If you have asked yourself these questions, read on. In this post I will briefly explain the stages of the healing process and how this relates to the type and intensity of treatment provided or recommended. The healing process is an extremely complex process and here we have provided a relevant account with regards to the treatment proposed at each stage. We have by no means attempted to include all the stages and actions of the healing process. This is an overview of relevant points with regards to the planning and reasoning of certain treatment types.

At the initial time of injury, an inflammatory response starts. The initial stage of the healing process is the inflammatory stage, where the tissue fibres are disrupted or damaged. This results in swelling, bleeding and the presence of debris from tissue damage. Specific cells known as phagocytes (Cell eating) or white blood cells clear and clean the area from the clotting blood and the tissue debris.

Treatment

Do`s – Protect, Rest, ICE, Compress, Elevate. (P.R.I.C.E.)

Dont`s – Deep tissue massage, Heat.

The aim of treatment at this stage is to reduce or stop bleeding from ruptured tissue and to reduce the severity of the inflammatory response. To do this we must follow the PRICE guidelines. Protecting and resting the area helps to stop excessive blood flow and reduce the potential bruising and swelling response. ICE also helps to reduce blood flow by causing the blood vessels to close (Vasoconstriction). Compression and elevation help with the flow of the lymphatic system so the phagocytes can easily transport and remove the clotting blood and cell / fibre debris.

The next phase of the healing process is known as proliferation.

Blood platelets help the blood to clot and provides the basic meshwork of fibres (Scar tissue)  for tissue to bond to and grow.  Cells known as Fibroblast (Cell builders) create delicate bonds (Hydrogen bonds) between collagen fibres and specific cells build specific types of fibres. For example a Myo fibroblast builds muscle fibre.

Treatment

Do`s – Gentle movement of the affected area, gentle stretching both as home exercises and in physical treatment. Strength and conditioning programme with static or low resistance exercises. Deeper massage can now commence but this is graded by the therapist, too deep will cause too much blood flow – not deep enough will not facilitate the required response.

Dont`s – Over load the area, this will break the delicate bonds formed and will lead to an increase in inflammation, further bleeding and potential scar tissue formation. Slowing and even reversing the healing process.

The final phase of the healing process is known as the Maturation phase / Remodelling phase.

Collagen fibres form strong (Covalent) bonds. This increases the tensile strength of the tissue and injured areas. Normal tissue is formed according to the type of tissue injured and if the healing process has been allowed to continue uninterrupted by activity or re injury, the tissue will heal correctly. With specific guidance and exercise the fibres form the correct type of fibres in the correct order and position to return the structure to a normal state. If this is not achieved, the scar tissue will strengthen and can lead to adhesion and permanent restriction.

Treatment

Do`s – Begin load bearing strength exercises, progression of the strength programme  deep tissue and friction massage.

Dont`s – Do not stop rehabilitation! Typically when someone feels better, the exercises stop. It is this that will lead and leave someone open to re-injury. If the healing process is not completed, the tissue will remain weak, fragile and vulnerable.

In the final stage of healing the tissue fibres need to be manipulated in such a way that the fibres of the tissue are organised correctly so that they can “slide” over one another. If the fibres do not have this flexible ability, they are more vulnerable to injury and more severe inflammatory responses if re injured.

If you have an injury that is not healing or improving give us a call to book an appointment or for a free telephone consultation.

Finally – please note that the information in this blog is not intended as a substitute for specific advice for your particular problem. Each injury needs to be assessed and treated as per the stage of the healing process and the stage of the injury.

Issue 3 – Standing posture and charity day

Ever wondered why you get a stiff achy back standing around in queues or waiting at the photocopier?

Shifting from one foot to the other to get comfortable? Suffering from neck, mid or lower back pain after standing for long periods?

In this post I am going to describe the three main standing postures I see in clinic and some of the problems that these positions can cause. In addition describing ways to correct these positions in order to achieve a neutral standing position (The correct posture!)

