Osteoarthritis (OA) of the knee and hip is a very common condition associated with aging and something we see quite a bit of at Central Performance. OA is a condition that involves changes to a joint and breakdown of the cartilage inside the joint, this can then also affect the bones and ligaments within the joint. Approximately 2.1 million Australians are affected by OA, with approximately 25% of Australians over the age of 45 affected.
It is becoming more widely recognised that exercise should be a front line treatment for osteoarthritis, particularly for the hip and knee. The Royal Australia College of General Practitioners (RACGP) put out new guidelines for the treatment of knee and hip OA in 2018. Within these guidelines for the treatment of knee and hip OA exercise and weight-loss were the only treatments that were strongly recommended. There was better evidence for exercise than there was for medications or surgery.
While changes to the joint associated with OA cannot be reversed, exercise can help to alleviate or manage the symptoms, improve your ability to perform activities of daily living, reduce disability and improve quality of life. Exercise physiologists, who are trained to prescribe exercise for the treatment of chronic conditions such as OA, are well skilled to develop and prescribe exercise programs for patients who are suffering from OA of the knee and hip.
An exercise physiology treatment program for OA will be personalised depending on the results of your physical assessment, your current functional ability, your confidence with exercise and your goals. A exercise physiology program for a client with knee and hip OA will generally program through three stages:
Your treatment will usually begin with exercises to increase strength of the muscles surrounding the knee and hip joints to help stabilise the joints and improve your symptoms. As your strength and pain improve your treatment will progress to increase range of motion at the hip and knee. The final step of your exercise physiology program is to progress again to full-body exercises that will have great carry over to day-to-day activities. The whole program will be guided by your symptoms and measured against your goals.
Running is an extremely popular form of exercise with almost no cost and fantastic physical and mental benefits. I’m sure we’ve all met runners who are almost obsessive about their running and are like a bear with a sore head when they can’t run. We see lots of runners at Central Performance, from office workers who run a couple of times a week for the health benefits to our elite running group coached by physio and track coach Ben Liddy.
One thing most of our runners have in common is that they would like to run a little better. Whether that’s reducing aches and pains they feel when running, improving their City2Surf time or lowering their 1,500m PB everyone wants to improve somehow. An often-overlooked way to improve running performance is to include some weight training into your training. The classic opinion was the weight training made you heavy and slow however there is a lot of good research that shows that weight training can significantly improve endurance, running performance and running economy.
It used to be thought that to improve performance in endurance sports like running that it was more beneficial to use a light weight for lots of repetitions when performing weight training. The theory was that it better replicated how the muscle worked when running and therefore it would lead to greater improvements in running performance. We now know that low repetition, heavy weight training and plyometric training is better for improving running performance and economy. This might seem counter intuitive but there are some good reasons for why that is the case.
First of all, heavy weight training and plyometric training both improve what is called Rate of Force Development (RFD). RFD means how quickly a muscle can produce force, the higher the RFD the quicker a muscle is able to produce force. A high RFD is important when running because ground contact time with each stride is so short. If you are able to increase the RFD of the muscles in the legs then you are able to decrease your ground contact time and increase your running cadence. Increasing your running cadence improves your running economy, making you a more efficient runner.
Secondly, a stronger muscle means that each stride requires relatively less effort from the muscles in your leg. For example, the soleus muscle in the calf has to deal with between 6-8 times body weight with each stride. That is an awful lot of force to be dealing with for a sustained period of time. A strong soleus, strengthened with the help of weight training, will be better able to handle 6-8 times body weight for a 800m race, 5km fun run or full marathon.
Thirdly, heavy weight training and plyometric training help to strengthen and stiffen tendons. A stronger, stiffer tendon is better able to transmit the force produce by the muscles into the movement of bones required for running. Better force transmission by the tendons again improves running economy and efficiency. It also has the added benefit of helping to guard against the development of tendinopathies such as Achilles or hamstring tendinopathy. We see many runners with these injuries and heavy weight training is the starting point for their rehabilitation.
As you can see there are some very good reasons for including heavy weight training and plyometric training to improve your running performance. As simple as two sessions of weight and plyometric training per week can lead to significant improvements in running performance. Below is an example of a simple weight and plyometric training session for runners.
