A patient well-known to me, came in a few weeks ago complaining of ongoing Achilles pain. She couldn’t remember any single trauma or injury, but rather a slowly increasing level of pain and dysfunction. I’ve treated her for various sporting injuries over the years. I knew her exercise and training routine well and previously helped shape her training plan. This injury was puzzling though, given there was no clear mechanism injury, the only thing that had changed was the fact that she had started to experience hot flushes. She recently saw her GP to discuss the menopause. At no point did she ever think that her Achilles tendon pain may have also been linked to the menopause.
What is Menopause?
The menopause is a normal and natural part of a woman’s life when she stops having periods. It normally occurs between the ages of 45-55 but can happen either naturally or for medical reasons following the removal of ovaries or with certain types of treatment. The ovaries no longer release an egg every month and oestrogen levels start to decline,
The word ‘menopause’ literally means the ‘end of monthly cycles’ (the end of monthly periods or menstruation), from the Greek word “pausis” (‘pause’) and “mēn” (‘month’).
In most cases, the menopause transition begins in a woman’s mid-to-late 40s (perimenopause) but it’s important to know that some women begin the transition earlier and others later. The average age for a woman to reach the menopause in the UK is 51. Around 5% of women will go through early menopause, between the age of 40-45, and 1% under the age of 40. An ovarian insufficiency known as POI is the result of premature ovulation.
It is possible for women to experience some symptoms, all the symptoms, or a combination of them. In 2019 Currie & Moger conducted a survey amongst 1000 women experiencing menopause symptoms. They were aged between 45 and 65 years and said that they experienced: Night sweats, problems sleeping/insomnia, change to flow/frequency of periods, mood changes, weight gain, low energy levels, problems with memory/concentration, loss of sex drive, vaginal dryness, increased urinary frequency/urgency, headaches palpitations, pain during sex.
Interestingly 38% of women had joint and tendon issues and pain associated with these.
How does declining oestrogen affect tendons?
Tendons connect muscle to bone. During a muscle contraction, tendons withstand tension, transmit forces and store energy. Tendons are comprised mostly of a protein called collagen. Collagen is both flexible and strong and resistant to damage. The fibres arrange themselves in bundles which helps make them even stronger as a unit. Oestrogen is an important controller of collagen metabolism. Mechanically, it acts to decrease tendon stiffness, and as a result, protects the attached muscle from injury.
When oestrogen levels decline, however, this negatively affects tendon metabolism and healing, reducing the rate of turnover of collagen. Consequently, this reduction in oestrogen causes a decrease in tensile strength (tension under load), a decrease in collagen synthesis, fibre diameter, density, and increased degradation of tendon tissue.
Tendons become increasingly stiff after menopause, and since they are attached to bones, they can be injured. Tendons have less compliance, so they do not respond as quickly to the demands of the muscles that they are attached to. This means that women experiencing menopause are more at risk of injury to tendons.
Did you know that small changes in the position of the clavicle, scapula, and spine all help move the shoulder? The shoulder is able to perform all these brilliant movements mostly because of its shape, but also because it’s supported by those other joints too. The accessory joints (between the clavicle, scapula, and spine ) allow us to create these complex movements. They also make these movements more stable and more powerful too! There are 7 movements that occur in the shoulder: abduction (away from the body), adduction (across the body), internal rotation, external rotation, flexion (upwards), extension (backward), and circumduction (a combination of all the above).
Taxing your shoulder over time with repetitive, overhead movements or participating in contact sports may put your shoulder at risk for injury. Many athletes endure micro-traumatic stresses on the shoulder which can be both unpleasant and painful too! Significant damage happens these injuries are left without being treated.
Is a SLAP tear similar to a rotator cuff tear?
A SLAP tear is not to be confused with a rotator cuff tear. A rotator cuff tear involves a tear to a rotator cuff muscle/tendon. A SLAP tear refers to a tear of the labrum – which is a thick piece of cartilage that lines the shoulder joint. In most cases, there is also damage to the bicep tendon that attaches to the labrum. Sometimes SLAP tears are confused with AC Joint problems. One of the key differences is that in SLAP tears, you’ll have pain when your bicep muscle works eccentrically (like going down on a bench press).
What is a SLAP tear?
This is a tear to the ring of cartilage (labrum) that surrounds your shoulder’s socket. A SLAP tear tends to develop over time from repetitive, overhead motions, such as throwing a baseball, playing tennis or volleyball, or swimming. Usually, you’ll have pain at the top of the shoulder, clicking, and pain with those overhead activities. If you’ve had a SLAP tear your:
Athletic performance decreases. You have less power in your shoulder, and your shoulder feels like it could “pop out.
Range of motion decreases. You may not feel able to throw or lift an object overhead like you used to, as your range of motion decreases.
Shoulder hurts and you can’t pinpoint the pain. You have a deep, achy pain in your shoulder, but you can’t pinpoint the exact location.
There are 4 types of SLAP tears:
Type I SLAP lesions have been described as isolated fraying of the superior labrum with a firm attachment of the labrum to the glenoid. These types of SLAP tears are typically due to degenerative changes. It has been suggested that the majority of the population has some variation of a Type 1 SLAP lesion. These often present with no symptoms and are no cause for concern.
Type II SLAP lesions are defined by a detachment of the superior labrum and the origin of the tendon of the long head of the biceps brachii from the glenoid cavity. This can often cause instability in the shoulder. This is the most common type of SLAP tear and often needs surgery for repair.
Type III SLAP lesions are tears in the shape of a bucket-handle. The labrum peels back, with no damage to the long head of bicep tendon.