In clinic I hear many reports from clients who tell me they have a tilted pelvis, their spine is out of alignment or they just have bad posture. If the spine was out of alignment or the pelvis was tilted or twisted we are talking about a structural skeletal problem. This type of injury requires either a large sudden impact to the pelvis or spine, or it is a long term chronic structural condition with far deeper causes. These are serious conditions and require expert assessment, specific treatment and discussion with orthopaedic specialists as to the treatment plan.

However, in clinic the majority of clients are not suffering with these conditions but are standing in such a way as to cause the pelvis to be tilted forwards or for the spine to be held in a flexed,

extended, rotated or tilted position. This means that we are consciously using, or not using our muscles in many cases and we fall into three main positions.

• The Flat back,
• The Tilted pelvis
• Forward shoulders

Before we get to that it is important to know why the correct standing position is so. It is basically down to anatomy and biomechanics (The way joints move and interact with one another).

The spine is known as being sigmoidal, meaning S shaped. This is because the spine should be curved, we have three natural curves in the spine which are the Lumbar lordosis (Lower back), Thoracic Kyphosis (Mid back) and Cervical kyphosis (Neck). This should not be mistaken for spinal conditions called Lumbar lordosis or Cervical kyphosis. We are referring to the normal and optimal position of the spine in a static position. See image right

The reason we have these three curves is due to the shape and size of the vertebrae, the cervical vertebrae are much smaller than thoracic and lumbar vertebrae. As we move further down the spine the vertebrae increase in size and change shape. Which in turn changes the angle of the spine and forms the natural curves. This is supported by a complex system of muscles which we control!

The flat back…

This is someone who stands tall through the spine. Often they will say to me that they have been told to imagine being pulled up through their head. This causes them to elongate the spine and causes the vertebrae to almost stack on top of one another. Standing in this way often leads to neck and shoulder pain resulting in headaches.

The tilted pelvis…

This is the lazy stance, much more common than the flat back. This is where someone stands with the knees locked back and the hips pushed forwards. This caused the pelvis to sit in a forward tilted position. Over time hip flexors and the quadriceps muscle become tight. This effectively holds the pelvis in this forward position. Standing in this way causes the forward tilting of the pelvis and increases the Lumbar curve of the spine. This then has a knock on effect throughout the spine and leads to a combination of anterior pelvic tilt and a forward shoulder position.

Forward shoulders

This position is seen most when clients are sat down, sitting slumped over a keyboard for 8 hours a day will lead to the shoulders falling forwards.  Over time, this altered sitting position starts to occur when we are standing and this is potentially due to a combination of learned behaviour and muscular restriction. This position can also combine with the tilted pelvis position but is variable from person to person.

Symptoms

It depends on you and your body as an individual as to how your back copes with this stress and where or when you start to feel discomfort. Potentially these positions will cause ankle, knee and hip pain, lower, mid and upper spinal / back pain, shoulder and neck pain potentially leading to headaches.

The main focus for all these scenarios is posture education and advice. Providing manual treatments such as manipulation (cracking the spine), massage, acupuncture and stretching will help to control the symptoms but will not resolve the underlying problem. If posture changes are not implemented it will only be a matter of time before the symptoms return….

Treatment

Here are the two main strength and conditioning exercises required. Doing these exercises will enable you to not only achieve but to be able to maintain the correct position. However it is important to note that doing these exercises will not resolve your back or neck pain. Consistently maintaining optimal posture can.  Once you have practiced these exercises for a week or so, start trying to move your pelvis and control the position of the pelvis and shoulders when you are not stood against the wall and see if you can control the movement more specifically. It is only then that you will be able to adapt or change your posture. This is the key to the whole process.

This exercise is designed to strengthen the muscles in the mid back and needs to be done in order to provide the strength and endurance to be able to hold the shoulders in the correct position when standing.

Try this with a tin of baked beans in each hand. Do 20 – 30 repetitions 2-3 times. Once a day.

