ADVICE ON COMMON CONDITIONS
In this section you will find information on common conditions treated by Physiotherapy.
Just click on the link below to read about a particular topic.
Check this section regularly as new information will be added on more conditions and current topics updated.
Back Pain
Neck Pain
Shoulder
Elbow
Wrist & Hand
Back Ache
The most common cause of back ache is known as Mechanical low back pain. The lower back or Lumbar spine is made up of 5 vertebrae which are circular shaped bones separated by a disc which acts like a shock absorber between the bones to cushion the forces generated as we move or put pressure through the spine in bending, lifting and sitting.
The Lumbar spine is arched in what is known as a Lordosis. The 3rd vertebrae (L3) is the highest point of this arch. When we stand up straight or lie down on our backs the lordosis is maintained. When we bend forward or sit down the Lordosis flattens especially at the L3 level and this increases the pressure in the spine and squeezes the discs, bringing the vertebrae above and below the discs closer together.
The least pressure put through the spine is when we lie down flat. This acts as a natural traction to the spine and we are therefore usually a few millimetres taller in the morning than we are by the end of the day. By sitting we increase the pressure in the Lumbar spine alone by about 1.7 times our body weight. This is when we sit properly, if you slouch that pressure increases further.
The spine is generally strong enough to tolerate this pressure for about 20 minutes, before the discs start to absorb the shock and the lordosis flattens to accommodate for the strain. Most of us will not have any problem with this and won’t be aware that your back is having to take this strain, especially if you are busy with work and have your mind on other things.
However, if your job primarily involves sitting either at a desk or driving or travelling then over the course of the day your spine is getting stiffer and stiffer. Most people roll into a ball in bed at night for perhaps 8 hours. They then sit for meals, drive to work, sit at work, drive home and then sit down and watch the telly before going off to bed again. This means that the spine is bent for approximately 20 hours out of 24 a day! On any given day this may not be a problem but sitting at a desk day after day, driving long distances without a break or repeatedly bending and/or twisting your back, leads to a gradual stiffening of the spine that will eventually result in low back pain.
Over the weeks and months and years, that leads to significant wear and tear on the spine and causes the joints to become stiffer and loose flexibility. When you loose that natural flexibility, trying to do 100% of activity on less than 100% available range of movement leads to injury.
This can range from occasional stiffness that you can walk off comfortably to severe low back pain and even muscle spasm. It is called Mechanical back pain because it is caused by the mechanical loading of the spine in various static positions for prolonged periods of time.
This is quite easily prevented by changing some simple habits and making these changes routine in your day to day life.
- Sit up properly and arrange your work station to best suit your height and shape.
- Stand up every 15-20 minutes to recover the arch in your spine, both at home and at work.
- Go for a long walk (40 minutes) per day, ideally in one go or split it in two, 20 minutes at lunch and 20 minutes when you finish work.
- Try to stretch regularly through the day.
- Don’t drive for greater than one hour without getting out to stretch your legs.
- See a Chartered Physiotherapist if you have pain that doesn’t settle down in 48 hours.
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Sciatica / Trapped Nerve
Another common problem resulting in back pain is the so called Trapped nerve or Sciatica. Sciatica is a catch all diagnosis for back pain resulting in pain down the leg often with pins and needles in the foot. The sciatic nerve is the largest nerve in the body and is made up of the roots of 5 nerves coming out from the spinal cord. These meet to form the trunk of the nerve which passes from the back down through the pelvis and into the leg all the way to the big toe. Along its journey down the leg it gives off branches to various structures in the leg like joints and muscle to give them their nerve supply.
People are under the misconception that a nerve is a thin wiry structure that is difficult to see. The sciatic nerve as it passes through the pelvis is about as thick as your thumb, so it is not uncommon for it to be the source of pain as a result of entrapment in or around a structure it passes through during its course.
The sciatic nerve is most likely to be “trapped” in the spine as it leaves the vertebrae to travel to the pelvis. This could be any one of the 5 vertebrae of the lumbar spine. Depending at which level of the spine it gets caught at, the symptoms may vary, with the pain travelling to different regions depending on its entrapment. This will also mean various levels of pain or disability as a result of where the nerve is “trapped” and what structures it supplies.