Type IV SLAP lesions are a combination of Type II and Type III tears. This involves a bucket handle tear to the labrum, which extends into the bicep tendon. This type of tear often causes instability in the shoulder and the long head of the bicep.
Do all SLAP tears heal on their own?
Unfortunately, SLAP tears do not heal on their own. Sometimes surgery is the best option, depending largely on the type of SLAP tear. If a SLAP tear is left untreated, the shoulder can become unstable, leading to dislocation. Reduced range of motion, chronic pain, and adhesive capsulitis (frozen shoulder) are also common. Discuss this with your trusted healthcare provider after a thorough assessment of the injury, and what the best option is for you. A good clinician will always be able to advise about the advantages and disadvantages of the treatment options.
What does conservative management look like?
Exercises that develop strong control of the rotation in the shoulder are very important. They help ultimately to manage the load placed on the upper labrum (superior labrum), relieve pain, and help overhead athletes move their arms more efficiently. Watch me show you my favourite SLAP tear exercises!
Rotator cuff tears are common. They tend to occur more often amongst people over the age of 50 than younger people in their 30s and 40s. Older people tend to get tears due to age-related changes. In fact, it’s so common almost 50% of people over 60 get them. One study showed that asymptomatic tears were twice as common as symptomatic ones! Younger and middle-aged people tend to get them due to trauma, trying to lift a very heavy object or catch something heavy. Tears can also happen from a fall onto the shoulder or arm. It can also occur from a boom-bust cycle too much too soon type of exercise such as trying a new sport and overtraining without sufficient strength and conditioning to support the shoulder. In older people, it tends to happen because of age-related changes from decreased blood supply to the tendons connecting muscles to bones.
Do I have a rotator cuff tear or a sore shoulder?
There are many conditions that can give you pain in the shoulder. Pain can be referred from the neck as well as other organs like the gall bladder, lungs, and even your heart. It’s important to know that your shoulder pain is not a symptom of any other condition. A good Physio (like all of us at Vitality Physio) will ask all the relevant questions to keep you safe.
Some of the most noteworthy features of rotator cuff tears are:
The affected shoulder hurts when lying on it while resting.
Pain when lifting or lowering the arm during simple activities such as reaching for a shelf.
A feeling that the shoulder is weak. It’s particularly noticeable when lifting your arm to shoulder level or when rotating your shoulder.
Does the rotator cuff always need surgery if it is torn?
Let’s take a closer look at the anatomy:
The rotator cuff tendons are special. They are all connected via the rotator cable. Therefore, they all work together to make the rotator cuff a continuous structure, working harmoniously together. The cable functions as a stress shield. It acts in the same way that a suspension bridge transmits loads across to its supporting towers.
Here’s the good news- this means that even when you have a large tear of a rotator cuff tendon, you can sometimes neither have pain nor a loss of function!
However, tears that affect the function of the rotator cable are likely to need surgery. Therefore, the location, more than the size of the tear is more relevant in deciding whether surgery is needed.
How can Physiotherapy help?
It is important to address all factors that may have contributed to tendon injury or tear when treating rotator cuff injuries when surgery is not needed.
With physiotherapy, you will improve neck, scapular, and thoracic spine function. All of the body parts are integral to good shoulder function. If your neck is stiff or weak, your shoulder joint can often have to work harder. By targeting these supporting areas, you will improve the way your body is set up before you move your shoulder. This means that you give your shoulder the best chance to move both easily and powerfully.
As movement experts, Physios are great at distinguishing whether your joints have the stability to move efficiently too. So, we can help you get your shoulder working to its best potential.
We can help you find interim solutions to find more comfortable positions to sleep, and ways to modify your technique for activities, while you are recovering or getting stronger.
Now, generic exercises – off the internet will help to a certain extent; however, they cannot be replaced by robust, goal-orientated, and bespoke training plans. They are often not targetted to your individual needs, and it’s difficult to guess without an expert to guide you how often, how many repetitions, and how heavy to load your muscles.
To make improvements rehab should always be:
Specific- meaning is it for endurance, strength, balance, flexibility, or a combination of these?
Measurable- it needs to be scored.
Prescribed- so that you know the:
Intensity: How many repetitions?
Sets: How many times should you repeat a particular number of repetitions of a given exercise?
Dose: How many sessions per week?
By working with a well-planned specific rehab program- you’ll make the best gains and use your time efficiently too!
The shoulder is a ball and socket joint. Its structure and form mean that it allows for many different movements, making it the most mobile joint in the body! The socket is pretty shallow but this allows us not only to complete day-to-day activities like washing our hair but also allows us to participate in overhead sports like tennis and cricket. Here at Vitality Physio, shoulder injuries are one of the most common injuries that we see. But first, some anatomy:
Shoulder anatomy
Your shoulder is made up of three bones: your upper arm bone (humerus), your shoulder blade (scapula), and your collarbone (clavicle). The shoulder joint is actually where the ball of the humerus meets the rounded shallow socket of the scapula, called the glenoid. The muscles of the rotator cuff keep the large head of the humerus, positioned and centered in the glenoid. Doing so, helps to keep the most mobile joint in the body moving optimally!
So, what are the common causes of Shoulder Pain?
The shoulder is a complex joint, but fear not, with the right approach rehab needn’t be overwhelming! Overusing or underusing muscles and tendons can cause pain. Too much too soon, boom and bust are often the biggest culprits! Irritation to the bursae (the fluid-filled sac under bones or tendons) is very common and can be painful, even disturbing your sleep at night. Age-related injuries such as frozen shoulder or rotator cuff tears can cause pain too. They can rob you of movement and limit your function! Sometimes impact injuries and dislocations cause immense pain and damage to ligaments. Occasionally, shoulder pain may be referred from a nearby structure like an irritated nerve in the neck.