This exercise is to help you to control the position of your pelvis. Stand with your back up against a wall and try to flatten the small of your back into the wall. You can use a hand towel in the small of your back to help, try to squash the towel with your back. You should feel your abdominal muscles tighten and your pelvis will tilt backwards. Whilst holding this try to squeeze your shoulder blades together as in the exercise above.

Practice this for 5 -10 minutes once a day

The movements required to achieve a neutral standing position or “good posture” are easy but require specific control, practice, strengthening and perseverance. In many case you will have ‘learnt’ to stand in the wrong position it can take some time to change this habit.

This information is a guide on how to achieve a neutral and optimal position when standing. It is not meant as a diagnostic reference and if you are suffering with symptoms you should seek further medical advice.

As always any feedback or comments are welcome.

Issue 2 – biomechanics and over pronation

Below is a link to our start, summit and finish on Snowdon, Cadair Idris and Peny Fan.

Welsh 3 peaks video

Click the link below to access the newsletter

Issue 1 – 1 Yr on – hip Ex

What is Plantar Fasciitis…?

The Plantar fascia is a long band of tissue which lies under the sole of the foot connecting the heel bones (Calcaneus) to the toes (Metatarsals). It has a supportive role acting as a shock absorber when walking and running and assists with formation of the in step or medial arch.

Plantar fasciitis is a condition when where the plantar fascia either becomes damaged suddenly by an injury or over time by wear and tear known as RSI (repetitive strain injury). In both cases the end result is the same, the tissue of the Plantar Fascia thickens due to inflammatory changes caused by injury or RSI.

The physical change within the structure causes tightening and restriction of the movement of the fibres. This is what causes the pulling sensation a lot of clients describe and subsequently with increased load the end result is pain, stiffness and dysfunction.

Additional causes of this may also relate to over pronation (Flat footed) or walking on hard surfaces. People who have an active job such as postmen, long distance runners, people aged 40-70 and those who are overweight are most at risk of developing plantar fasciitis. A combination of these “risk factors” will increase the likely hood of the condition developing

Symptoms

Symptoms include heel or arch pain, particularly in the morning where the foot hasn’t been mobilised and is stiff. Diagnosis can also be assisted with Ultrasound imaging but this is rarely done nowadays.

With activities which increase the load going through the foot, the symptoms will be aggravated and leads to restriction of physical activity such as running, tennis and many other court related sports.

Treatment

The most important treatment for plantar fasciitis is REST!!! If we do not rest from physical activity the inflammatory process will be fuelled due to aggravation of the condition. This will only set you back and it will take longer for your symptoms to fully resolve!

ICE is extremely important, to reduce the effects of and the length of time the inflammatory process lasts for we need to use cold therapy. Put a small bottle of water in the freezer and roll your foot over the bottle. This will help to cool the area reducing inflammation and you can also use it to massage the foot at the same time! Spend about 10 -15 minutes every evening doing this.

Strapping under the sole of the foot helps to support the plantar fascia and relieve some of the stress placed on it when walking or running. This is especially good if the symptoms are new as the support provided reduces the likely hood that the Plantar Fascia becomes irritated and this aids the healing process.

Stretching the calf is also important as the Plantar Fascia is actually an extension of the achilles tendon. There is positive research evidence to show (and positive results in clinic too!!) that stretching the calf reduces pain and stiffness in the Plantar Fascia. There are two main  muscles which make up the calf, see the pictures below for guidance on these.

This stretches the Gastrocnemius muscle! This  is the larger of the two calf muscles, you should feel the pull at the top of the calf and into the back of the knee.

Position yourself as shown in the picture to the left, try to push your knee straight and your heel to the floor. Then move your hips forwards keeping your heel on the floor and your knee straight.

Hold this position for 20 seconds and repeat 2-3 times. Frequently throughout the day!

This stretches the smaller of the two muscles, Soleus. When stretching this muscle you should feel the stretch at the bottom of the calf and potentially into the achilles tendon.

