful structures need to be identified and offloaded. This can be with a combination of approaches including manual treatment, taping and advice. Weakness of the Gluteal Muscles is very common and often present with inhibition (muscle not working correctly) or poor patterning (not co-ordinating well with other muscles). Treatment combined with strengthening and rehab is very effective in resolving this.

If you are suffering from buttock pain, contact us now to book your appointment or find out more.

Sacroiliac Joint Dysfunction (SIJD)

This is one of the most common problems that we see as Chiropractors. The SIJ is the largest joint in the spine and has a huge amount of nerves therefore a large capacity to cause pain. There are 2x SIJ’s in the body - one on either side of the body. They join the sacrum to the rest of the pelvis as it creates a “keystone” effect at the base of the spine.

Dysfunction of the SIJ can be extremely painful and debilitating but rarely requires surgery. Pain will be localised to the dimple the SIJ creates at the base of the spine. These dimples appear just under the bony prominences of the ilium (large pelvic bone). This can also be very tender to press. Pain commonly radiates from here into the buttock and can go down the leg right to the foot. It may also create aching and pain across the lower back.

The 2 major issues associated with SIJ’s are “hypomobility” and “hypermobility”. Although the SIJ does not move far, it creates and flex in the pelvis that allows “give” through movements like walking, bending and sit to stand. When that motion is dysfunctional (not working correctly) it has a huge impact as the SIJ is very important for control and stability within the pelvis - the foundation from which your legs and back work! Treatment for hypo mobility can be very straightforward as we have a number of techniques that look at restoring motion to still or restricted joints. However hypo-mobility will invariably require some strength and retraining elements to get the best results for you. But that just means you are less dependant on treatment and more in control of your symptoms which is no bad thing!

SIJ treatment is an area we specialise in at the Chiro and Physio clinic. We have a huge amount of experience in treating this condition and a huge amount of success from our comprehensive approach.

If you are struggling with SIJD call the clinic to book in or find out more.

Piriformis Syndrome

This affects the Piriformis Muscle which lies deep in the buttock. If the muscle becomes very tight it may irritate the Sciatic Nerve causing local pain to the buttock and pain that radiates down the leg. Aggravating activities include prolonged sitting, especially in lower or harder seats. Treatment is focussed on relieving pressure and irritation on the nerve and releasing tension in the tight Piriformis muscle.

We have many techniques that can address these issues including Neural Interface Technique developed by our Lead Physiotherapist Leigh Halfteck and Manipulation, taught by our Lead Chiropractor Donna Strachan. Piriformis Syndrome responds well to conservative care and our approach of additional advice, ergonomics, exercises and individual lifestyle monitoring means the best and quickest results for you.

If you are suffering from Piriformis Syndrome, call to book now or ask us more.

Coccyx Pain

Although it is not life threatening, Coccyx Pain is extremely uncomfortable and life impacting. Most often this occurs after a fall onto the buttocks, usually downstairs or during a sporting activity. It is important for us to know how badly traumatised the area was and so we will ask questions to ascertain this including;

• Was the pain immediate or did it come on some days or weeks after the trauma?
• Was there bruising or swelling after the trauma?
• Did you have any difficulties with defecation/emptying your bowels after the trauma?

Most commonly when presenting with this, if you have been to the GP you will not have received x-rays as it was not deemed necessary. If you are looking to receive imaging of this area, we will assess you on an individual basis and can refer where necessary. At the Chiro & Physio Clinic our approach is to assess and treat the coccyx externally. We do not undertake internal coccygeal examination or treatment. If you are looking for this treatment we recommend that you discuss this option with your GP.

External Coccygeal treatment including fascial and ligament release work, manipulation with function and active release is very effective for pain relief and symptomatic improvement of Coccyx Pain. So if you are struggling with Coccyx Pain, call us at the clinic to book your appointment or find out more.

