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A healthy and well-functioning knee joint is vital to participate in every-day activities as well as performance in sport. The knee joint is made up of bone, cartilage, ligaments, tendons and muscles. These structures work together to provide stability during movement.

From seniors to high level athletes, Knee injuries and knee pain are very common. Physiotherapists are very well placed to assess your knee and give an accurate diagnosis. It is extremely important to know what is going in at the knee to then get the right treatment and fix the cause of it!

Knee pain or injury can arise from many different causes, such as; tight or weak muscles, injured tendons, ligament damage, cartilage damage, torn meniscus inflamed bursae, arthritis or even overload and poor biomechanics.

Patellofemoral Pain syndrome “Runner's knee” Runners knee is an umbrella term for this type of knee pain as the cause of it may vary depending on physiotherapy assessment. It usually involved mal tracking of the kneecap within the groove that it sits in. 

How do I Know if I have “Runners Knee”?

• Ache at front of knee, often around kneecap
• Pain develops gradually 
• Pain increases with – walking up or down stairs, kneeling, wearing heels, squats or knee pain after getting up from sitting for a period of time.

How do I fix it?

• Hands on manual therapy – soft tissue massage, stretches or joint mobilizations
• Quadriceps and glute strengthening exercises 
• Taping
• Orthotics 
• Changing technique or biomechanics in exercise – running, squats, lunges etc 

Osteoarthritis Wearing away of the knee joint including cartilage, bone surfaces, ligaments and capsule.  

How do I know I have it?

• Knee pain and stiffness first thing in the morning or after periods of inactivity 
• Swelling, warmth and redness around the knee 
• Grating or clicking
• Knee irritated by stairs, kneeling, squatting, long walks etc 
• Physiotherapy assessment and X-ray to confirm 

How do I manage it?

• Manual therapy – massage and stretches to offload the tension 
• Swelling management – RICER and swelling massage 
• Strength training – Gradual and monitored strength training can help off load the joint are reduce pain intensity 
• Hydrotherapy 
• Braces, taping, orthotics 

ITB syndrome or “ITB friction syndrome”ITB syndrome is an overload injury resulting in inflammation at the ITB on the outside of your knee.  

How do I know I have it?

• Pain on the outside of your knee
• Pain made worse with running or downstairs 
• May hear some snapping sounds as knee bends
• The Physiotherapist will conduct specific tests to diagnose ITB syndrome?

How do I Manage it?

• Activity modification 
• Manual therapy – massage/deep tissue trigger point therapy and stretches to offload the tension at hips and thighs
• Foam rolling 
• Hip and quadriceps strength exercises
• Biomechanical analysis – E.g. Running/ exercise

Anterior Cruciate Ligament is one of the 4 major ligaments in the knee. 

Role 

ACL’s role is to ensure stability for the knee holding two surfaces of the knee joint (femur and 

tibia) together, during multidirectional movements. 

Mechanism of injury 

High speed of rotational/ pivoting move in weight bearing position. 

Interestingly enough the majority of of tears have a non-contact mechanism of injury. 

Symptoms of ACL injury 

The majority of the cases have a traumatic / sports related incident. 

At the time of injury ,an audible POP and sudden sharp pain are commonly reported followed by an immediate large amount swelling. 

ACL tear diagnosis 

Clinical examination 

The history of the injury has a significant role when it comes to diagnosis. 

Your physio will implement a series of tests to confirm the diagnosis.

Scans 

MRI is the most accurate scan to identify a torn ACL. 

When to operate 

This areas is getting more and more controversial. 

The notion that all the ACL tears ,who want to return to sports, have to be operated is changing a bit. 

It is still a working progress, but there are solid evidence that not every single torn ACL necessarily needs surgery; even if the ultimate aim is returning to contact sports. 

Obviously every ACL case has to be individually examined. In our clinics, the best action plans, are normally created as the result of a team work between physios and surgeons. 

Non operative management

Physiotherapy

Once you, your physiotherapist and your specialist e.g orthopaedic surgeon and/or sports specialist, decided against operation then you will be taken through a comprehensive non operative rehabilitation program

The non operative ACL program consists of:

• Lower limb stability and strengthen with major focus on hamstrings, quadr and hip
• Proprioceptive training e.g. balance and agility 
• Sports specific rehab with focus on minimising the load on the ACL 

Surgery 

The procedure is a reconstruction and nor a repair. 