Position yourself as shown in the picture to the right, try to push your heel to the floor as you bend the knee. Then try to do a little squat keeping your heel on the floor. You should feel the stretch in the back leg (Right leg in the picture)

Hold this position for 20 seconds and repeat 2-3 times. Frequently throughout the day!

The third stretch is specifically for the plantar fascia. Stand in the position shown in the picture to the left.

Try to push the ball of your foot into the corner of where the wall meets the skirting board. You may feel a stretch in the sole of the foot at this point. If not, try to push your hip towards the wall, this will put more pressure through the foot and will increase the intensity of the stretch.

Hold for 20 seconds and repeat 2-3 times, frequently throughout the day.

More treatment options….

Provision of insoles to support the foot and specifically the instep can be a useful tool for chronic conditions.

Pain may also be relieved by the use of NSAID’s. (Non Steroidal Anti-Inflammatory Drugs)

This information should not be taken as a form of diagnosis and you should consult your Physiotherapist for a thorough assessment and  confirmed diagnosis.

I hope you have found this blog useful, any comments or feedback is always appreciated.

Struggling to find a comfortable sitting position? Suffering from neck, mid or lower back pain after sitting for long periods? You are not alone….

We all know about the slumped position which we ALL adopt from time to time. However simply saying “sit up” is not specific enough to promote correct positioning. It is important to note that we do not expect or recommend anyone to stay in the same position for long periods as this will lead to problems of its own. What we do recommend is that whilst you are in a sitting position that you try to maintain a neutral position for the shoulders, spine and pelvis.

There are a few potential scenarios which we see regularly in clinic, the two main positions are the slumped (C shaped position) and the “sitting up too tall” presentation (See pictures below). The slumped position is adopted if we are being a bit lazy and resting back on the chair. Unfortunately if we continue to adopt this position, over time the back muscles become weak through lack of use. This can lead to difficulty with normal day to day activities and we generally have “a bad back”.

Equally if we sit up too much because we are conscious of our posture we will cause a similar presentation of symptoms to the slumped position. This is due to muscle over activity and the muscle fatigue due to constant use. We then start to feel the well known dull achy sensation which alleviates when we get up and move around for 5 or 10 minutes. Movement allows the muscles to relax a little and when the pain reduces we sit back down and “carry on”..

The main focus for both these scenarios is posture education and advice. Providing manual treatments such as massage, acupuncture and stretching will help to control the symptoms but will not resolve the underlying problem. If posture changes are not implemented it will only be a matter of time before the symptoms return….

The slumped sitting position causes the head to be forward of the body (Poking chin), shoulders which are held forwards and sometimes down, with a rounded mid and lower back (Thoracic and Lumbar spine).

The “Too tall” position” causes the pelvis to be tilted forwards, increases the curve of the lower back and places excess stress on lid and upper back musculature. See pictures below…

Slumped posture                                                                                                       Too tall

It depends on you and your body as an individual as to how your back copes with this stress and where or when you start to feel discomfort. Potentially these positions will cause hip pain, lower, mid and upper spinal / back pain, shoulder and neck pain potentially leading to headaches.

The movements required to achieve a neutral sitting position or “good posture” are simple sounding but not so simple to perform. Over time I have developed some simple cues which I have found most effective and have described these simply below.

Sit on a dining chair to practice, now let yourself slump, then sit up as tall as you can. Now relax and try to “find” the middle of the two movements. You should feel the bony bits in your bum, this is what we call the seat bones (Ischial tuberosity). This aligns the pelvis.

The lumbar spine sits on top of the pelvis so if the pelvis is in a neutral position, the lumbar spine is in a neutral position.

Next is to think about the shoulders, push your shoulders as far forwards as you can, then brace the shoulders as far back as your can. Now let the shoulders relax a little and this should set you  into the correct position.

Finally, we do the funky chicken! poke you chin forwards then tuck your chin in as much as you can, relax a little. Here is a picture of good sitting posture…

You can have a friend or partner take a picture of you (Side on!) Try a before and after and see if you can match the movements and positions in the pictures….