Olecranon Bursitis

The suffix -“itis” indicated inflammation, therefore just as appendicitis means inflammation of the appendix, bursitis is the inflammation of a bursa. Bursa’s are fluid filled sacs providing cushioning - classically of tendons from bones. However with overuse they can become inflamed themselves. This is accompanied by pain, heat and swelling. Olecranon Bursitis is inflammation of the bursa over the olecranon. The olecranon is essentially your elbow. If you cup your hand under your elbow, the olecranon will be in the palm. Both bone and bursa are quite superficial which means there are no big muscles over the top of them. Therefore when inflamed the back of the elbow will be visibly swollen - usually quite significantly - and hot and painful.

Treatment unusually involved rest/avoidance of irritation, compression and ice. Topical or oral anti-inflammatories and/or pain killers can also be used. If the pain is persistent or recurrent, injections of steroids or aspiration can help. In rare cases surgery may be required.

Ulnar Nerve Entrapment

Also known as Cubital Tunnel entrapment, the Ulnar Nerve is the second most common entrapment after Carpal Tunnel Entrapment. The Ulnar nerve supplies the skin at the little finger side of the palm and the little finger and some of the next finger (4th digit). Entrapment will therefore cause pain and numbness and/or tingling into the fingers and palm as above. Pain in the elbow and forearm is also common. Where the entrapment is severe or has been there for a while, weakness of hand grip and loss of dexterity can also occur.

Ulnar Nerve Entrapment most commonly occurs with overuse injury or trauma to the elbow. Also leaning your on elbows for a prolonged period of time or repetitively can cause this.

Any time that you experience pins and needles or numbness that is recurrent and particularly that is recurrent, you should get this checked out. If you develop weakness, it is essential to seek medical advice. These are hallmark symptoms of nerves and as we advise at the clinic, muscles, tendons and ligaments recover from injury quicker than nerves do. Nerves to not regenerate or heal quickly. They are also extremely important structures in that they control your muscles and movements. Therefore any signs of damage should be examined to minimise damage and avoid permanent loss of function.

If you are suffering from Nerve Entrapment, from the Ulnar Nerve or anywhere else, call us to book in or find out more.

Rib Strain

Rib Strains though not particularly common can be extremely painful. Also they tend to involve pain with actions such as breathing (especially deep breaths in), coughing and sneezing which can make them worrying. If you have any concerns regarding chest pain, see your GP. Pain usually involves the area of strain beside the spine but can radiate around the ribcage and even come through to the sternum (breast bone) at the front of the chest. Pain is often aching and nagging, with sharp catches on sudden or unguarded movements like coughing, putting on a jacket or reaching for your seatbelt in the car.

Rib Strains often occur after chest infections where chronic and repetitive coughing has caused the strain. If you have a temperature or are feeling unwell within yourself, physical therapy would not be recommended. You need to rest and recover with plenty of fluids first and when you feel better if you are still experiencing pain, seek manual therapy at this time. Another common cause of rib strains are impact - common in contact sports such as rugby.

Rib Strains respond well to chiropractic and physiotherapy techniques. We use manipulation, mobilisation and soft tissue release techniques to address restriction and relieve painful tissues. Where appropriate we can also use taping techniques to offload painful structures. If you are suffering with a rib strain

If you suspect someone or yourself is having a heart attack, you should call 999. Symptoms of a heart attack include;

• Chest pain with a sensation of squeezing, tightness or pressure in your chest.
• Arm pain (especially left) neck, jaw or back pain
• Lightheaded or dizzy feelings, nausea or sickness
• Sweating
• Shortness of Breath, coughing or wheezing
• Symptoms of anxiety attack like an overwhelming feeling of anxiety

T4 Syndrome

Although reported as rare in the literature, T4 or “Upper Thoracic Syndrome” is something that is not uncommon for us to see in clinic. The underlying theory is that irritation of the upper back (between the shoulder blades) can cause symptoms to the arms and hands. This is most commonly reported as a “hand in glove” distribution or pins and needles and tingling of both hands. This is accompanied by upper back pain, aching or stiffness and you may also have aching or heaviness into the arms. The theory as to why this happens is because a section of the nervous system called the “Sympathetic Nervous System” that supplies the upper limbs originates from T2-T5. These levels are in between the shoulder blades in the upper back. So irritation of these levels is believed to cause symptoms via the Sympathetic Nervous System.