Reconstruction consists of borrowing a section of another tendon, commonly hamstrings or patella tendon and replacing the torn ACL. 

The most recent procedure is called Lars Procedure, which includes parts of the torn ACL in the new graft. Quicker recovery is the significance of this version, however there have beer reports of more vulnerability in the graft. 

Post op rehabilitation 

The role of having an efficient post op rehab is extremely crucial. 

Your Physio will focus on the followings during the course of your rehab

• Regaining full knee range of motion 
• Strength 
• Power 
• Balance (proprioception)
• Sports specific drills and agility prior to return to sport 

Failing to address one or more of the above can lead to increasing the risk of re-injury and further damage to the joint cartilage and early onset of arthritis. 

Is it possible to prevent?

Full prevention might be difficult but there are strategies which definitely could reduce the risk of ACL tear. 

The secret is gonna be in the mechanism of injury. 

As we explained before, sudden, pivoting motion in the weight bearing position is the common culprit. Therefore, reducing the twist (within the knee joint) and increasing the stability in the knee would be the answer. 

There have been major focus on an approach called neuromuscular training as a significant part of ACL injury prevention, and post op rehabilitation. 

Nueromuscular training is a customised program which includes resistance , strength, plyometrics and agility with main focus on on deceleration techniques.

Back to sport 

Post op return to sport program has to be conducted by a physio who is experienced in the ACL rehabilitation, otherwise there is a high rick of re injury and/or secondary complications. 

A safe return to sport is greatly feasible when the rehabilitation have been wisely implemented and followed by the patient. 

We work closely with the best sports and orthopaedic specialists on the Northern Beaches to ensure the best possible outcome for our patients. The goal is always regaining the highest possible quality of life for our clients.

Neck pain or a stiff neck is a very common complaint that we see in both of our Dee Why Clinics. 

Whether it be a dull ache, an inability to achieve full range of movement in your neck, a sharp pain or even causing headaches, a sore neck can be very frustrating and even debilitating.

Causes - 

There are many causes of neck pain. It is crucial to get an accurate diagnosis so that an individualised management plan can be determined to target the exact cause. 

Most Commonly, neck joints become stiff, similar to a rusty door hinge. This in turn has a follow on effect of protective muscular spasms of related neck/shoulder muscles and also weakness of neck postural muscles. Its crucial to get treatment and develop a rehabilitation plan as the longe this abnormal physiological pattern exists, the longer it takes to reverse the habit

Facet joint pain - 

Facet joints are joints between the vertebrae of your spine; there are two facet joints (left and right) in each segmental spinal level. The function of these joints to guide and also limit movement of that spinal level. Facet joint pain is one of the most common causes of neck pain.

Facet joint movement can be restricted (known as hypo-mobility) following simple movements such as a mild twist, awkward movement or just doing something your body didn’t expect (tripping over). Unless rehabilitated correctly, recurrences of facet joint pain becomes easier to appear due to local muscle weakness. 

Wry neck - 

Wry neck is a cervical condition whereby neck pain and stiffness develops and is often accompanied by muscle spasms of surrounding muscles. It can be quite a debilitating condition, with which even simple neck movements can cause severe pain. Fortunately early treatment is quite effective in relieving symptoms in a short period of time. 

Commonly patients report waking with a stiff and painful neck, and onset is often sudden. Most wry necks can be resolved in the fist few days, however the residual effects may last for up to one week. It is crucial to normalise cervical joint and muscle function to prevent recurrences. 

Whiplash - 

Whiplash generally occurs following a traumatic event involving sudden acceleration and deceleration. The most common cause being a car accident. Neck pain or stiffness can develop anywhere from immediately to even several days following the incident. 

As the causing factors are generally more traumatic for a whiplash associated injury, there is an increased risk of more serious injuries. The physiotherapists in both of our Dee Why Clinics will perform an in-depth assessment to determine if there is anything abnormal present that may warrant further investigation. 