Every body is different and therefore every injury can present and have an impact on life in many different ways. A tendon injury for example may prevent someone from participating in sport, whereas a frozen shoulder can prevent someone from getting dressed in the morning. No matter the cause of injury, it is important to establish the cause. It helps prevent further injury, and will limit further longer-term issues too. Why leave it to chance?
What should I do if I have shoulder pain?
Distinguishing what is causing the pain, will impact your rehab. Sometimes, shoulder pain can be a result of an underlying illness such as diabetes or cardiac issues. Your Physio will flag the symptoms associated with causes other than the structures of the shoulder, and refer you to the right medical professional as needed.
If you have sudden crushing pain in your shoulder, call 999 straight away! If the pain runs from your chest to the left jaw, arm, or neck, or occurs with shortness of breath, dizziness, or sweating.
Do I need a scan of my shoulder? Why?
A thorough examination of the shoulder, alongside a detailed history of the injury, will often provide the most information required for our Physios to make a diagnosis. MRI scans are not always needed. In fact, a study in 2014 showed that MRI scans showed changes and pathology in both symptomatic and asymptomatic shoulders. It also demonstrated that symptoms may not match the MRI findings. The notable financial burden of ordering MRI scans and the pertinency of the findings are therefore sometimes questionable. This does not mean that you will never need a scan, however, this should be done to either confirm a diagnosis, rule out dangerous pathology, or if you have failed conservative therapies for a reasonable amount of time.
What can you expect from Physiotherapy?
Your Physio will offer you a tailor-made plan, based on the problems you have and the goals you’d like to achieve. Maybe you’d like to play tennis again, go bouldering or even the simple everyday activities such as getting your arm into a coat or reaching a high shelf. We are all different, so why should your treatment be exactly the same? The primary principles of our problem-solving treatments however, will all resonate with any shoulder condition that you may have. They are the mainstays of quality Physiotherapy, including education about injury, modified training, adequate strength work, restoring function, and returning safely to sport.
It’s really important to load and train the shoulder, even when pain and dysfunction are resolved. This should include a combination of strength and mobility work. Train the shoulder muscles from the famous rotator cuff, deltoids, and traps as well as the scapular and spinal muscles.
What can you do now?
If you are experiencing shoulder pain, come and see us, we will help you understand what exactly is going on. Don’t let the pain hinder you any longer. Let us help you with a tailored rehab program specific to your injury and goal.
Struggling with back pain in pregnancy? Need to know what exercises to do?
Having a baby can be joyful and daunting at the same time.
The thrills and spills of every trimester bring new challenges and new opportunities to experience the delight of motherhood.
But with all of the joys that come with pregnancy, there can also be a range of pregnancy-related physical changes and symptoms that can be tricky to overcome.
One of the most common complaints is back pain in pregnancy.
This article gives you 5 pilates-based exercises to help you ease your discomfort and feel more mobile so you can get on with your day with less pain.
How pilates exercises help for back pain in pregnancy
These low-impact exercises (no bounding or jumping) offer significant benefits, including enhancing your breathing, and helping you build and maintain strength throughout your pregnancy.
This can help prepare your body for carrying your baby and support your recovery after birth, regardless of whether you have a vaginal delivery or caesarean section.
More upsides to Pilates are that you can do it with or without equipment and it’s very versatile. So you can adapt it to your needs and abilities as you progress through your recovery.
At our clinics, we offer clinical pilates sessions tailored to your condition using props when necessary, such at the Pilates ring and Swiss ball.
Although we may use props to enhance the impact of the exercises in clinic, we also show you how to do your exercises at home without any equipment. So you can practice them as regularly as you like.
How to do these pregnancy exercises safely when you have back pain
In the video below you’ll see the top 5 exercises we recommend for pregnant patients experiencing back pain.
Before you do the exercises, it’s important to keep these precautions in mind so you don’t worsen your pain or cause further injury:
Ensure you have enough floorspace and room around you for performing the exercises.
Listen to your body; don’t push through pain. If something doesn’t feel right, take a break, or skip the exercise.
Try not to look at the screen while you’re doing the exercises. It can affect your balance and may hurt your neck. Instead, watch the demonstration then pause it. Do the exercise, then go back and continue to the next one.
Tips for getting these pregnancy back pain exercises right (and why they work)
Exercise 1: Lateral breathing
Lateral breathing will:
Enhance your joint position sense (proprioception)
Increase your lung capacity (how much air your lungs can hold)
Lengthen your spine
Condition your deep abdominal muscles (core)
Exercise 2: Thoracic rotation
Thoracic rotation is key to reducing lower back pain because it helps stabilise and strengthen your lower back muscles, which take on more and more load as your baby grows.
The trick is keeping your waist and hips facing forward, while your ribs and shoulders rotate around your central axis.
Exercise 3: Quadruped hip hinge
A crucial skill to master to prevent lower back pain and control it when it flares, is being able to move your hips without moving your pelvis.
In pregnancy, your pelvic ligaments can become more mobile as a result of hormonal and weight distribution changes. This can cause your pelvis to lose some of its support functions and resulting in lower back pain.
This exercise helps add extra support in your pelvis while moving your hips.
Exercise 4: Quadruped lateral rotation
Similarly to exercise 2, here we focus on opening the chest, whilst keeping the lower back stable.
Notice the difference between stabilising the pelvis here and during exercise 2: Which one did you find easier?
Exercise 5: Semi supine pelvic rotation
This is the most challenging exercise (that’s why it comes last).
As you shift your weight from the left to the right side of your pelvis, focus on maintaining a neutral curve in your back.