This is usually more common if you have experienced chronic (long term) and recurrent upper back problems. It is also associated with poor posture or weakness of the upper back and may ba aggravated by prolonged or sustained postures. Symptoms cal also be worse by the end of the day when your muscles are tired and fatigued. Usually lying flat on your back can give relief although it is not uncommon to wake up with the tingling in the hands.

Chiropractic and Physiotherapy are very effective in addressing T4 Syndrome. This requires a combination of hands on treatment to relieve the involved spinal segments with appropriate exercises designed to address postural dysfuntcion, weakness or muscle imbalance. You need an experienced practitioner to deliver this mix of techniques and achieve the best results for you. If you are suffering with T4 Syndrome and would like to book an appointment or find out more, call us now.

If you suspect someone or yourself is having a heart attack, you should call 999. Symptoms of a heart attack include;

• Chest pain with a sensation of squeezing, tightness or pressure in your chest.
• Arm pain (especially left) neck, jaw or back pain
• Lightheaded or dizzy feelings, nausea or sickness
• Sweating
• Shortness of Breath, coughing or wheezing
• Symptoms of anxiety attack like an overwhelming feeling of anxiety

1. Bialosky, J. E., Bishop, M. D., Price, D. D., Robinson, M. E., and George, S. Z. (2009) The mechanisms of manual therapy in the treatment of musculoskeletal pain: a comprehensive model. Manual Therapy, Vol. 14, pp. 531-538
2. Bodduk, N. (2002) Innervation and pain patterns of the thoracic spine. In: Physical therapy of the cervical and thoracic spine ed Grant R. Clinics in Physical Therapy, Vol. 17, 3rd ed, Churchill Livingstone, pp. 73-81
3. Conroy, J. L., and Scneiders, A. G. (2005) The T4 syndrome. Manual Therapy, Vol 10, no. 4, pp. 292-296
4. Crawford, H.J., and Jull, G.A, (1993) The influence of thoracic posture and movement on range of arm elevation. Physiotherapy, Vol. 9, pp. 143-148
5. Edmondson, S. J., and Singer, K. P. (1997) Thoracic spine: anatomical and biomechanical considerations for manual therapy. Manual Therapy, Vol, 2, no. 3, pp. 132-143
6. Evans, P. (1997) The T4 syndrome: some basic science aspects. Physiotherapy, Vol. 83, no. 4, pp.187-189
7. Fruth, S.J. (2006) Differential diagnosis and treatment in a patient with posterior upper thoracic pain. Physical Therapy, Vol. 86, no. 2., pp. 254-268
8. Maitland, G., Hengeveld, E., Banks, K. and England, K. (2005) Maitland’s vertebrall manipulation. 7th ed. Edinburgh: Butterworth Heinemann
9. Jowsey, P., and Perry, J. (2010) Sympathetic nervous system effects in the hands following a grade III poster-anterior rotatory mobilisation technique to T4: a randomised control trial. Manual Therapy, Vol. 15, pp. 248-253
10. Watson, L. A., Pizzari, T., and Balster. S. (2009) Thoracic outlet syndrome part 1: clinical manifestations, differentiation and treatment pathways. Manual Therapy, Vol. 14, pp. 586-595

Costochondritis/Tietze’s Syndrome

The joints between the ribs and the sternum (breastbone) where they attach at the front of your chest are called the costochondral joints. Inflammation of these is called costochondritis. This common problem causes sharp chest pain and tenderness. The pain will be worse when deep breathing, coughing or sneezing.

If you are also experience swelling, redness and heat over the affected joints then you are suffering from the far more rare Tietze Syndrome which is a separate entity. Tietze Syndrome is not appropriate for manual therapy treatment where as costochondritis can be. Tietze Syndrome is usually self limiting and can be treated with Anti-Inflammatory medication.

It is important to find out why you are suffering from inflammation of your costochondral joints. If this is secondary to a chest infection for example, the joints may be irritated by recurrent coughing. However it is important to know they are not being infected from that chest infection. The formed would be best treated with physiotherapy or chiropractic whereas the latter would require assessment and treatment as required from your GP. Therefore your physiotherapist or chiropractor will take a thorough history including if you are currently experiencing lethargy, fatigue or fever to find out which is the best course of action for you.