As with mechanical back pain above, if the vertebrae of the spine get closer together the space for the nerves to travel out from the spine will become narrower. If the space narrows further as a result of deteriorating mechanical low back pain or a sudden twisting injury to the spine, the nerve exiting the vertebra may become pinched resulting in referred pain down the leg.
So, what can you do to prevent sciatica? It’s the same as for Mechanical low back pain above.
- Sit up properly and arrange your work station to best suit your height and shape.
- Stand up every 15-20 minutes to recover the arch in your spine, both at home and at work.
- Go for a long walk (40 minutes) per day, ideally in one go or split it in two, 20 minutes at lunch and 20 minutes when you finish work.
- Try to stretch regularly through the day.
- Don’t drive for greater than one hour without getting out to stretch your legs.
- See a Chartered Physiotherapist if you have pain that doesn’t settle down in 48 hours.
But what do you do if you already have Sciatica? The important thing is to stay mobile. Bed rest is not an appropriate treatment for sciatica but most people will find it more comfortable to lie down when resting, especially with the knees bent and feet flat on the floor. Try to walk around as much as possible. Don’t sit if you can avoid it and only sit in a firm chair if necessary with your knees lower than your hips so you can sit up straight. It may be necessary to take some anti-inflammatory medication for the pain but check with your doctor first if necessary. Heat is also useful to relax the muscles of the spine which can feel very tight or spasm when you have trapped the nerve. Use heat, such as a hot pack or hot water bottle wrapped in a towel for about 20 minutes at a time, but you can use it 3-4 times a day if necessary. Not too hot, just comfortable.
If the pain has not improved in 48 hours, see a professional such as a chartered Physiotherapist for advice and treatment. “Sciatica” can present in different ways and have different consequences depending on the injury. You will hear many stories from people who have been told they have sciatica and they will all have a different answer as to what you should do and shouldn’t do. If you have a problem, consult a professional who can give you the correct diagnosis for your specific problem and how best to manage it.
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Slipped Disc
Many people have heard of the term “Slipped Disc”. This is a misleading term as the disc itself can not move in or out. It can however change shape. Just like your ear, the outer layers of the disc are rings of semi rigid cartilage that can mould and twist as we move. This is known as the annulus of the disc. The middle of the disc is filled with a fluid type pulp called the nucleus which will also move depending on the pressures put through the disc.
For example, when we bend forward, the disc is squeezed at the front, this forces the pulp in the disc to be pushed backwards to compensate for the change in pressure. If this is done repeatedly, the pulp in the disc will eventually push into the annulus of the disc causing it to change shape and bubble. Similarly to a Rugby player who gets cauliflower ear from the friction generated in a scrum, the ear changes shape, as can the disc. When the disc forms this bubble to release the pressure generated by repeated bending or lifting or indeed sitting, it is known as a disc herniation. If this herniation becomes large enough for the disc to bulge significantly that it hits a nerve running close by, it becomes known as a prolapsed disc or “Slipped disc”.
Prolapsed discs can present with pain similar to Sciatica, but a Physiotherapist can assess the situation to see what damage has occurred and give the most appropriate advice. If you think you may have a prolapsed disc then see someone straight away. If you can’t get to anyone then follow the advice for sciatica by keeping as mobile as possible with short periods of lying down with the knees bent and feet flat on the floor.
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Arthritis of the Spine
Arthritis of the spine can be sub classified into 2 broad categories. Spinal Spondylosis and Spinal Stenosis. Continue reading to find out more.
- Spondylosis
The spine is made up of many moving parts. Each joint in the spine hinges on the vertebrae above and below it allowing us to move in all directions. Excessive movement of the joints will lead to wear and tear in the joints. This is known as degeneration.
We all will have some degree of degenerative changes as we get older, however in some people this is more significant than others. All areas of the spine are subject to degenerative changes but the parts that move the most will suffer the most. Therefore the neck and lower back are the areas greatest affected.