Imagine your tailbone always being the heaviest point, with a sense of lightness in the lower back.
Keeping the two sides of your pelvis aligned (without dropping one half during the rotation) helps to strengthen the pelvic ligaments and balances out the pregnancy-related changes mentioned above.
Conclusion
These exercises will help you enjoy your pregnancy more by reducing your back pain. They work by improving your posture and keeping your pelvic floor and deep abdominal muscles strong and functional well.
Things to remember:
Make sure to practice these exercises regularly so your muscles remain balanced throughout your pregnancy.
Exercises should feel comfortable and no movement should be too difficult – always modify where necessary!
If you still experience pain or the exercises aren’t getting easier after a few weeks, you may need a hands-on physiotherapy assessment and individual treatment to get to the root of your problem and heal it.
If you’re experiencing back pain after pregnancy, our Mummy MOT sessions can help you identify the causes.
Need some help getting started or progressing with these exercises?
Prefer to see a specialist physiotherapist in person to assess and treat your pain properly?
Book an appointment with us today and we’ll help you get back on your feet as soon as possible and feeling like yourself again in no time.
In our recent blog, we talked about back pain during pregnancy. Let’s take a look at how a specialist Pilates programme can support the health and good functioning of the pelvic floor in women and men, thus mitigating the risk of developing back pain and reducing it when it occurs.
What is Pilates?
Pilates is a system of training for the body and mind, based on principles created by Joseph Pilates.
By fostering a deep connection between body and mind this incredibly graceful exercise, creates a unique awareness and focus. Pilates practice leads to an intense and deeply satisfying workout, which leaves you feeling stronger, more flexible and at ease in your body.
During a Pilates session at Vitality, you use a range of small props (such as bands, balls, and weights) and equipment, including the Reformer.
Pilates is the optimal complement to other physical rehabilitation and training programmes, such as physiotherapy, because:
It helps re-integrate the injured joint with the rest of the body.
It restores and re-trains optimal movement patterns, to prevent the recurrence of issues.
It addresses the postural factors that contribute to injury and pain.
The powerful changes that Pilates can bring
How does Pilates help pelvic floor issues?
Pilates exercises can mitigate and improve the following conditions caused by pelvic floor issues:
Back pain.
Urinary incontinence.
Anal and vaginal air.
Recovery from vaginal birth and episiotomies.
Prolapse.
Pelvic floor muscle disorder and pain.
A Pilates-based pelvic floor reconditioning programme focuses on:
Training the deep core muscles of the inner unit (transversus abdominis, multifidi, diaphragm). This means conditioning these muscles and learning how to coordinate them.
Developing efficient breathing mechanics. Optimal intra-abdominal pressure is needed to ensure the correct functioning of the pelvic floor muscles.
What does this look like in practice?
During a Pilates session at Vitality, our specialist will take you through a series of exercises to condition:
The abdominal muscles (lower abdominal fibers and transversus abdominis). For instance, you will perform exercises in a supine position where the spine is neutral and the hips move, e.g. lifting your legs up.
The back extensors. For instance, exercises in a prone or standing position where the spine is extended or stabilised against gravity, e.g. moving your limbs when in four-point kneeling.
The diaphragm. For instance, breathing exercises to practice coordinating the different muscles in the inner unit, and to practice moving in sync with different breathing patterns, e.g. the classic Pilates exercise ‘Hundred’.
How do I know if I need this?
If you are experiencing lower back pain or any other of the symptoms listed above, book your assessment with us. Our experts will determine the root cause of your issue and develop a personalised programme tailored to your needs and goals.
The third trimester promises that the fulfillment of the joys of pregnancy is imminent. Your little bundle of love is almost ready to arrive on dry land to say “hello world”. Now, the second trimester brought with it the fun days of nesting, energy, glowing skin (for some) a nice, neat bump to be proud of. Your forte was planning and organising, everything was peachy. However, with less than three months to go something seems to be going to pot. Yes, I have been there too! As a mom of two, I can totally relate to the tricky third trimester where back pain is prevalent amongst many pregnant women (every second one of us).
Back pain can be experienced in all stages of pregnancy. Often regarded as a self-limiting problem, many women are left in the dark to scrounge around the internet to find some solutions. It DOES NOT have to be this way. But first, let’s clear up a few important facts about back pain in pregnancy:
Not ALL back pain in pregnancy is self-limiting. You should see a doctor immediately if the following occurs:
You’re unable to pass urine
You have a complete loss of bowel or bladder control
Unremitting (day and night) severe back pain
Numbness in the groin, genitals, and bottom
Sudden unexplained weight loss
The above is not that common (about 2% of pregnancies). However, NEVER ignore them! They could be as a result of a concerning condition called Cauda Equina syndrome. Your spinal cord may be compressed which may result in permanent nerve damage. You should seek a surgical opinion in A&E as a matter of priority.
So, what causes back pain in pregnancy?
Back pain is complex and multidimensional, yes even in pregnancy. Our beliefs, lifestyle, habits, diet, health, sleeping, resting, exercise and emotions can influence it.
The obvious scapegoat is the cocktail of hormones to many an expectant mom in pain. I felt so guilty, when I was sick, in pain, or could not sleep at night because I was meant to be endlessly grateful for the hormones giving my growing baby all the best to expect in Chez Utero.
What do hormones do for us?