Cervical Radiculopathy - 

Commonly referred to as a pinched nerve, a cervical radiculopathy involves pain, weakness or numbness spreading down the arm. It is caused by irritation of the nerve root at a specific spinal level.

The physiotherapists at Team8 Physio in Dee Why Northern Beaches are skilled in determining the spinal level at which the irritation has occurred which will then in turn guide their treatment. There are certain questions and assessment techniques which they will use to determine exactly the level affected. 

Management - 

Following an in-depth assessment, your Physiotherapist will give you a diagnosis and prognosis and outline the rehabilitation process. They will utilise a range of joint treatment technique and soft tissue therapy to normalise neck function and begin the rehabilitation programme.

The aim of treatment for neck conditions are as follows:

• Confirming the diagnosis.
• Unlocking any stiff facet joints and normalising joint range of movement, with mobilisation techniques.
• Relaxing muscle spasms with soft tissue therapy and even dry needling if relevant. 
• Normalising muscle lengths with soft tissue therapy and home exercises.
• Rehabilitating deep neck and superficial muscle strength.
• Ensuring normal cervical posture and function.
• Development of a home rehabilitation programme to prevent recurrences. 

The elbow is often a very overlooked area of the body when it comes to injuries. However, without the elbow and its surrounding structures being able to function properly, a lot of movements and actions that we take for granted become a whole lot harder.

In this article we will go over some of the more common conditions of the elbow as well as those, which can severely limit upper limb movements and basic tasks.

We can usually break these conditions down into 1 of 2 categories: Acute/traumatic injuries and chronic/overuse injuries.

Acute/traumatic injuries: 

These are usually caused by a severe trauma or overstretching of the elbow joint and forearm during some sort of activity or movement.

• Fractures and/or bruising to the Humerus, Radius and/or ulnar bones
• Ligament tears/joint dislocations
• Forearm and elbow muscle tears

These sorts of injuries will be managed generally through rest and/or a period of immobility in some cases initially, then a gradual progression and return to normal activities through the addition of specific strengthening and mobility exercises and treatment.

Chronic/Overuse Injuries:

These are usually caused by repetitive movements/actions, which are performed with poor technique causing small muscle strains over time, or as a result of poorly rehabilitated acute injuries such as some of the ones mentioned above.

• Tendinopathies: Tendon Irritation/inflammatory conditions. 
• Tennis elbow (lateral epicondylitis)
• Golfer’s elbow (medial epicondylitis)
• Biceps insertional tendinopathy
• Triceps insertional tendinopathy

Tendinopathies are the most common elbow injuries we see in our Dee Why Physio clinics. Typically these elbow injuries can take a while to improve due to the fact that we are constantly gripping and manipulating things with our hands, which in turn affects the ability for those tendons at the elbow to rest.

Resting from and/or changing the aggravating movement or technique is a crucial part of any tendinopathy rehabilitation program. 

Once the initial inflammation or flare up has settled down the tendons must be re-strengthening through specific exercises, which allow the muscles to re-load without flare-ups or re-aggravating the tendons.

If you think you may be developing an elbow tendinopathy, do not hesitate in making an appointment to see one our experienced physiotherapists in Dee Why and having it assessed. Like most other injuries and conditions, elbow injuries will recover quicker the sooner they are diagnosed and treatment has started.

There are four major environmental factors that decide the longevity of joints and the onset/severity of arthritic changes.

1. Weight Bearing

Quantity - Body weight

Quality - Distribution of weight throughout the surface of the joint

(see images below).

The quality of weight bearing also applies to multi-directional sports such as tennis and squash which both require frequent uneven application of the joints when players constantly have to change direction.

2. Impact

Impact is the sudden contact between the joint surfaces. This can occur in sports such as long jump, pole vault and parkour.

3. Stability

Dynamic - The ability to activate the muscle around the joint immediately.

Static - Anatomy of the joint e.g. the level of joint surfaces' accommodation on each other.

4. Injuries

Injuries to the joint can damage cartilage and cause weakness of the supporting muscles (instability).

Compensatory/overuse related wear and tear due to the injuries to the adjacent joints.

Of course, factors such as the quality of the cartilage which is reliant on the genetics and nutrition should not be ignored. But we tend to leave these factors to the relevant experts!