The goblet squat is a fantastic way to introduce the squat movement into your training program and it is the first version of the squat we use with our clients. The squat is one of the key movements in weight training programs we develop for runners as it is fantastic for developing quad strength. This is important as the quads take the second most load during running after the calf muscles.
Single leg deadlift:
Another key movement in the weight training programs for our runners, the single leg deadlift is great for developing strength in the hamstrings and muscles of the lateral hip, particularly the glute medius. The glute medius plays an important role in maintain lateral stability of the hip, helping to prevent hip drop and subsequent valgus collapse of the knee when your foot strikes the ground. We also aim to have a mix of double leg and single leg exercises in our programs and the single leg deadlift is one of our favourite single leg exercises.
Bent knee calf raises:
An often overlooked muscle group when weight training, the calf muscles have the highest demand on them of any muscle group when running. As stated earlier, the calf muscles must handle between 6-8 times body weight with each stride. Therefore, it is important to strengthen the muscles of the calf. The bent knee calf raise helps to prioritise loading on the soleus muscle and better replicates the ankle position during running.
Hurdle hops are one of our first plyometric progressions we introduce into our runners programs. It is a great exercise to help develop power on one leg and get our clients used to the landing forces associated with plyometric exercises. With a hurdle hop we emphasise ‘sticking’ the landing which requires our clients to be able to control the landing forces.
In Part 1 of this blog series on back pain we reviewed the three types of low back pain, plus busted some myths about scans and radiology findings. In this post we will review the way physiotherapists can treat back pain, plus the lay out the best advice on what you should do at home or work to make your recovery as quick as possible. In Part 3 of this series we’ll review things that you can do to reduce your risk of future pain episodes.
As we have discussed in Part 1 there are three main types of back pain. Getting a correct diagnosis for your back pain is an important because it guides your initial treatment.
Physiotherapy treatment for this type of back pain focuses initially on relieving your pain and restoring your range of motion. We need to get you back to doing your normal daily activities as fast as possible, allow you to sleep normally, and be able to do your usual work duties. We use a combination of hands-on (manual) treatment together with structured exercise to increase your joint mobility, plus release muscles that are tight or in spasm.
As well as prescribing the right exercises for you, your physio will also clearly explain do’s and don’ts for you at home and work so that you help your back pain to settle as fast as possible. It has been extensively proven through research that staying active within your comfort levels, avoiding bedrest, and returning to your normal work and daily activities as quickly as possible is by far the best way for you to help your back pain resolve. Using basic medications like Panadol, Neurofen or Voltaren can also be very helpful at this stage.
Once your pain is resolving well your physiotherapist can guide you through a progressive exercise program to fully restore your strength, ensure you are moving correctly, and get you confident in returning to the gym or your usual sporting activities. Completing a supervised strength program with an accredited exercise physiologist is the gold-standard later-stage management program for low back pain, especially if you have already had several episodes of pain or are lacking confidence in returning to your full normal gym or exercise activities. If you prefer, Pilates is also an excellent way to exercise following low back pain.
The initial focus for physiotherapy treatment for back pain where a nerve is compressed (or pinched) is to relieve the pressure on the nerve. The degree to which the nerve is pinched or irritated can be gauged by the amount of referred pain that travels down your leg, plus the presence of other neurological symptoms including numbness, pains-and-needles or weakness. Hands-on treatment plus specific exercises are used to relieve these neurological symptoms as quickly as possible, plus medication such as Voltaren can be helpful. You will also be given exercises to do at home by your physio to help you relieve your pain and get moving again.
Once the pressure on your nerve is relieved, the physiotherapy management for radicular or nerve-related low back pain is largely the same as for non-specific low back pain. A combination of hands-on therapy plus structured exercise progression will relieve any remaining pain, restore your movement, and then reactivate your muscles. Staying active within your comfort, returning to work and daily activities as soon as you are able, and avoiding bedrest is strongly shown to be beneficial for this type of back pain.
