Obviously, a blog post should NEVER replace the advice of your physician or treating therapist. A blog is merely an opinion and meant to be read with an inquiring mind!
Meet Charlene, Jennifer and Greg.
They are my fictional patients. They are a composite of many many patients I’ve seen over the years.
Charlene is in her early 50’s. She has recently noticed that reaching overhead is feeling a bit stiff and tight. When attending physiotherapy for the initial assessment, she could not identify an incident that lead to her loss of flexibility. It just seemed like one day, the range of motion was suddenly not there! In my early days as a therapist, I would have focused on her shoulder…but after a few years of experience, it became apparent that working on improving the mobility of the thoracic spine (aka ribcage) when it was limited would yield MAJOR results! Often, shoulder elevation (the motion of reaching overhead) would increase by 10-15 degrees WITHOUT touching the shoulder. Try this yourself- sit very tall and lift your arm overhead. Now sit very slouched and try to lift your arm overhead- less motion right, feels bunched at the top or front of the shoulder right? Sitting “tall” represents a smoother surface for the scapula to glide down and therefore easier movement.
This illustrates a principle of synergistic movement- moving your shoulder overhead ALSO requires movement of the upper back- if that is not available, the shoulder can get blocked resulting in impingement or “pinching” of tissues. With repeated pinching, tissues start to whine or get inflamed. The word “inflamed”, with flames, indicates heat has been created- not a good thing in our tissues. Inflammation is characterized by heat, pain and swelling. Swelling takes up space- ie. limits range of motion. So the shoulder doesn’t move, but the CAUSE is a lack of motion in the thoracic spine. Message? When you see your physiotherapist and your shoulder pain has an insidious onset (meaning no trauma/crash/fall), ask them to check your thoracic mobility.
Jennifer has just started going to “bootcamp” classes, which involves her doing lots of new moves to strengthen her body. One of the moves she has noticed has been causing some front of the knee pain is the lunge. Jennifer also has no history of injuries. She has never sprained her knee or noticed any swelling. As her physiotherapist, I checked her hip strength and flexibility, because I’ve noticed over time that these factors come into play with non-traumatic anterior (front) knee pain. On testing, Jennifer’s hip external (outward) rotation flexibility is reduced to 50% of normal and her strength is noticeably weaker on her painful side (3/5). During our first session, I gave her hip strengthening exercises for homework. On our second session, the pain was still present on lunging so her problem was NOT resolved. We did some hip mobilizations to improved her hip external rotation and then she was able to lunge without pain at the end of our session. I advised her to continue her hip external rotation strengthening because she still had a score of 4/5 (at our first session she had a 3/5). We didn’t treat her knee, even though at school we were taught to treat the inner quad muscle (vastus medialis) to affect the kneecap’s tracking. I’ve noted over the years (since this is a very common problem to treat, for a manual therapist) that treating only the knee rarely solves the problem. The fact the her lunge was immediately painfree was the cue for me that her problem was a result of too much femoral internal rotation and an inability to control this motion- when she had more available external rotation, she could chain the position of her knee and avoid the pain. I’ve subsequently read other physiotherapy blogs that refer to problems with femoral internal rotation, that when remedied, lead to resolution of the anterior knee pain. Seems that femoral internal rotation can “look like” poor kneecap tracking, so the kneecap is fine but the “track” is the problem. On our third visit, Jennifer had a 80% reduction in her pain with lunging. The remaining pain was coming from a lack of ankle bend (or dorsi-flexion)! A lack of bend at the ankle forces the knee forward of the line of gravity during a squat or lunge, which can cause pain in a sensitized knee cartilage.
Several years before, Greg had sprained his ankle very badly. At the time, he couldn’t afford much therapy so he rehabilitated his ankle on his own. He was pain free within a few months of the injury. Recently, he has been hiking up the Chief (or more specifically, he has been trying to RUN up the Chief). He has noticed that on the side of his ankle sprain, he has a swollen Achilles tendon. He is now limping around town and can’t do to the hike up the Chief anymore because he is afraid he won’t complete. During his first visit to physiotherapy, we worked on mobilizing his ankle to improve it’s flexibility and loosened up his calf muscle. This helped for a few days but the pain returned immediately with his next hike. On our second session, I noticed that Greg’s pelvic bone (called the innominate) was sitting in a forward rotation due to a tight hip flexor and tight back muscles, mostly. Try this activity. Stand up and notice where your weight falls on your feet. Is it over the heels, the ball of your foot or right in the middle (the correct answer is over the middle of the foot). Now, arch your back slightly- where does your weight fall now….it should go to the ball of the foot- this causes the group of muscles on the back of the leg (gastrocs, soleus etc) that attach into the Achille tendon to work much much harder. If the innominate bone (pelvis/hip bone) LIVES in a forward rotation, the Achilles tendon is always being stressed. While Greg’s ankle tightness from the old ankle sprain, continuously “living” in a hip position that puts more strain on the Achilles tendon is likely contributing to the ongoing nature of his pain when he “loads” up the tissues, such as in hiking. I suggest to folks like Greg that they discuss with their therapist why the pelvis is sitting in this position, rather than doing one more session of ICE or ultrasound on the Achilles tendon because you may only be “treating” the symptom, not the cause.
Do you see yourself in any of this situations? Why not talk to a physiotherapist, your movement specialist.
This post was written by Sue Shalanski. Her patients are very familiar with her approach of solving the “biomechanical issues” causing the pain, rather than just treating the local tissues that hurt.
“Id like to thank my patients- who have been patient in seeing this approach through- I feel I owe it to you to explain my reasoning. I have your best function at heart!”