How to maximise the life of your joints and minimise the arthritic changes

1. Weight Management

2. Alignment and weight distribution

3. Techniques and form for the relevant sports

4. Comprehensive rehabilitation program following an injury

5. Staying active

Your joints act like hinges which encapsulate fluid called synovial fluid which itself acts like oil in the hinge.

Movement and staying active creates circulation in the fluid which guarantees flexibility and range of motion in the joints e.g. the reason behind your joint stiffness in the morning that tends to disappear as the day goes on.

The Rotator Cuff and common injuries to the shoulder 

The rotator cuff is a group of 4 muscles attaching the top of the arm bone to the shoulder blade. The rotator cuff muscles provide stability and strength at the “ball and socket” shoulder joint during movement of the arm and may be described as the “dynamic stabilisers”. For example, if you perform a tennis serve, throughout that entire movement your rotator cuff muscles act to keep the ball stable and centred in the socket whilst still allowing smooth movement and function of the shoulder. As well as being stabilisers these muscles do in fact play a role in moving the arm assisting in rotation and elevation. These muscles sit deep to the bigger muscles like the shoulder and the lats.

The 4 muscles are named and shown below: 

Below you can see how much movement occurs in the shoulder joint and how much movement is required of the shoulder blade with just simple arm elevation.

Rotator cuff tear

This is a tear to one of the 4 muscles or tendons seen above often described as “partial” or “full thickness”.

Graded 

• Small tear: less than 1 cm
• Medium tear: 1 - 3 cm
• Large tear: 3 - 5 cm
• Massive tear: >5 cm

How do I know I have it?

• Severe pain during time of injury
• Pain on side of shoulder radiating down arm
• Pain at night
• Lots of weakness
• Stiffness
• Pain with activities involving raising arm over head 
• Can be caused by a trauma Eg. Falling on outstretched arm or a push/ pull force or even during a shoulder dislocation

A proper clinical physiotherapy assessment is required for diagnosis. In conjunction with this your physiotherapist may decide to send you for imaging in the form of MRI, ultrasound or X ray. 

How can I manage it?

Physiotherapy management
 

• Settle pain - through modifying activity, heat/ cold, settle down muscle spasm through massage
• Improve shoulder joint mobility - through manual therapy targeting pecs, traps, elevator scapulae and stretching the capsule of the shoulder
• Reduce and muscular stiffness around scapular and neck to promote better movement at the shoulder joint 
• Promote shoulder joint awareness through “proprioception” exercises 
• Improve the position of the “ball in the socket” to restore efficient and maximal movement of the scapular and the arm bone together 
• Improve strength of the stabilisers around the shoulder blade 
• Gradual strengthening of the torn muscle until it is at full function 
• Return to sport/ work - adding speed and agility to program to ensure a full recovery 

Other forms of management 

• Surgery - Open repair or arthroscopic repair 
• Cortico steroid injections 
• NSAIDs (non-steroidal anti-inflammatories)

Rotator cuff tendonitis/ tendinopathy  

Rotator cuff tendinopathy affects approximately 30% of the general population and it refers to pain full and weak tendons in the shoulder. The tendon integrity and structure are affected by this pathology and function is impaired. Tendinopathies do not always have an inflammatory component to it, particularly in chronic (long term) tendinopathies. They are caused by a variety of intrinsic and extrinsic factors such as repetitive over head dominant sports, muscle imbalances, poor movement habits and many other anatomical irregularities. Other terms you may have heard of “Calcific tendinopathy” is where calcium (bone) has formed within the tendon and 

“Tendonitis” which is the inflammatory component of a tendinopathy. 

How do I know I have it ?

• A physiotherapist can perform clinical tests to diagnose or send for an ultrasound if necessary. 
• Painful in the shoulder joint or around side of arm even down to your elbow 
• Red and slightly warmer over injured area
• History of sports or work involving repetitive overhead activities or lifting
• History (recent) increased load or lifting
• History of trauma to the shoulder 
• Poor biomechanics in which the tendons are being “impinged” more then they can handle 
• Weakness
• Dull ache
• Difficulty sleeping on affected side
• Difficulty reaching behind back or lifting above head
• Stiffness

How can I manage it ?