Once your pain has settled then completing a supervised strength program with one of our physio’s or accredited exercise physiologists will get you fully back to your normal sport, exercise, work and daily activities. Pilates can also be very helpful, if you prefer this style of exercise. Any contributing movement problems that may have contributed to your pain can also be corrected to reduce your chance of future problems.
Serious lumbar (low back) pathology is very rare – present in less than 1% of back pain cases. It includes things like spinal fractures (broken bones), tumors, and some types of infections and inflammatory conditions. During your initial assessment your physio uses specific and effective tools to screen for serious pathology, and they are concerned they will explain their concerns to you and provide you with a referral back to your GP for further investigation.
So, now you know the guidelines for how physiotherapists treat the different types of low back pain. A key take-home message for you is that staying active within comfort, avoiding bedrest, and returning to your normal activity as soon as you are able has clearly been shown to be the best way for you to help yourself recover from back pain. Your physio will give you more guidance on this, plus use hands-on techniques and prescribe the most effective exercises for your specific situation to help you recover as fast as possible.
In the next post in this series on how physiotherapists treat low back pain we’ll review things you can do to reduce your risk of future pain episodes. As always, if you have any questions in the mean time please feel free to contact one of our friendly physio’s to see how they can help!
Low back pain is a very common problem that our physiotherapists treat every day here at Central Performance. There are lots of myths and conflicting advice out there, and this is very confusing and overwhelming for someone looking for treatment during a back pain episode. Although everyone’s presentation is unique and an individual assessment is the foundation of gold-standard treatment, there are some solid research-based guidelines that can really help you understand the process.
In this post we summarise some of the main things you need to know about the 3 different types of low back pain. The next post talks more about how physio’s can treat the pain, and the final one is about reducing the risk of having more problems in the future.
The first thing to know is that low back pain is REALLY common, with approximately 80% of Australians experiencing at least one episode of back pain in their lives. Whilst back pain can be very severe and debilitating, the good news is that the majority of cases of back pain DO NOT involve serious damage and will improve within 6-8 weeks.
Unfortunately there is a very high recurrence rate for back pain, meaning that if you have one episode you are very likely to have another one. Reducing this risk of future pain episodes is one of the major goals of physiotherapy treatment for low back pain. As well as physio you will often get great benefits from seeing an exercise physiologist who can prescribe an effective exercise program for you to reduce your risk of future problems.
Even though most cases of back pain improve within 6-8 weeks, seeing a physiotherapist early can help you in three major ways;
There are two very important findings to keep in mind from extensive back pain research looking at the use of radiology investigations like x-rays, MRI’s and CT’s;
1. The vast majority of back pains DO NOT need radiology investigations. Except in specific circumstances (see below), early imaging is not needed from a diagnostic or treatment planning point of view, and therefore it is generally unhelpful. Importantly, there is a solid body of evidence to show that merely having the scan in the first place can make your pain worse or persist for longer! This is because unrelated findings that often show up on scans can make people worry more about their pain (see the next point).
2. When people have scans for low back pain the report will almost always show “stuff”. A bit of degeneration here, some wear and tear there, a loss of disc height at this level or a bit of a bulge in a disc or two. But research clearly shows that most of this “stuff” is not actually really related to pain! Extensive research repeatedly shows that people who don’t have low back pain also often have disc bulges, disc degeneration, loss of disc height, facet joint degeneration etc… As a clinician I regularly see situations where a client is being treated for one-sided low back pain yet they bring in scans that they have already had done that show more degenerative findings on the other side. These things are usually just normal parts of the aging process, like getting grey hairs or wrinkles!
So, whilst there ARE times when imaging is indicated and the results ARE helpful when taken in the bigger clinical picture, it is important to remember that most back pains DON’T need imaging. Also, if you do have a scan then get your physio or doctor to thoroughly explain the results to you because many of the scary-sounding words are actually not relevant.
Whilst there are several systems around to classify low back pain, the most useful to the general population uses three categories.
1.Non-Specific Low Back Pain: this is by far the most common type of back pain, accounting for approximately 90% of cases. It describes pain that is felt in and around the low back area, and can sometimes extend down in to the legs. The pain can be anything from mild to severe, however there is no numbness, pins-and-needles or muscle weakness. It can be due to structures including joints, discs, muscles and ligaments. There may have been a specific incident to start the pain, eg a heavy lift, or it may just come on for no identifiable reason.