If our brain was the mothership for all human conscious and unconscious processing, our endocrine system would certainly be the first commander for all missions.The entire development of the baby from when they are simply two cells with ½ the DNA each on a mission to unite, divide, thrive, and conquer is controlled by hormones. In the early stages,
FSH (follicle stimulating hormone) is responsible for the growth of eggs in the ovaries.
hCG (Human chorionic gonadotrophin) is a hormone produced by the cells that surround the early embryo and can be detected in the urine after as little as 7-9 days after fertilisation. Over the counter pregnancy tests reveal the presence of this hormone and hence whether you are pregnant.Those cells that produce hCG go on to form the placenta.
Oestrogen
Not only is a female’s sexual development and menstrual cycle, but this hormone is also the wonder hormone that protects bones and joints. Oestrogen not only helps the uterus grow but maintains uterine lining too, but acts as an important, regulator for other hormones. Oestrogen also helps the development of baby’s organs. This powerful hormone also causes pregnant women to have a stuffy nose and causes hyperpigmentation patches on the skin.
Progesterone
Progesterone helps to regulate the menstrual cycle, and in pregnancy, helps thicken the lining of the uterus. The lining is like a soft cushion ready for a fertilised egg.The ovaries usually produce progesterone but when pregnancy occurs, higher levels are produced by the placenta.Progesterone together with, relaxin are on a common mission to prepare the mom’s anatomy for later pregnancy and eventually labour. They help soften ligaments and cartilage, and make a mom’s joints more pliable and mobile to allow for the growth of your little one.
Relaxin
I remember when I first read about this hormone as a 4th year Physiotherapy student, I was convinced it was an oversimplified and convenient name for a hormone, (akin to renaming the uterus- the womb). But no, it is indeed the scientific name and relaxin meets the full expectation of what it sounds like.Over each trimester it “relaxes” or softens your ligaments and joints in preparation for labour. However, because the hormone is released into your circulatory system, it does not only affect the pelvis but the entire body, making joints more mobile. It can sometimes cause you to feel unbalanced too. In the third trimester, relaxin also softens widens, and lengthens the cervix.
Oxytocin
Dubbed as the love hormone, oxytocin has been found to be present in higher volumes in people in the early stages of romantic attachment. The warm fuzzy feelings like trust, security, and contentment are linked to oxytocin too. In pregnancy, it is mostly known for stimulating labour contractions. Once your little baby has been born, it helps mobilise milk into the breasts and also aids with decreasing the size of the uterus.
Watch this handy video about what hormones do in pregnancy:
Biomechanics
The incredible multiplication of cells is complex, beautiful, genetically predetermined. This astounding process mind-blowing to say the least is so rapid, with profound changes in ligament laxity and an enlargening uterus. Your centre of gravity moves forward, a lot! So, the lumbar spine and sacroiliac joint have to work harder to withstand these changes and increase in load. Let’s put this in context. According to Yousuf et al. 2011, the angle of the thoracic spine curvature increased by 12% between 12 and 22 weeks and increased by a total of 24% between 12 and 32 weeks. They also found that the lumbar spine curvature increased by 18% between 12 and 22 weeks and by a total of 41% between 12 and 32 weeks. The human spine is robust and responsive to change, however, these rapid changes in the spinal curvature can sometimes cause overload, and if the supporting muscles and structures are not robust and strong enough, it will cause a failure of the tissues, and can cause a strain on discs, facet joints and the sacroiliac joint too.
Similarly, as the baby grows in size, the abdominal muscles stretch and lose their effectiveness as dynamic stabilisers of the lower back too. Sometimes the muscles can separate (diastasis recti) which can cause an inefficiency in the way your back and sacroiliac joint tolerates load and can cause pain too.
Weight gain
Have you heard the urban legends and old wife’s tales before?
“Eat what you want- you’ll lose it when you give birth”
“The baby will keep you busy and the weight will fall off”
“Keep eating, the baby gets it all”
There are others too, some so ridiculous, I cannot even bear to type them!According to a 2020 study, women with a Gestational weight gain (GWG of ≥15 kg) had a higher prevalence of persistent lower back pain.But why? The reason may not be as simple or obvious. The reality is that our spines are strong, robust, and resilient and can withstand load. We will keep reminding you of this because there are far too many worry mongers out there spreading false information. In 2014, researchers found that BMI (body mass index) did contribute to back pain but did not necessarily cause structural changes in the spine. However, increases in adipose (fat) tissue may cause metabolic changes that could be responsible for back pain. In patients with a BMI over 30 overexpressed pro-inflammatory cytokines are present. Those increased levels of cytokines are considered to be the link between obesity and inflammation.
Why should you avoid obesity in pregnancy?
Elevated levels of chronic inflammation can cause and detrimentally increase leptin in the body. Leptin is a hormone in the body, secreted by fat cells that helps us regulate our body’s energy. Too much leptin will stop your hypothalamus from knowing when it is full. (The hypothalamus is in the middle of the brain and lets us know when we are full and satisfied by food, or thirsty) The more fat cells that we have the more leptin your body will make. So, too much leptin means not knowing when you are actually full! Therefore, again we can see that maintaining a healthy BMI during pregnancy will help you know when you have eaten the correct amount of food!
Stress and anxiety
Pregnancy is a life-changing life moment and can come with a rollercoaster of emotions, highs, lows, even the expected. Birth stories, the financial considerations of preparation for your little one, changing family dynamics, the impact on relationships can all set your mind racing. Everybody responds differently to stress, some of us need it to motivate us and some of us suffer negative consequences. A recent study amongst healthcare workers showed that psychological stress increased the incidence of lower back pain. There’s plenty of evidence in good-quality research about the negative effect that stress has on back pain. Pain is complex and has many dimensions and should not be oversimplified. There are so many contributing factors! Perceptions, history, and social factors also play an important part. We call this the biopsychosocial framework. A complex model demonstrates that pain is complex and multi-factorial. I prefer calling it the patient-centered approach. What we need to understand is that pain has many influences and that a variety of psychological and social factors not only affect back pain but also can impact your life, and function.