Physiotherapy management

• Reduce swelling and pain in affected tendon (manual therapy, massage, isometric exercises)
• RICER - including modified activity or sport
• Brace/ support products 
• Education and guidance around loading the affected tendon 
• Restore full range of motion in shoulder 
• Restore full movement in neck, upper back and shoulder blade 
• Stability exercises for the scapular and shoulder joint to optimise biomechanics and off load unnecessary strain on tendon 
• Progressive strength training to return shoulder to full function pain free

Other forms of management

• NSAIDS
• Corticosteroid injection
• Platelet rich plasma (PRP) injections

Shoulder Impingement Syndrome 

Shoulder impingement is a umbrella term referring to structures (most commonly rotator cuff tendon or bursar) being compressed and irritated with shoulder elevation and internal rotation. 

Impingement left untreated may result in inflamed bursa or damage to the rotator cuff or biceps tendon. As seen in the image above, the area that this impingement occurs is between the arm bone and the acromium which is the highest part of the shoulder blade. Most commonly impingement is caused from poor movement habits such as postures or poor technique with certain exercises. Some other causes of impingement may be structural, referring to bony growths or arthritis in subacromial space narrowing the area. Other causes include weakness and tightness in the muscles surrounding the “ball in the socket” shoulder joint. This will compromise the position of the shoulder joint leaving it susceptible to impingment. Another contributing factor is the poor control or position of the shoulder blade. It needs to move smoothly with full motion in order to support the shoulder joint and the “ball and socket” throughout arm movement. 

How do I know I have it?

• Your physiotherapist can perform a clinical assessment to diagnose shoulder impingement or may refer you for imaging
• Ultrasound can show bursitis, rotator cuff tear/ tendinopathy or calcific tendinopathy 
• A X ray can show structural causes of the impingement such as bony spurs
• Your physiotherapist can inform you as to what is causing the impingement Eg. Shoulder blade or muscle tightness etc/
• Pain in the front/ side of the shoulder when raising arm or reaching behind back
• Pain when laying on shoulder
• Clicking in shoulder
• Weakness with lifting shoulder to the side or in front 

How can I manage it?

• Reduce swelling and pain in affected area (manual therapy, massage, exercises, tape)
• Education - advice around modifying activity and movement habits
• Restore shoulder joint mobility so no structured are being impinged 
• Reduce and muscular stiffness around scapular and neck to promote better movement at the shoulder joint through manual therapy and specific exercises
• Improve the position of the “ball in the socket” through muscle control exercises 
• Restore efficient and maximal movement of the scapular and the arm bone together 
• Improve strength of the stabilisers around the shoulder blade 
• Gradual strengthening of the shoulder girdle
• Return to sport/ work - adding speed, power and agility to program to ensure a full recovery

Shoulder instability due to rotator cuff weakness 

The shoulder joint is a shallow ball and socket joint, meaning it has lots of movement but requires a great deal of stability. It gets its dynamic stability through ligamentous and muscular systems surrounding it. When the rotator cuff or the shoulder stabilisers are weak, it will sacrifice the centred positioning of the ball and socket shoulder joint causing a in stability or unwanted movement of the ball with in the socket. This will loosen the shoulder joint including the capsule and ligaments and lead to impingement (compression of rotator cuff tendon/ bursa) and may increase risk of shoulder subluxation. 

How do I know I have it?

• Your physiotherapist can perform a clinical assessment to diagnose shoulder instability 
• Pain in the front/ side of the shoulder when raising arm or reaching behind back
• Apprehension or pain with arm being raised above head and out to the side 
• Pain when laying on shoulder
• Clicking in shoulder
• Excessive shoulder movement 
• Weakness with lifting shoulder to the side or in front
• Shoulder described as painful and weak

How do I Mange it ?

• Improve the position of the “ball in the socket” or keep it central through guided exercises  
• Support/ brace may be required 
• Manual therapy/ stretches to muscles that have developed tightness
• Improve strength of the stabilisers around the shoulder and shoulder blade 
• Gradual strengthening of the entire shoulder girdle 
• Return to sport/ work - adding speed and agility to program to ensure a full recovery

Lower back injuries are easily one of the most common injuries we see in the clinic and the vast majority of those are disc related.