If you are suffering from chest pain, call the clinic to make an appointment or find out more.

If you suspect someone or yourself is having a heart attack, you should call 999. Symptoms of a heart attack include;

• Chest pain with a sensation of squeezing, tightness or pressure in your chest.
• Arm pain (especially left) neck, jaw or back pain
• Lightheaded or dizzy feelings, nausea or sickness
• Sweating
• Shortness of Breath, coughing or wheezing
• Symptoms of anxiety attack like an overwhelming feeling of anxiety

Chest Pain

Chest pain can occur from a number of sources including rib strain, costochondritis or T4 Syndrome. However if you suspect someone or yourself is having a heart attack, you should call 999 immediately.

Symptoms of a heart attack include;

• Chest pain with a sensation of squeezing, tightness or pressure in your chest.
• Arm pain (especially left) neck, jaw or back pain
• Lightheaded or dizzy feelings, nausea or sickness
• Sweating
• Shortness of Breath, coughing or wheezing
• Symptoms of anxiety attack like an overwhelming feeling of anxiety

Medial Tibial Stress Syndrome (MTSS)

Symptoms

Pain on the inside of the shin, this is usually associated to a sudden change in exercise intensity or volume. Some of the causes are weakness in the muscles, stiffness in the foot, inappropriate footwear to name a few. Unfortunately this condition is multifaceted and the goal is to understand the underlying cause in which to solve the issue.

Treatment

Soft tissue release techniques help to mobilise the tendons that should glide and slide along the inside of the bone, which is often one of the causes for the pain. We will give you strengthening exercises for the muscles that support and stabilise the ankle (please log in to the patient portal to see some of the exercises that will assist).

Calf Strain

If you perform a sudden movement and feel ike you have bitten, shot or kicked in the back of the lower leg, this is usually assocated to a calf strain. The pain if this is so is usually higher than where the Achilles is, often at the junction of where the Achilles meets the muscle, known as the myotendinous junction.

There is often a large amount of pain, it will often be sore placing the foot on the floor and coming up on to your toes.

There are different grades of this injury, the severity will also dictate the time to recover.

Treatment

Initial management requires you to let the muscle rest and recover. This should only be done for the first 2-3 days. After that some very strong scar tissue would have been formed which allows you to progressively stress the area. This does not mean run on it but some very mild stretching and strengthening can begin.

If you rest a structure for too long, it heals as if it is immobile and will cause problems further down the line.

Once the scar tissue has formed soft tissue techniques will aid recovery.

Soleus Strain

Very similar to a calf strain but is specifically in a muscle called Soleus. There are two muscles on the back of the calf that are essential for producing force for walking and running. The Gastrocnemius and the Soleus. The Gastrocnemius spans both the ankle and knee while the Soleus is just over the ankle. This means we can preferentially load the soleus by asking the patient to bend their knee when exercising.

There are different grades of this injury, the severity will also dictate the time to recover.

Treatment

Initial management requires you to let the muscle rest and recover. This should only be done for the first 2-3 days. After that some very strong scar tissue would have been formed which allows you to progressively stress the area. This does not mean run on it but some very mild stretching and strengthening can begin.

If you rest a structure for too long, it heals as if it is immobile and will cause problems further down the line.

Once the scar tissue has formed soft tissue techniques will aid recovery.

Tib Post Tendonopathy

This condition often presents as pain along the inside of the shin and toward the inside of the ankle. This condition is usually associated to a sudden change in exercise intensity or volume. Some of the causes are weakness in the muscles, stiffness in the foot, inappropriate footwear to name a few. It is very similar to the MTSS also explained here, however this does not affect the bone. It is often thought that if this condition progresses it can develop into MTSS.

Treatment

The first ting to do is understand what has caused the issue. This will aid in prevention in the future. Initially the goal is to settle the tendon and remove the pain. As soon as you have overcome that stage the goal is to strengthen the muscle and there are ways of targeting that muscle and tendons specifically.

The final stage is to integrate the muscle strength into functional activities such as running. Please do not be alarmed if the therapist treating you also assess your hips, pelvis and lower back as these areas are often related to the cause of this condition.