2. Radicular Pain – Commonly Called Sciatica, Nerve Root Pain or a Pinched Nerve: this type accounts for 5-10% of low back pain cases. It occurs when a nerve is compressed as it exits the spine, causing pain running from the back down into the leg. The pain may also be associated with neurological symptoms including numbness, tingling/pins-&-needles, or weakness. Clinical testing of nerve function may show reduced reflexes, power or sensation, and also positive neural tension tests including the straight leg raise (SLR), prone knee bend (PKB) or slump tests. If this nerve compression is present then it is important to begin treatment to relieve the pressure from the nerve as fast as possible. As with non-specific low back pain, radicular back pain can also be either from a specific incident or for no memorable cause.
3. Serious Pathology: this is very rare – less than 1% of low back pain cases are due to serious pathology. It includes things like spinal fractures (broken bones), tumors, and some types of infections and inflammatory conditions. There are specific and effective screening questions and tests that physiotherapists use to identify possible serious pathology and if they are concerned your physio will refer you for further investigation.
Well, that wraps up part one of our series on physiotherapy treatment for low back pain. Next time we look at how physiotherapists treat back pain, and then finally how to reduce your risk of future pain episodes. As always, if you’d like any further information please feel free to contact one of our friendly physio’s at Central Performance!
Patellofemoral pain syndrome (PFPS) is a condition typified by a vague, diffuse pain around the knee. It is often most noticeable during running and walking up and down stairs or hills and is a frustrating injury because it can severely limit a sufferer’s ability to partake in sports and activities they enjoy. While the pain usually isn’t associated with significant damage, the pain itself can be severely limiting. One of the first steps to getting back to activities pain-free is to reduce the aggravating activities to allow the pain to settle and to start a strength training program.
Traditionally it was thought that the most important muscles to help prevent and relieve PFPS were the VMO (one of the quadriceps muscles on the inside of the patella) and the gluteus medius (one the glute muscle on the outside of the hip). However, recent research shows that specific exercises for those muscles have no better outcomes than general exercises. Therefore, the goal of strength training for PFPS should be to have a comprehensive program to strengthen the whole lower body to not just rehab PFPS but improve performance and reduce the risk of other lower limb injuries.
Here is a sample of exercises we use for runners and other athletes recovering from PFPS:
A fantastic foundational exercise, split squats help develop strength in the quads, hamstrings and lateral (outside of the hip) glutes as well as develop balance in a split stance position. These place more emphasise on the quads and lateral hip muscles than the other exercises in the program.
Another fantastic foundational exercise, deadlifts are great for developing strength in the hamstring, glute max (the big, main glute muscle) and back muscles. Deadlifts particularly strengthen hip extension which is very important in running and athletic movements.
Surprisingly the calf muscles (gastrocnemius and soleus) are the muscles that receive the most load during running (6-8 x bodyweight), more than the quads (4-6 x bodyweight), hamstrings, glute medius (2.6-3.5 x bodyweight) or glute max (1.5-2.8 x bodyweight). Therefore, it is important to strengthen these muscles to improve their ability to cope with the loading they receive during running .
A great, simple exercise for the lateral core muscles which play an important role in helping keep the pelvis level during running.
These four exercises together provide a comprehensive strength program that strengthen almost all the muscle of the lower body. Together with a temporary reduction or modification to activity and exercise they can help get you back to what you want to do pain-free.
Low back pain is one of the world’s most common conditions and is a leading causes of disability and work absence worldwide. It affects over 80% of the world population and can result in a significant personal, social and financial burden.1 Low back pain usually settles down within 4-6 weeks but has an 80% chance of reoccurring within 12 months of the initial injury. Exercise therapy is the most common form of treatment for low back pain. It is low cost, easy to access, has a positive biological affect on the body and is recommended in most clinical practice guidelines.2
The Pilates method aims to improve posture and body awareness while building strength. The six basic principle of Pilates includes tightening the ‘powerhouse’ (trunk and gluteal muscles), concentration (cognitive attention), control (postural management), precision (accuracy), flow (smooth transition) and breathing while performing a range of exercises.2
It is a great way to get people moving in a smooth and controlled way. At Central Performance we use the reformer, wunda chair and mat-based exercises in a circuit style approach so that the exercises are varied and fun. These exercises use springs and body weight as resistance and can be adjusted to your ability. Our initial assessment involves a history of your injury and a physical examination to determine your exercise program. Than we get started! Starting on four 1-on-1 sessions to get used to the various exercises on your program. From there the choice is yours. Continue with 1-on-1 sessions or move to our group classes (max 4 people).