Disc injuries can be particularly difficult to deal with, especially if the injured person does not understand the injury.

When we hear the words “slipped disc” or “bulging disc”, most of us will cringe at the mere mention of it. 

Firstly, the idea of a disc actually “slipping” out of position is not proven to actually occur. Discs can bulge, tear, herniate and become degenerated however.

All through your spine, there are discs between each and every vertebra. These discs act as shock absorbers between the vertebrae and contain a type of fluid, which allows the disc to cushion those loads that are constantly moving through your spine as we walk and move around. 

When these loads are not evenly distributed through the discs, the vertebrae can force the discs into unnatural positions, which can cause the discs to bulge and even herniate. A disc herniation occurs when the disc actually tears as a result of a severe bulge and the fluid within seeps out into the rest of the vertebral joint. This can often lead to nerve root impingements and other more serious conditions.

As well as these types of injuries, discs can also degenerate over time due to normal wear and tear, which causes the discs to thin and lose their shape. This, in turn, can lead to chronic lower back pain and a lot of stiffness, as we get older. 

For most people, disc bulges and even herniations can be managed conservatively with physiotherapy and exercise. Some severe cases that do not improve with normal physiotherapy may require cortisone injections and/or surgery. 

With the degenerative disc conditions, most cases are also conservatively managed with a strong emphasis placed on ongoing core and whole body strengthening as well as weight loss in some cases, to try to reduce the loads placed through the already warn out discs.

As with almost all injuries, prevention is better than treatment. People most likely to succumb to a disc injury are those who are sitting a lot for work and those who are in a flexed or bent over position for long periods. Core strengthening and stability and the ability to maintain a neutral spine, are both hugely important in regards to preventing disc injuries and recovering from them.

If you would like any more information on preventing lower back disc injuries, or anything else lower back related, we would love to hear from you!

 Achilles tendonitis is one of the most common causes of ankle pain that we see in the clinic. Tendonitis means inflammation of the tendon and it can occur in all the tendons in the body. The most common tendons that are affected include the quadriceps, biceps, forearm extensors (tennis elbow) and of course the achilles tendon.

What is it?

The Achilles tendon connects the calf muscle, made up of the gastrocnemius and soleus muscles, to the calcaneus or the heel, as it is better known. We use our calf muscle for almost every movement we perform with our foot and knee. This includes, walking, running, hopping, squatting and any other activity that involves those movements. 

Why does it happen?

Tendon issues usually arise due to an increase or sudden change in an activity or movement that involves that tendon. Usually it is a repeated movement and sometimes it could be caused by incorrect technique for that movement, which then causes the tendon to be loaded incorrectly over and over again. This sudden change to the load being placed on the tendon, then leads to microscopic tears and disruptions in the tendon fibres, which can lead to inflammation and pain. 

Who get’s it?

Achilles tendonitis is often seen in runners, especially if they have recently increased the volume of their training and/or the incline that they are running at. It can also affect people who have just started exercising recently and have got back into walking or running for the first time in a long while. Poor footwear can also contribute to Achilles tendinitis, particularly if they have poor foot control generally and have also got back into walking or running for the first time in a while. As you can imagine, it is also common in a huge range of sports from squash to rugby and even cricket. 

How do we fix it?

Like all tendon issues, reducing or adjusting the activity/movement that is aggravating the tendon is the first step in settling down the inflammatory affect of tendonitis. Massage and soft tissue release techniques are usually performed to help reduce the ‘pull’ on the tendon via the surrounding muscles and special eccentric exercises are used to strengthen the tendon without aggravating it. Once things have started settle further, your physio can help guide you on returning to those activities, usually by adjusting your running or walking technique, orthotics, adjusting your training loads and programming, and having a look at other areas in your body that might be contributing to you’re tendon loading issues (e.g. glut weakness, lower back pain, other muscle imbalances).

If you feel like you’re getting Achilles tendonitis or you want to try and prevent getting it in the first place, book in to see one our physiotherapists today and we’ll be able to show you what to do.