Tibialis Anterior Strain

The role of the Tibialis anterior is to lower the foot to the floor with control when walking. If you decide to go on a long walk and your body is not used to it you can often find the muscle is unable to cope and therefore displays pain after. This muscle can also become injured if you have a fall on the ankle the places the toes into a forced pointed position.

Treatment

If the cause has been established i.e. a sudden increase in the amount you walk, the goal is to assist the muscle in performing the task, i.e. get it stronger. In the mean time we will assess the ankle and make sure the cause of the strain is not a stiff ankle which asks more of the muscle when working. We will also discuss the type of footwear you are using and make sure it is adequate for the task at hand.

Syndesmosis Sprain

Also referred to as a high ankle sprain the mechanism is slightly different to the customary ankle sprain. The method of injury in this case often involes your foot being placed firmly on the floor and a twisting motion occurs. The twist then causes the ankle joint to open slightly and can cause a tear to the ligaments. Often the pain is then felt when you place your foot on the floor, which causes stress to the ligaments again. There is also often a restriction in how high up on your toes you can get.

Treatment

The treatment often goes against what you think in this case. The goal is too tighten your ankle joint. The pain associated with this condition is often due to excessive movement of the joints in the ankle.

Therefore exercises to stiffen it are usually required. Mobilising joints around the ankle and into the foot also assist. Please log in to the patient portal to see some of the exercises that can help in the ankle and foot section.

Visceral Manipulation

Which means manipulation of the fascia overlying and supporting the organs of the abdominal region.

I appreciate that this sounds a little strange, and in all honesty at first I didn't believe it. I was studying a range of osteopathic treatments and visceral manipulation was one of them. It was also the one I overlooked for the first 3 years. Thinking it sounded like voodoo and too weird and wacky to use.

The change came when I realised there were a number of people presenting to the clinic that had symptoms similar to others but we're not settling. I know I was able to settle the symptoms of others with a very similar presentation - why not these?

I remember 'trying' some of the techniques I had been taught and had amazing results. The stubborn symptoms that were almost impossible to settle suddenly started to reduce in intensity. The change was profound. From that moment I was a convert.

We all know as physiotherapists that the organs can refer to certain regions, we know that the liver and gall bladder can refer to the right shoulder, the stomach to the left. Personally I have witnessed my wife 2 days post surgery for her Appendix complaining of right shoulder pain (the appendix being on the right side of the body) and recognising that this could be an issue but still too soon post operation to treat, but then a friend also had his appendix out a couple of months later and 2 days post operation, complaining of right shoulder pain.

Now their shoulder pain settled without any intervention required, but what if it had continued? They would present to the clinic with right shoulder pain. We would go through all the tests and assessments we would normally, certain things are likely to be positive and some negative but the pain originated 2 days post operation and I don't believe that is a coincidence. These are the types of patients that have a grumbling shoulder for years - mainly because their pain is not coming from the shoulder.

Another example is women who suffer back pain at various times of their menstrual cycle. The Uterus is attached to a bone in the back called the sacrum, if the Uterus is unable to move correctly it will pull on the ligaments of the sacrum which can give rise to back pain.

There is one Osteopath who has conducted the research and developed the techniques for visceral manipulation, his name is Jean Pierre Barral.

In the clinic we use this technique widely, firstly you must understand that the technique can also be used for abdominal pains and discomfort as well as digestive issues. However, this technique, when used for these issues is only done so when all other medical conditions have been ruled out. Please seek advice from your GP first.

Abdominal Muscle Strain

This type of injury is relatively rare due to the muscles in the abdomen being very big and usually very strong, therefore, to strain this muscles usually takes a large amount of force. The type of situation that can injure these muscles is in a road traffic accident, or full contact sport, such as rugby.

There is usually a point at which you remember injuring yourself. This is not one of the times that the patient describes it coming on over a period of time, there is usually a distinct mechanism. Once the injury has occurred, any movements which involves contracting or stretching them will be painful. Unfortunately this is most movements. Getting up from lying down, twisting or turning, are the most common.

Happily though it is an injury that heals well and with the right input, quickly.