But how does this help with low back pain?
Just move! Our backs love movement. The worst thing to do when you have low back pain is to stop moving and stop exercising. Pilates allows you to move and exercise in a nice controlled and monitored way without using heavy weights. It can be a way of progressing your exercise tolerance or to transitions back into gym-based exercise.
I need a stronger core to get rid of my back pain!
This is often a very common perception in today’s society. We are often told to strengthen our core to prevent low back pain. However, if you have had ongoing or episodic low back pain than you may already bracing and overusing your core subconsciously to help ‘protect’ your back. Before strengthening your core it is important to regain normal relaxed movement of the spine. This relaxed spinal movement can fundamentally change the way your back behaves day to day. Pilates is a good way of starting off this process, using controlled movement of the spine before progressing to more progressive strengthening exercises, whether it be at the gym or harder Pilates exercises.
Swimmers shoulder is a generic term used for what is an overuse issue for the shoulder, particularly concerning the muscles and tendons of the rotator cuff. Despite the name, this painful shoulder issue isn’t specific to swimmers but is seen in a variety of people, from those who are highly active to people who are couch potatoes.
People with swimmers shoulder generally experience a dull pain in the morning which ‘warms up’ throughout the day but may not necessarily disappear completely. You may also feel a sharp pinching pain in the shoulder with overhead activities. As with most musculoskeletal injuries, swimmers shoulder can have a number of contributing factors including load management, muscle strength and endurance deficits, stiffness or tightness, and inadequate neuro-muscular control of the shoulder.
Swimmers shoulder will often come on due to an increase in the use of the shoulder. For example a swimmer may have had a sudden increase in the amount of time they’ve been training per week, the intensity, or have been training a new stroke. In those who are less active, it may be due to things like giving the house a new coat of paint or doing some spring cleaning. The reason these rather innocuous activities may cause shoulder pain is not so much related to the activity itself but to the ability of the shoulder to tolerate what you’re asking it to do (i.e. having the strength and control of the shoulder and shoulder blade to perform the activity).
In order for the upper limb to move freely and allow us to complete tasks like reaching up to the top shelf to grab something or to reach behind us to do up the zip on a skirt, the joint itself relies less on bony stability (like the deep ball and socket joint of the hip) and relies more heavily on active stability (muscles). When these muscles don’t have the strength and/or endurance to control the shoulder joint, we can get excess movement and aggravation of the structures surrounding the joint. Often there can be an underlying weakness, but you won’t know it until you ask the muscles to do something quite difficult or something you’re not used to, such as spring cleaning, painting or a sudden increase in training load.
Although a sudden increase in activity is usually the catalyst, there are other factors that can leave you more susceptible to this issue and these should be targeted in terms of treatment. Tightness at the front of the chest, weakness of your upper back muscles, thoracic cage mobility and shoulder blade control all may have some contribution to a swimmers shoulder issue. As with many musculoskeletal issues, swimmers shoulder is a complex pathology which requires thorough assessment in order to identify the contributing factors. Once these have been identified, a thorough rehabilitation plan targeting the contributing factors is paramount in achieving the best outcomes for you and your shoulder moving forward. If you think you have a case of the swimmers shoulder, come in and see one of our physiotherapists for a comprehensive assessment and treatment plan that targets your specific goals!
Foam rolling is an extremely popular form of self-massage, with a huge number of athletes from almost all sports using it in one way or another as a part of their preparation for either training or competition.
Here at Central Performance, we get a great number of new clients asking about foam rolling, and whether it will be helpful to them not only as a part of their training, but in their everyday injury maintenance. We encourage our clients to utilise the foam rollers in their gym or homes every day, as they are a great way to not only help prepare for exercise, but also recover from it!