Family history can account for significant degeneration of the joints of the spine and stress to the spine will compound pre-existing weakness. As mentioned above frequent loading of the spine in static postures is the greatest offender. Sitting most of the day and getting very little variety of exercise will increase the strain on the low back and neck. Bending without taking a break if working in the garden or doing DIY all add to the problems. Obviously lifting poorly and items beyond your capability all adds to the problem.
Spondylosis is the name given to degeneration of the joints of the spine. This usually results in small increases in boney growth in the joints as the cartilage covering the bone starts to wear away. These bony projections, known as osteophytes, cause the spaces in the joints to narrow and the spine to become stiff. This stiffness leads to increased strain on the spine and further degeration will continue.
The stiffness in the spine can be mild at first and not always painful. Indeed some people can have very stiff spines with hardly any pain. Most people unfortunately will have increasingly painful backs as the degeneration progresses. If you have read the information above you will now know that this degenerative process will cause mechanical back pain, increase the chances of developing a trapped nerve and possibly a prolapsed disc.
There are options to help. Early intervention is key. A good exercise program to improve strength and improve flexibility is essential. Regular changes in position to reduce the load on the spine and a good diet to improve bone strength and reduce weight will all help. A physiotherapist can guide you through these stages and also mobilise or manipulate the spine to decrease pain and improve movement. Occasionally a course of pain killers may be necessary but it is best to try and treat arthritis of the spine with physiotherapy and exercise.
If the degeneration becomes too severe pain killing injections may help, such as a nerve block or epidural. Surgery is a final answer but is required in very few cases. It will usually involve fusing together with metal rods and screws the joints of the back that are causing the most problems. It can help to reduce the pain but it will greatly stiffen the spine and therefore should be considered only when necessary.
How can you prevent or reduce significant degenerative changes to the spine:
- Sit up properly and arrange your work station to best suit your height and shape.
- Stand up every 15-20 minutes to recover the arch in your spine, both at home and at work.
- Go for a long walk (40 minutes) per day, ideally in one go or split it in two, 20 minutes at lunch and 20 minutes when you finish work.
- Try to stretch regularly through the day.
- Don’t drive for greater than one hour without getting out to stretch your legs.
- See a Chartered Physiotherapist if you have pain that doesn’t settle down in 48 hours.
- Spinal Stenosis
As mentioned with Spondylosis the joints of the spine are susceptible to degenerative wear and tear. This wear and tear is at the small joints at the side of the spine where the nerves exit the vertebrae to travel into the arms and legs. Spinal stenosis occurs when the large central space in the middle of the vertebrae containing the spinal cord starts to narrow as a result of increasing bone growth.
The pain of spinal stenosis is very similar to that of trapped nerves and / or disc prolapse but may affect one of both, arms or legs. Pain is usually worse when walking and relieved by sitting. This is the opposite to mechanical back pain, arthritis of the spine and disc prolapse.
Spinal stenosis can be a serious problem and professional help is advised as soon as possible. Investigations should be carried out such as an x-ray and perhaps a scan to see the extent of the narrowing of the spinal canal.
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Stiff Neck
The majority of neck ache is postural in nature. The vertebrae of the neck squeeze together when you sit in the same position for long periods of time. This causes the muscles and ligaments controlling the movement of the head, neck and shoulders to become stiff and painful. The neck has more ability to rotate than any other part of the spine and is therefore susceptible to strain. The symptoms often include waking up with a stiff neck that loosens up as the day goes on but gets stiff and sore by the end of the day. The neck will often get painful if kept in the same position for long periods of time such as sitting at the computer, watching television or driving.
Classic mistakes are turning you head slightly to one side when working on the computer or watching television at home. Also looking down for long periods when typing or reading .Using too many pillows in bed. Any and all of the above lead to changes in the postural alignment of the spine and over time leads to ache or discomfort in the neck including headaches, shoulders, between the shoulder blades and even further down the spine.
As a result of increased dependence on computers, more time is being spent at a computer each working day. It is very important that the work station is set up correctly to allow the minimum of stress through the joints. An occupational health adviser can help address any concerns you may have with the help of the physiotherapist if necessary.