This is our first health blog post and today we are looking at achilles problems. Hopefully you find the information useful, if you have any suggestions or requests for topics to discuss please leave a comment.

There are a few types of achilles problems, grades and severity but we are going to look at two to keep things simple, these are tendinitis and tendinopathy.

Tendinitis = short term problem, inflammatory – early stages, acutely painful and swollen

Tendinopathy = long term problem, chronic swelling and physical changes to the achilles tendon.

We are also going to look at some of the causes we see in clinic, the theory behind the injury and the treatment plan to resolve the issue in relation to the different scenarios.

The time of onset is important to know as this starts to give us an impression of the stage of the injury. Severity of pain, location, functional limitation and daily patterns indicate the severity of the problem and the impact on lifestyle. Generally the achilles area will be stiff and potentially painful first thing in the morning but once it “warms up” the pain reduces and function improves.

What causes it?

To know this we need to know the time of onset, was there a specific time of injury? For example, playing a game of tennis or squash and it suddenly became painful? Or has it gradually started and just got worse?

The types of causes we see in clinic include, when runners suddenly start hill training, change running style or speed. The calf muscle and achilles may not be strong enough to cope with the change in activity so the achilles takes the strain and becomes injured (or the calf muscle tears).

We also see patterns where a client may exercise regularly, hasn’t changed anything in the routine but the symptoms gradually come on, this can indicate a lack of stretching or lack of strength for the activity the person is trying to perform.

A more sedentary picture may be someone who works at a desk and gradually over time the calf muscles become shorter. Due to a general lack of activity the calf muscles will become tight and slowly place more strain on the tendon, even during minimal physical activity. Subsequently leading to irritation.

When feeling the calf muscle it will be firm to the touch, tight on movement and painful on palpation. To check for a full rupture, kneel on a chair and squeeze the calf muscle the foot should move, if it doesn’t this would indicate a rupture. Feeling through the calf muscle down to the achilles and squeezing the tendon will help to identify the source of the irritation. This often feels like a little lump on the side or back of the achilles and will often give a sharp type discomfort.

So what do we do about it?

STOP EXERCISING!

One of the main problems is an urge to get back to exercise. This is critical in the rehabilitation of the achilles tendon and the calf muscle. The tendon does not cope well with high levels of stress if it is already irritated or inflamed, you need to avoid pain. If you are doing something which is causing the achilles pain to start or get worse the inflammation will worsen and it will slow down the healing process.

The required exercise regime is fundamental to the treatment programme and should include stretching the soleus and gastrocnemius muscles (The two calf muscles). In addition and only if the exercise is pain free, we can include a heel raise exercise. This needs to be monitored closely as this exercise is aimed at rehabilitation of the tendon rather than the calf muscle, that comes later. The heel raise exercise can be started by simply standing on the floor and lifting your heels. Progressing to standing on a step, letting your heels drop so you feel a calf stretch then pushing up on to your toes. However this is the important one and the specific exercise needs to be set according to ability and onset of pain and be progressed as the symptoms improve. Technically the exercise is performed eccentrically, meaning the muscle is working but getting longer. Allowing the heels to drop slowly causes the load on the achilles to increase and aids normalisation of the fibres of the tendon.

Manual treatments including calf massage, acupuncture, passive stretching and specific tendon massage will all be beneficial in speeding up the recovery of the tendon. If you relieve the stress on the achilles by stretching and releasing tension in the calf, the achilles can recover and the body will heal.

Once pain and stiffness has resolved it is important to look back at the cause of the injury. This is the bit most people miss out and generally leads to re-injury! If the runner went up the hill too fast and was not used to it, we would need to look into specific strengthening of the calf muscle. For the individual who doesn’t stretch we would recommend a programme of stretching exercises for the whole leg to be done after physical activity. For the person sat at the desk we would recommend gluteal, hamstring and calf stretching as these are all vulnerable for this individual.

Please feel free to comment, question and discuss but remember the information provided is for information only and is not to be substituted for medical advice.