Survival of the fittest, does stress really need us to react this way?
Stress, can raise your body’s resting cortisol, stimulate, and exhaust your fight or flight system (sympathetic nervous system) and perpetuate pain. The stress associated with having a baby and the chemicals associated with that can then make it easier for future stresses to bring on pain. It becomes a bit like a trigger such as a piece of music or a fragrance that can remind you of a specific moment in your life. Inevitably over time, this can change the way the body behaves. Eventually, this can actually cause a depletion of serotonin (happy hormones).
We live in a stressful world, so what?
Stress is a normal part of life. It is not the stress that is bad but our response to that stress. If you have a big increase in stress or something has changed in your life where it’s harder to cope with stress, then stress can increase your sensitivity and can increase your chance of having pain. Not only is stress (and stress tolerance) related to the persistence of pain, it is also related to how we recover. Prominent levels of stress can impair our recovery from physically taxing components of our lives. Sometimes a stressful or traumatic event can cause us pain. That stress and the chemicals associated with that can then make it easier for future stress to trigger pain. Has a song or smell ever brought a memory back to your mind? So too can a stressful moment trigger pain. It does not mean that you are weaker or have injured or re-injured yourself! All it means is that you have a heightened sensitivity and it’s easier for normal life stressors to trigger a pain response.
Lack of sleep
Sleep is protective. It helps us to both heal recover. A powerful desensitizer, often more potent than medicines. It builds our tolerance to all the things that can sensitize us. Lack of sleep (less than 7 hours for some) or interrupted sleep can sensitize you. So, perhaps your pain should be 1/10 but consistently missing sleep amplifies that pain to 4/10. . Lower levels of sleep have been linked with both increases in injury (e.g stress factors in athletes or the military) and increases in pain related to changes in the nervous system’s sensitivity. In his book “Why we sleep” by Matthew Walker, shares two of his sleep studies- one online and the other in a sleep lab. Walker shows how sleep deprivation and poor quality sleep affect the brain and how we perceive pain.
Does a lack of sleep make you feel grumpy?
Walker found that there was increased activity in the pain centres of the brain (the somatosensory cortex) and not to our surprise, decreased activity in the reward seeking part of the brain (nucleus accumbens) . Dopamine, the “feel-good hormone” is a neurotransmitter. It’s associated with satisfaction, pleasure, and rewards. Eating a delicious meal, winning a game or helping someone in need caused a surge of dopamine in the brain! Dopamine helps obtain goals, through the feelings of pleasure-reward and also helps us avoid unpleasant or painful stimuli. So, a lack of sleep caused decreased levels of dopamine and hence explains the misery we often feel when we lack sleep.
What is pain sensitivity and what does it do?
Another key brain region found to slow down in the sleep-deprived brain was the insula, which evaluates pain signals and prepares the body to respond. Even small changes in sleep patterns showed changes in pain sensitivity. This means that even slightly less sleep in a night showed that patients experienced higher levels of pain the next day. The self-preserving part of the brain analyses pain and picks our own body’s painkillers to kick in to help. However, a lack of sleep causes this mechanism to not work as efficiently.
It’s really important to us at Vitality Physio to debunk myths and give answers to our patients about their pain. We will empower you to understand, manage, cure, and prevent injury. Book with us for a free chat about your back pain and we can advise the best ways to help! Whichever stage of pregnancy you’re at, you can count on us to help you with your back pain.
What is an anterior cruciate ligament and what does it do?
The ACL is a connective tissue band in your leg connecting your tibia (shin bone) to your femur (thigh bone).
It is a crucial ligament – physically stabilising your knee and acting as a data center in the leg with its rich and complex sensory nerve receptor supply. It acts as a beacon for your brain, sending signals about your knee’s position when you’re moving, twisting, running, or jumping. Thus, giving valuable information about the knee’s tension, stretch, and movement. Unfortunately, much of that vital information is lost when you damage the ACL, making your knee feel unsteady.
Causes of ACL tears in football
Direct (DC), Indirect (IC) and Non-Contact (NC) ACL injuries
According to a recent study published in 2020 where 134 ACL injuries in elite football were examined. They found:
44% of ACL injuries were non-contact
44% of ACL injuries were indirect
12% of ACL injuries involved contact to the knee
88% of ACL injuries in these football players were NC and IC injuries. These were caused by:
Pressing or tackling an opponent (47%)
Being tackled by an opponent (20%)
Maintaining balance from kicking (16%)
Landing from a jump (7%)
What is ‘pressing’ and ‘tackling’ in football?
Pressing means putting pressure on the ball to win it from your opponent. In contrast, tackling is interfering with the player in possession of the ball while they advance. Mechanical perturbation was identified as a significant cause of injury. Aggressive movement interactions and body distortions while players are defending or attacking (like during pressing and tackling) can cause ACL injuries.
For example, if a player’s upper body is bumped, pushed, or pulled while their lower body is fixed on the ground or performs an action, it can increase their risk of ACL injury.
A dominant movement pattern in ACL injury
The most common position in which ACL’s become injured is in a dynamic knee valgus. This is when your knee is bent, and your hip is out to the side and rotated inwards. It is a high-risk position for your knee and ACL.
Example of dynamic valgus load on knee.
Treating and preventing ACL injuries in football
The 2020 study mentioned earlier found that 25% of all ACL injuries happened in the first 15 minutes of the match.
Another study published in 2021 found that your cognitive skills, reaction time, and processing speed are also significant factors in preventing re-injury.