Looking after your posture can go along way to helping ease the discomfort. Making sure you move away from static postures regularly helps. Stand up and have a stretch every 20 minutes at work or when watching television at home. Make sure your looking directly straight on at the computer or television and that the screen is at the correct height. Don’t hold the mouse or gear lever in your hand when your not using it and don’t put your elbow up on the window of the car when driving.
Postural neck ache can usually easily be treated with some gentle mobilisation by a physiotherapist and a stretching program to prevent recurrence. You can also prevent its onset by following the same advice as given for low back ache
- Sit up properly and arrange your work station to best suit your height and shape.
- Stand up every 15-20 minutes to recover the arch in your spine, both at home and at work.
- Go for a long walk (40 minutes) per day, ideally in one go or split it in two, 20 minutes at lunch and 20 minutes when you finish work.
- Try to stretch regularly through the day.
- Don’t drive for greater than one hour without getting out to stretch your legs.
- See a Chartered Physiotherapist if you have pain that doesn’t settle down in 48 hours.
Trapped Nerve
Just like with the lower back, if the vertebrae of the neck get too close together they can pinch a nerve exiting the spinal cord on its way down to the arm. The nerve can be trapped as a result of increased wear and tear in the joint spaces therefore reducing the gap through which the nerve travels. It may also be squeezed by a bulging disc similarly to that described in prolapsed disc mentioned above in the back pain section. This can produce pain in various patterns throughout the course of the arm depending on which nerve is affected. The pain can range from a dull ache to severe burning pain with or without pins and needles and/or numbness.
It is important to try and reduce the pressure on the nerve, therefore decreasing the arm pain and localising the symptoms back to the neck. It is possible to have a trapped nerve in your neck and not have neck pain. This can be confused with other injuries to the shoulder or arm or Thoracic spine.
As with most spine injuries, stay mobile. Plenty of walking around spreads the load through the spine and reduces the stress at the level of the nerve affected. When resting keep the head supported by resting your head in a neutral position either lying flat or sitting with the head and neck supported by a pillow wrapped around the neck. Keep the neck warm by wearing a scarf or using hot packs regularly. Gently try and move your neck from side to side but only within comfortable limits.
You may need medication to help with the pain and your doctor can advise you on the best course of action. This may range from simple paracetamol to anti-inflammatory drugs, muscle relaxants and in severe cases steroids. Your doctor may also prescribe anti-depressants at a low dose as these can sometimes help with nerve pain and also help people sleep and it is not necessarily because you are depressed.
Physiotherapy can be useful in mobilising the spine safely to un-trap the nerve and should be considered if there is no improvement in pain in the first 48 hours.
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When a muscle is been used or overused a lot of the time it may develop what is known as a trigger point. A trigger point is defined as a taut band within a muscle that on palpation will generate a local twitch response and causes a deep aching pain radiating from the region. These are commonly known as ‘knots’. All muscles are susceptible to developing trigger points and many muscles have what are known as dormant trigger points. A trigger point is active when it is causing pain and twitches when compressed.
A common area of the body susceptible to trigger points are the muscles connecting the shoulders to the neck or upper trapezius muscles. The Upper trapezius muscles are responsible for keeping your head up straight, rotating your head away and bringing your ear down to your shoulder or vice versa bringing your shoulder up to your ear.
Commonly when sitting at a computer for long periods of the day the trapezius muscles are working to maintain your head position. If your work station is unsuitable you may be increasing the load on these muscles because you are looking down at the screen, particularly the lap top, or your head is rotated slightly to one side more than the other. Not quite as common nowadays is holding the phone between your ear and shoulder but if you do this especially when using a mobile, that is most likely to cause the development of a trigger point in the muscle.
In the upper trapezius muscles the trigger point will produce an aching pain deep in the shoulder blade area and can refer down the arm to the back of the elbow. It may even cause pins and needles locally. It can also radiate up the skull behind the ear and be responsible for tension headaches.