Foam rolling is a fantastic tool to use as a part of rehabilitation because they enable you to release tight areas of the body on a daily basis, leading to improved movement and performance. These tissues can be tight due to injury from regular training, or even sustained postures throughout everyday activities e.g. desk-based workers often experience tight hip flexors from having their hips in a constantly flexed position at their desk all day.
Foam rolling is also extremely useful when recovering from exercise. Evidence shows that Delayed Onset of Muscle Soreness (DOMS) is significantly reduced when performed immediately following exercise, and then both 24 and 48 hours on muscle groups that were the main focus of the exercise session. Enhanced recovery leads to a greater level of ability and performance, hence why elite athletes everywhere are using it!
1. Quads: rolling is very helpful for reducing tightness is your thigh. Runners find this especially useful, and it can help prevent or manage patellofemoral (kneecap or runners knee pain) and quads strains. To do it, lie on your front with a foam roller under one leg and slowly roll up and down the length of your quad.
2. Calf: excellent for runners with tight calves, place a foam roller under one calf and lift off the floor with your hands, rolling up and down the length of your calf.
3. Lateral (outer) thigh: great for reducing soreness on the outside of the hips or knees, lie on your side with a foam roller under the outside of your leg and roll up and down the length of your thigh.
So if you are feeling a bit tight and sore with running, training at the gym, netball or whatever, give these a try and let us know if you need any help!
For more tips on training, mobility, strength and rehab make sure to follow us on Instagram (@centralperformance, #centralperformance), Facebook (@centralphysioandperformancefitness), or Twitter (@centralphysio). And keep an eye out over the coming weeks for more great recovery tips!
Patellofemoral Pain Syndrome (PFPS) is a common complaint we see here in the clinic. This usually presents as a gradual onset of pain in the front of the knee which is generally vague and difficult to pinpoint. This knee pain usually progressively worsens over time and can interfere with your daily activities and overall function. There can be a number of contributing factors to PFPS and therefore it needs a thorough examination to identify the important factors for each individual patient. Factors such as load management, range of motion, strength and control of the hip, knee, ankle and foot can all play a part in the development of PFPS. It is important then, that we identify the contributors and target these factors with an individualised rehabilitation program. Let’s take a look at these factors in some more depth:
Load Management: As with many injuries we see here at Central Performance, the main contributing factor tends to be a sudden increase in activity (running or loading) e.g. getting back to running after a break but trying to do the same distances you were running before you stopped. Although PFPS often affects runners, it can also occur from other repetitive activities such as stair climbing, hiking or hill running as well as excessive compressive activities such as squatting and kneeling. Key to the successful rehabilitation of PFPS is to manage your load in an appropriate and graded way.
Knee Strength and Lateral Tightness: Research shows that people suffering from PFPS tend to have a weakness in the quadriceps muscles. We also see that the structures (eg the ITB) on the outside of the knee and hip are tight and this affects the position of the patella, pulling it laterally and causing increased wear and tear on the cartilage of the knee due to this sub-optimal tracking.
Hip Strength and Control : A lack of hip strength or control, particularly in the gluteal (“glutes”) muscles to the side of your hips, can result in a rolling inwards of the knee during single leg activities (e.g. walking, running, steps etc). This inward rolling (“valgus collapse”) also pulls the patella outwards, which causes further wear and tear on the under surface of the patella itself and on the contact points of the femur.
Ankle and Foot Factors: Stiffness or restriction of the ankle can transfer excess load up the leg and place more stress through the knee. Similarly, if there is a lack of strength in the calf complex, then this can result in an increase in load through the knee joint in order to compensate. Foot posture has also been linked to PFPS, with those people having flat or “pronated” feet more likely to present with patellofemoral pain.
As you can see, managing Patellofemoral Pain Syndrome is as complex as it is to spell it! It requires a thorough assessment and an individualised rehabilitation program addressing the factors that are specific to you and your pain experience – there is no “one size fits all” treatment recipe. So if you are experiencing anterior knee pain our talented team of physio’s can help!