Why is this good to know?
It matters because it helps us focus our treatment and prevention strategies on the right things.
In the case of ACL rehab, readiness to play, when your muscles and nervous system are in sync and alert, is more relevant than any accumulated match play fatigue.
This indicates that your ACL injury rehab should involve cognitive or brain training to achieve the best outcomes. Examples include reactive drills and small-sided football games such as gates games or possession vs. pressure games.
It’s not only about musculoskeletal and cardiovascular fitness.
Is an ACL tear, a career ending injury in Football?
Don’t despair. There’s hope.
A 2018 study reports that 83% of athletes return to professional sport following ACL reconstruction.
And there is a real-world example you may be familiar with.
Football pundit and Newcastle’s favourite son, Alan Shearer CBE, ruptured his ACL in a game against Leeds United on Boxing Day 1992 while playing for Blackburn Rovers. The injury occurred in the first half of the game, unbeknown to him. Nevertheless, he scored 2 goals, and his team won 3-1 in that game. After his injury, the most prolific scorer in the history of the Premier League returned in the 93-94 season to score 31 goals in 40 games. Shearer attributes his success to return to play to this “Be patient, don’t cut corners, and do everything the Physio tells you.”
How long do most players take to return to play after an ACL tear?
9 months is the usually prescribed timeframe for a return to play following an ACL tear. Virgil van Dijk, from Liverpool FC, made his return after 9 months. Still, some players take 12-18 months to get back to full play.
Return to sport should be considered carefully. The decision-making process is complex and involves multiple stakeholders, depending on your competition level.
Usually, it’s a team decision with the athlete (you) at the centre of any it all.
The “must haves” for returning to football play include:
Single Leg Vertical Hop
Single Leg Forward Hop
Timed 6-meter single Leg Hop
Single Leg Triple Hop
Single Leg Triple Crossover Hop
Single Leg Lateral Hop
Single Leg Medial Hop
Single Leg Lateral Rotating Hop
Single Leg Medial Rotating Hop
Oh yes, even more hops than the Rapper’s delight.. -a hip, hop, the hippie, the hippie o the hip hip hop-a you don’t stop the rock.
These are a few examples of questions that may be asked by your rehab team before you can get back on the field safely:
Are you, the athlete, confident about returning to play? Do you trust your knee?
A structurally strong ACL replacement with robust integrity would make a happy Surgeon. What does your surgeon think?
Is the Physio happy with your range of movement, strength, and power around your knee? Can you achieve 90% or higher in the battery of hop tests in the return to sport assessment? How are your reaction times and adaptability?
Has your Coach been satisfied with your performance on the pitch? For example, can you adapt, move forward and backward at speed, change direction, jump when needed, or stop from a pace safely?
Does your Sports Psychologist feel confident that you have an optimistic attitude and mindset to return to sport unruffled and with a sense of assertiveness? Have you trained your “inner voice” appropriately? Do you have any other personal concerns that may adversely affect your match fitness?
Return to football infographic by Vitality Physiotherapy
The final whistle
An ACL tear does not mean relegation. Instead, a well-structured plan with clear goals and the right team behind you is a recipe for a triumphant return to the pitch.
At Vitality Physio, we have the experience, knowledge, and wisdom to take you from your ACL injury back to the game you love.
We’re here to help you get fit and strong, and prepared with renewed confidence.
Want to chat with us about your injury? Book a free 15 min chat with us from the convenience of home.
Call to speak to one of our ACL experts: 02071939928
We've all come across a friend or famous athlete who has had their season cut short through an ill-timed knee twist and alongside the dreaded "popping" sound. When this happens, it can be daunting.
Understanding ACL injury and knowing what steps to take to recover will help you get back to the sport you love sooner.As mentioned in our ACL tear article, the ACL is one of the main ligaments controlling the stability of your knee, and injuries to the ACL occur more frequently in sports involving landing and pivoting actions like football, netball, or skiing.
Diagnosis of ACL Injuries
The Lachman Test
John Lachman (1919-2007) was an orthopaedic surgeon at Temple University in Philadelphia who invented the technique. It's considered the most reliable way to diagnose an ACL injury. It is used by Physios and Surgeons the world over.
How is the Lachman test performed?
The Lachman test is performed like this:
Lie flat on your back. Relaxed, with legs straight.
Your Physio places your knee in a slightly bent (and sometimes rotated) position.
One hand is on the back of your lower leg (just under your knee joint), and the other is on the front of your thigh.
They then pull your shin forwards firmly while stabilising your thigh.
Why do we do the Lachman test?
To measure the endpoint and joint laxity.
The endpoint is where the end of the joint movement is felt as the shin is pulled forward. If this endpoint feels further away than what's expected, then this may indicate an injured ACL.
Joint laxity is the general feel of your joint movement and the sense of how lax (or loose) your ACL feels compared to your other knee.
Grading ACL tears with the Lachman test:
Normal. There's no difference in movement or laxity between your left and right knees.
Mild (grade 1). There's slightly more (about 2-5mm) movement than in your other knee.
Moderate (grade 2). There's moderately more (about 5 to 10 mm) movement than in your other knee.
Severe (grade 3). There's much more (10 to 15 mm) movement than in your other knee.
Because we're all different and have varying baselines of "stiffness", the test should be done on your other leg too. This will give the Physio an accurate idea of what's typical for your joint.
Anatomy of the L knee showing a ruptured ACL
The Pivot Shift test
How is the pivot shift test performed?
1. Lie flat on your back. Relaxed, with legs straight.
2. The Physio places one hand on your heel and the other just below the outer side of your knee.
3. They apply pressure to the outside of your knee while internally rotating your lower leg and bending and straightening your knee.