In order to treat a trigger point it is essential to find the route cause of the problem. This may be something so subtle that you won’t be aware of it until it is pointed out to you. It is best to get someone to observe you as they can see you move, or not as the case may be, than you can see yourself. Common faults are the computer being at the incorrect height or angle, poor posture sleeping, having your arm up on the window frame when driving, television being in the corner of the room so you have to turn your head to see it, etc.
Once the main cause is established, this of course can be altered. To treat the trigger point the physiotherapist has a couple of options. They may try some myofascial release which will involve deep tissue palpation of the trigger point in order to desensitise it. Another option is to treat the area with what is known as trigger point needling. This involves putting a fine needle (usually an acupuncture needle although it is not acupuncture) into the muscle to deactivate the trigger point. An acute spasm is felt in the muscle and a release of tension follows.
You will then be shown how to stretch the muscle and this will have to be carried out regularly. Trigger point needling may be very effective in one session or may take a number of sessions to fully resolve the pain depending on the severity of the problem.
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- Impingement
Shoulder impingement is not a diagnosis, it is a symptom. When we talk of impingement there is a catching or pinching of structures underneath the Acromioclavicular joint (joint on top of the shoulder where the collar bone meets the shoulder blade).
Any one or more of a number of structures can get pinched in this space. Usually one of two structures are involved. Most frequently it is a tendon of the rotator cuff. The rotator cuff is a group of four muscles coming from the spine and shoulder blade. They wrap around the shoulder joint to suck the ball of the shoulder into the socket of the joint. They give stability to the joint and are also involved in the movements of the arm particularly rotation as the name would suggest.
The tendon that is most exposed in the rotator cuff is the supraspinatus tendon. This tendon lifts the arm away from the body and helps rotate it away from the body. When the arm is lifted overhead the tendon can become squeezed between the shoulder joint and the Acromioclavicular joint on the top of the shoulder. If this happens once or twice it is not a great problem. Repeated catching of this tendon will cause it to become inflamed. That results in a tendonitis making the shoulder painful, weak and increasingly stiff.
If the tendonitis is not treated early it can cause a chronic impingement of the shoulder. Prolonged inflammation will weaken the tendon and could eventually cause the tendon to fray or tear. The tendon can also be torn as a result of trauma such as a fall on an outstretched hand or onto the shoulder. If the arm is suddenly forced backwards or rotated this could also tear the tendon or by lifting something too heavy or repetitive overhead lifting. A torn rotator cuff tendon is a painful and debilitating injury that can take months to years to resolve.
It is important to ask why the tendon would become squeezed between the shoulder and AC joints in the first place. Normally there is enough space between these joints for the arm and tendons to function properly. So what would cause the space to narrow? The most common reason is posture. If you allow your shoulders to slouch forward as when sitting at a PC or folding your arms in front of your chest, this will narrow the joint space. This is a gradual process and slowly causes the shoulders to become rounded and will eventually cause an impingement. Another possibility is degenerative wear and tear of the AC joint. If the AC joint becomes worn, Small boney projections called osteophytes can protrude from the joint. These act like little daggers into the soft tissues under the joint. Both of the scenarios above will result in a shoulder impingement.
The other structure in the Acromioclavicular joint space that gets squeezed is the sub acromial bursa. This is a fluid filled sack much like an airbag that sits between the rotator cuff and the point of the shoulder. It is there to act like a shock absorber in the joint. If there is repetitive squeezing of the bursa it can slowly become inflamed. It will also become acutely inflamed as a result of direct trauma such as a fall onto the arm compressing the joint or if something falls onto the shoulder from above.
The swollen bursa will reduce the space between the shoulder joint and the Acromioclavicular joint and will be squeezed or pinched when the arm is raised. This also causes an impingement syndrome.
Depending on the source of the impingement there are different ways to treat the problem. Firstly it is important to establish the correct diagnosis. The physiotherapist has a number of clinical tests they can carryout to help achieve this. If they are unsure or need to confirm the diagnosis it may be necessary to carry out other tests. An x-ray of the shoulder can identify or rule out the possibility of an osteophyte. An MRI scan may be able to establish a tear in the rotator cuff or a swollen bursa. Ultrasound scans are also useful to see the rotator cuff in various positions as it is possible to move the shoulder while carrying out an ultrasound scan. This is not possible when performing an MRI scan. One or more of these tests may be required to finalise a diagnosis.
Once the correct diagnosis is established the treatment begins. An acute tendonitis can be treated with Ice, anti-inflammatories and an exercise program. A traumatic rotator cuff tear needs to be placed in a sling and rested for about 3 weeks. Also during this time the physiotherapist will work on the tendon to prevent the formation of scar tissue and then rehabilitate the shoulder girdle complex when appropriate.
A bursitis may need a cortisone injection to kill the inflammation but the physiotherapist can normally reduce the pressure on the bursa by mobilizing the joint and strengthening the shoulder. Impingements as a result of posture or osteophyte formation need a lot of work on improving posture and mobilising the Acromioclavicular joint to improve joint space. The underlying tendonitis or bursitis also needs to be treated and the shoulder rehabilitated.
If conservative management is not effective then other interventions such as injection therapy or surgery are available. Most surgeons will tell there patients to try conservative management for at least 3 months before resorting to surgery and will often insist on waiting a year before operating. The earlier treatment begins the greater the success.
Often over or misdiagnosed a frozen shoulder is a painful and stiff joint that can not move beyond 50% of its normal range of movement. A shoulder X-ray will be normal and it is usually of unknown cause or idiopathic.
There are two types of frozen shoulder. Primary or idiopathic frozen shoulder is of unknown cause. It classically occurs in females more than males and in those usually over 45 years of age. It will normally be in the non dominant arm and is more likely to occur in those in a sedentary profession. Secondary frozen shoulder follows significant trauma to the shoulder such as a fracture, dislocation or severe burn. However this injury may have occurred some years previously.
The shoulder joint is surrounded by a capsule, which is like a layer of cling-film covering the joint. It provides fluid to the joint to lubricate it and allow the 360degrees of movement we enjoy in the shoulder. In frozen shoulder it is believed that this capsule starts to shrink and be come stuck or adhere to the shoulder joint. There is some evidence to say that in the early stages this capsule is inflamed and it is sometimes referred to as an adhesive capsulitis. There is other evidence to say that the capsule is not inflamed but that the capsule shortens similarly to that of a Dupuytren's contracture in the hand and that this will have to take its own time to burn itself out.
figure: Frozen shoulder sometimes known as adhesive capsulitis.
A frozen shoulder will run 3 stages. Stage 1 is the freezing phase where the shoulder becomes increasingly stiff and painful. Phase 2 is the frozen phase where the shoulder is so stiff that it will not move above shoulder height. This is often the most painful stage and it is then people will usually seek help for the shoulder. It is painful to sleep on and the shoulder usually becomes very sensitive even to small changes in movement. The third and final stage is the thawing phase when the pain reduces and the movement slowly improves.
Each stage of a frozen shoulder will last from 4 to 8 months. Therefore taking anywhere from 1 to 2 years to resolve. Frozen shoulders will solve themselves eventually and will never occur again in them same shoulder. There is unfortunately a 13% chance of it occurring on the other arm, usually within a year of the initial shoulder resolving.
Treatment for a frozen shoulder will vary depending on what stage you are at. In the early phase it is important to try to maintain the movement and control the pain. Anti-inflammatory medication may be useful or even a cortisone injection. There is some debate as to the presence of inflammation in frozen shoulder but research is split on the topic. Physiotherapists can help to control pain and maintain movement.
In the second and most painful stage aggressive manual therapy is counter productive. Patients try a variety of modalities to help ease the pain such as ice or heat or electrotherapy. There is evidence for and against each of these. Whatever works best for the individual should be continued. The aim of treatment at this phase is to control the pain. Acupuncture has been shown to be the most effective. Your physiotherapist may be able to perform this for you or refer you to a suitably qualified person.
In the third phase the pain drifts away and it is then time to get the joint moving. Mobilisation of the joint should be carried out by the Physiotherapist and an exercise program established to get you back to full function.