The test is positive if your lower leg sinks backward when the knee is bent at 30-40 degrees. Sometimes a 'clunk' can be heard when this happens.
Treatment options for ACL tears
There are two treatment options for an ACL injury: Conservative or surgical management.
Your age, previous injury, and fitness and rehab goals should be considered when deciding the best route to follow.
Conservative management
Conservative or non-surgical management involves a period of Physiotherapy treatment to restore your knee function to pre-injury level.
Surgical management
Having ACL surgery usually requires a minimum of 9 months of rehab tailored towards getting you back into your sport. This may sound like a long time, but returning to sport too early can have negative implications. Mainly increasing your risk of re-injury.
ACL Surgery
What surgery is there for ACL tears, and what you can expect?
The most common type of ACL surgery is a reconstruction of a new tendon called a graft. This is typically a minimally invasive procedure done via keyhole surgery using an arthroscope (a small camera through which your surgeon passes tiny surgical instruments). First, the damaged ACL is removed, and then the graft is attached in its place. There are different types of grafts. They include:
Autografts - Formed from tissues taken from another part of your body (like tendon tissue strands from your hamstring or patella tendon)
Allograft - Formed from tissues taken from another person's body
Synthetic - Formed from an artificial source or donor.
Rehab is paramount to your ACL recovery (with or without surgery) . Without rehab, ACL surgery is meaningless. All the top knee surgeons agree. Your ACL rehab determines the success of your recovery. We recommend an evidence-based programme that's divided into four progressive phases. In our experience, this process takes 9 to 18 months to complete.
Phase 1: Restore knee extension and reduce swelling
Immediately after sustaining your injury or after your surgery, the muscles around your knee may feel weak, and your joint may be swollen and painful. In addition, you may not be able to completely straighten your knee. During this stage of your recovery, the aim is to reduce swelling and pain and get your knee completely straight again. This phase typically takes 2-3 weeks.
Phase 2: Strength & Neuromuscular control
After you've passed the criteria to move onto phase 2, the fun stuff begins! You'll introduce a new set of exercises, including squats, lunges, leg presses, and more. These will continue throughout your rehab programme, becoming more complex as you advance through the various stages.
Phase 3: Plyometrics
After passing all the phase 2 criteria, you can ramp up the fun a little more and start introducing hopping, jumping, landing, and running movements. These sport-specific functional activities need to be retrained for your to safely return to your sport.
Phase 4: Return to Sport
Until this moment you have been working towards Phase 1-3. Before you get back to your sport, you and your Physiotherapist should discuss how and plan how you will do it.
General guidelines for ACL rehab
Follow each phase-specific exercise and test and only move on to the next phase once you have mastered the current one.
You need to achieve your rehab goals in the correct order to ensure you fully recover.
If you stop or skip steps in your rehab, you can worsen your current injury or increase your chances of re-injury when you eventually return to your sport.
Conclusion
Now that you know how to get a diagnosis, choose the proper treatment, and understand the rehab process better, you can move on from your ACL injury in the right direction.Yes, the rehabilitation process is long and requires dedication and patience. But, with the right team supporting you, your progress can be smoother, and it can be a whole lot more fun!
Our highly experienced and knowledgeable Physiotherapists can get you where you want to be. So, call us now and put your ACL recovery planning in our hands!
Knee pain is common. For some, the simple activities of daily living such as walking or climbing stairs can become cumbersome when your knee hurts. For others a niggle in the knee can deteriorate and adversely affect sporting performance. There are many causes of knee pain, so it is important for you to know what is causing the pain. There are however some common themes that occur with most types of knee pain.
Why does my knee hurt?
The knee is comprised of many structures including ligaments (connects bones together) tendons (attach muscles to bone) and cartilage (the connective tissue between bones). Most injuries in this area are caused by multiple problems over a long period of time- this could include muscular weakness, overuse, direct trauma or even lifestyle factors.
Most patients say that when their knee hurts, they tend to want to do less activity as more activity requires bearing extra load through the knees. Otherwise simple activities such as climbing the stairs or even going on a run can feel scary. Often, it leads to us searching for answers by having x-rays or scans. Sometimes a scan can look really scary, and sometimes we are told that we have “bone rubbing on bone” or our cartilage has “completely gone”. This can increase fear and further reduce activity and weight bearing through the knee.
However, just like we all get wrinkles or grey hair, age related chages to our knees are inevitable. Researchers now believe that inactivity is a major contributor to age-related diseases and disabilities, and that regular exercise can reduce or reverse those risks.
What should I do if I have knee pain?
Most knee pain can be treated through a graded rehab programme. Typically, this consists of a combination of strength training, education and a good understanding of how to implement your programme. It is important to have a supervised programme so that you know exactly where to start and know exactly how you are going to progress over the course of the rehab programme.
When we strengthen the muscle around our knees we increase our knee’s ability to withstand the load that we tend to put on them on a daily basis.
FUN FACT: Forces transmitted across the knee joint during normal walking range between 2 and 3 times body weight!
This makes them much less likely to experience pain in the future. Over recent times we have seen a huge body of evidence to suggest that an 8-12 week exercise programme can significantly reduce knee pain and symptom progression.
What Should I Do Now?
Seek out advice from a healthcare professional who understands knee pain and is up to date with the current research.
As mentioned before, scans are not always needed, and scans often do not correlate with the pain you are experiencing.
Begin strength training with the supervision of a healthcare professional.
Other factors to consider are sleep, diet and body weight- all of which can contribute to pain and pain sensitivity.
Here are some great simple knee exercises to try at home:
What is an anterior cruciate ligament and what does it do?