There are surgical options for frozen shoulder but these are carried out rarely and like everything else in frozen shoulder are debatable. Manipulation under anesthetic is carried out to try to break any adhesions in the joint and kick start the movement. Other more invasive procedures attempt to release the capsule covering the joint in order to free some movement.
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The tendons that extend or straighten our fingers all come from the same point of the elbow. This area is known as the lateral epicondyle or extensor tendon origin. Pain in this region is often described as lateral epicondylitis or tennis elbow. There are a number of tendons all originating from the same point and moving out into different directions to get to the fingers. As these tendons overlap and are working to move the hand and fingers particularly in gripping activities they can rub against each other creating friction, inflammation and eventually become scarred.
The tendon that moves the middle finger sits on top of all the other tendons and is the one that can rub the most. This tendon is called Extensor Carpi Radialis Brevis. In tennis elbow it is this tendon that is affected. There are other tendons that can be affected or other areas of pain on the lateral aspect of the elbow, however it is not tennis elbow unless the middle finger is involved.
Classically the tendon will be rubbing and slowly fraying for months. It usually takes about 6 months for the process to lead to pain or inflammation. Tennis elbow is characterized by pain in the lateral or outer aspect of the elbow. The pain often originates behind the elbow joint and radiates out from there over the outer upper one third of the forearm. It is intermittent at first and gradually deteriorates becoming increasingly stiff and painful. Most patients present with symptoms occurring for approximately 3 months at which time the tendon has become scarred and very weak. In all they have had the problem for 9 months by this time.
It is necessary to establish the source of the problem. With careful questioning a source is usually identified which more than likely will involve an increase in gripping activity in the previous 6-9 months. Classic examples are a short intense spell of DIY, gardening, gripping sports such as tennis or golf or perhaps a lot of right clicking with the mouse using the middle finger.
This intense period of activity may have started the scarring process and although not painful at the time, slowly degenerates resulting in the pain of tennis elbow 6 months later. If the cause can be identified this will greatly improve the chances of recovery.
Physiotherapy can conservatively manage tennis elbow and will result in full pain free and functional recovery in 70-80% of cases. The physiotherapist will break down the scar tissue and start the patient on a graduated exercise program. It will take 12 weeks to fully recover and the patient will need on average 8 sessions in that time.
The physiotherapist may consider a brace to help reduce the pain during treatment. Most of these are ineffective. The best tennis elbow supports are those that stop the hand from moving rather that restrict elbow function as it is gripping of the hand that is responsible for the damage in the first instance. The physiotherapist may also try acupuncture to control the pain during treatment.
If physiotherapy is unsuccessful the next option is to have one or a series of cortisone injections. There is much debate over the effectiveness of cortisone in tennis elbow as there are many who believe that there is no inflammation. There is also debate as to how many and where exactly these injections should be administered. The general consensus is that 3 injections would be the maximum over a 6 month period.
Surgery is the final resort and this will either involve debridement of the scar tissue or a tendon transfer. Tendon transfers are the more successful surgical procedure as it changes the angle at which the tendon pulls. This relieves the stress on the tendon and should reduce it’s recurrence in the future. Post surgical rehabilitation with a Physiotherapist is essential for good long term results.
Carpal Tunnel Syndrome is when the median nerve gets trapped or squeezed in the wrist as it works its way down the front of the forearm from the elbow to the fingers. The wrist is a gutter of 8 bones that is formed into a tunnel by a layer of connective tissue over the top. Inside this tunnel various structures pass through from the forearm to the hand including the tendons that flex the fingers, some blood vessels and the median nerve.
The median nerve is one of many nerves in the arm. It supplies power to some of the muscles in the hand and also sensation to the thumb, index finger, middle finger and half the length of the ring finger on each hand.. When the space inside this tunnel is compromised the median nerve is squeezed and this results in pain and pins and needles in the thumb and 2 and a half fingers of the hand.
The nerve can be squeezed if there is an increase of swelling in the area such as fluid retention in pregnancy or if there is a tendonitis and inflammation. The nerve can also be squeezed if the carpal tunnel itself starts to narrow if there is some arthritis or wear and tear in the bones or if the wrists are extended / bent back for long periods of the day when typing or using a mouse. The connective tissue covering the bones can also shorten as we get older and this may be the cause.
Most people with carpal tunnel syndrome complain of pins and needles in the hand and fingers especially in the morning and this may even wake them at night. The hand or hands often feel heavy and numb and they will have to shake them out to “get them going in the morning”. The symptoms may also be aggravated throughout the day if there is a build up of pressure in the wrists for any of the reasons mentioned above.
In order to treat carpal tunnel syndrome the main cause needs to be established. In an office environment incorrect keyboard or mouse use can be a very significant factor. Adjusting the hand, wrist and forearm position so that the hand is in a relaxed and neutral position allows all the structures to pass through the carpal tunnel with the greatest of easy. If you are unsure of how to achieve this contact a Chartered physiotherapist who can arrange a work station assessment for you.
If sleeping is the biggest problem wrist splints can be useful which help keep the wrist in a neutral position overnight so that the median nerve does not get squeezed during the night if you bend your wrist while you sleep. However, if localised swelling is the source of the problem, such swelling is often worse at night and splints may be of limited use. If swelling is a factor then the source of that swelling needs to be address either with appropriate medication as prescribed by your GP or a steroid injection by a specialist.
Physiotherapy can help to identify the correct diagnosis and cause of the problem and may also be able to treat the source of the problem. If all else fails there is a simple surgical procedure which can release the pressure in the tunnel and “fix” the problem.
Remember that carpal tunnel syndrome is not the only cause of pins and needles in the fingers and a thorough assessment is necessary to establish the correct diagnosis.
We have all heard of the expression wear and tear and all to commonly it is used as the answer to many aches and pains. This may very well be true but it is not a diagnosis. Our bones are a living tissue and are constantly being re modelled. If we stress the bone more than its ability to recover from this stress the bone will start to show signs of strain and fatigue which can result in a change to the surface of the bone.
Relatively minor stress to the bone is often classified as wear and tear. If this stress is as a result of trauma, such as a fall where there is bone pain but no fracture, it may be a bone bruise. Stress from repeated weight bearing on the joints may cause wearing of the cartilage covering the bones, leading to wear and tear / osteoarthritis, which can progress into inflammatory arthritis.
People are fearful of the word arthritis, but there are many different types. Generally speaking when people talk of arthritis they usually mean osteoarthritis (OA) or wear and tear arthritis. OA in itself can broadly be broken down into hereditary arthritis as a result of significant family history and secondary arthritis as a result of over use and progressive wear and tear. A classic example of secondary OA would be a professional footballer who develops wear and tear arthritis in their knees as a result of the stresses and strains of training daily and competitive matches on top of injuries to the knees through out their career.
If there is a family history of OA, such as a close relative needing a joint replacement it would be sensible to discuss various do’s and don’ts with the physiotherapist or your GP to help look after your joints for the future.
On the other hand we are all susceptible to the normal ageing process and the stresses and strains to our joints that it involves. If you are involved in any activity that requires repeated and sustained weight bearing on the joints you may be prone to wear and tear or bone strain.
Examples of this in the workplace may be osteoarthritis of the base of the thumb with prolonged use of the hand in lifting, grasping, pulling, pushing etc. This may result in a painful and swollen joint that’s stiff and sore to begin with but often settles down as the day progresses only to get sore again when rested.
When the joint is going through an active phase or is inflamed it is important to allow relative rest. Try to stop the activity that is producing the pain before the pain begins. This may involve typing for only ten minutes at a time, before giving the hand or joint involved a rest for 2 minutes and resuming typing again. This is better than typing for 30 minutes and then requiring a rest for 10-15 minutes. This example can be followed for any joint with some minor wear and tear. It is important to understand the limitations of the area affected and stay within them.
A physiotherapist will be able to advise you on what activities may be irritating the joints and may also be able to treat any pain and swelling by mobilisation of the joints and various modalities at their disposal. They will also be able to show you how best to strengthen the joint and prevent relapses.