Knee pain: The ins and outs of patellofemoral pain
Do you get knee pain? Well this month we are looking at the knee joint and specifically talking about patellofemoral pain. So what does the word patellofemoral actually mean? You can break it down into ‘patello’, which refers to the knee cap, and ‘femoral’ which refers to the long bone (the femur) that runs down your thigh from your hip to your knee (remember, the thigh bone connects to the leg bone, the leg bone connects to the ankle bone, and so on!). The connection between your kneecap and thigh bone is called the patellofemoral joint and we’re going to look at some of the problems associated with this part of the body.
The phrase ‘patellofemoral pain’ is an umbrella term for many causes of pain at the front of the knee. The knee is a complex joint made up of lots of different parts, ranging from the bones that form it, the ligaments that hold the bones together and the various soft tissue parts that form and cross the joint, such as joint capsules, muscles, tendons and fat tissue. All of these (and more) can be involved in pain at the front of the knee.
The knee can bend and straighten, as well as twist and shear forwards and backwards a little. When our knee is straight, the kneecap, which is held over the knee within the tendon of the quad (thigh) muscles, sits over the end of the thigh bone. As we bend our knee, the surface of the knee cap and end of the thigh bone come closer together and slide over each other in a lovely smooth way, allowing us to perform movements like squatting, jumping, walking and running (basically anything that bends the knee) more efficiently.
What are the causes?
The main causes of patellofemoral pain include overuse of the various parts that make up the knee, or problems that affect the smooth gliding or ‘tracking’ of the kneecap over the end of the thigh bone while moving.
With an overuse issue, think of a person who spends their days walking up and down stairs, or having to squat down constantly. The constant bending and straightening of the knee can lead to overloading of the joint and surrounding tissues, leading to irritation and pain. Another example is that of a runner who may start to get knee pain having recently increased the distance or the amount of days in the week they run.
As we mentioned earlier, the kneecap is held within the quad tendon as it crosses the knee. The quads attach higher up at the pelvis and hips, and down below on the shin bone. So it makes sense that any issue that affects the back, pelvis, hips, ankle and feet can all lead to poor or incorrect tracking of the kneecap over the joint. Common issues here include muscle weakness of the glutes (buttock), quads and lower leg muscles, a twisted thigh or leg bone, and weakness in the ankles and feet, such as having a collapsed arch of the foot. Some people also have a misshapen kneecap, or one that doesn’t sit perfectly over the joint as it should, which can affect the line of tracking over the joint. Throw in having to consider a person’s size and weight, how they walk and run, and the types of footwear they use, and you can see there is a lot to consider.
Unfortunately ladies, this is one of those conditions that affects us more than our male counterparts. Researchers believe this may be because we tend to have wider hips than a man (yep, thanks for that). A woman’s wider pelvis increases the angle where the bones in the knee joint meet. Therefore, leaving more room for imbalance, misalignment or issues moving. Interestingly, research exists that looks into the link between the menstrual cycle and knee pain in women. Whilst the evidence is not 100% conclusive, it is believed that during the different phases of the menstrual cycle, sex hormones can affect the activation of the thigh muscles (quads) and how the body’s nervous system functions during lower limb movement, leaving a woman at potentially higher risk of injury in the knee region. Watch this space… When research catches up, we’ll fill you in on the finer details! What doesn’t break us, makes us stronger eh!
So, what can we do to help? Well prevention is key at first:
- Make sure you’re strong
- Think about correct knee alignment when walking, running, stair climbing and so on.
- People within a healthy weight limit also tend to experience less pain.
- When starting an activity, increase intensity gradually.
- Always warm up properly.
- Keep up those stretches!
But if you do have knee pain, it’s best to source help to find out what is going on. Because there can be a variety of reasons for knee pain, there is, of course, a variety of treatments. Here at Physio for Women, we assess all knee pain in a consultation. We figure out what is causing the issue, and help you fix the underlying cause. This could be treatment via massage or other manual therapy techniques, strengthening or stretching exercises, postural alignment work and more.
So, there’s no knee-d to be experiencing knee pain! Come and see us and we’ll get you hopping, skipping and jumping back to normal in no time.
Ab separation in pregnancy: Diastasis what now?
Are you pregnant, or have recently been pregnant? Are you now internet trawling trying to find out what this abdominal separation thing is everyone keeps telling you about? You’re overwhelmed and busy enough either preparing for, or experiencing, newborn life to worry about ‘how many centimetres is yours?’ And rightly so. But it is important to look after yourself, so you can get your strength back, and avoid issues down the track like bulging belly and back pain. So, here’s a quick run down of what ab separation is and how you can treat it.
What is an abdominal separation?
An abdominal separation, or in medical terms, a ‘Diastasis Recti’ (yes, we prefer the non-medical term too), is a separation of the abdominal muscles. This regularly occurs in women during trimester three of pregnancy and can also affect them post-pregnancy.
Picture your ‘six-pack’ or ‘Rectus Abdominus’ muscles. There they are in all their glory (maybe just in your head, and that’s OK) – pairs of muscles nicely lined up, down the front of your belly region. These strips of muscles are separated by a piece of tough connective tissue called the ‘Linea Alba’. So your body can expand during pregnancy, the Linea Alba widens. This creates a gap between the two strips of rectus muscles. This gap can be felt by lying your own hand flat on the abdomen. If a person can fit two or more finger widths in this gap, that person is said to have an abdominal separation. Please note this is a very rough guide. We always advise to get an experienced health professional’s opinion when testing this.
It’s also not just pregnant women who get this problem… Post-menopausal women, newborn babies and men can also develop abdominal separation.
What causes it?
Contrary to popular views, being pregnant is not the cause of this issue (remember, men & babies can get it too), although it is a contributor. It is caused by excessive increases in intra-abdominal pressure. Yes, having a growing uterus inside you can lead to increases in abdominal pressure, but so can pushing during delivery, straining on the toilet, and obesity. A newborn may develop this issue due to under-developed abdominal muscles, but this will usually resolve itself with time.
What does it mean if I have ab separation?
There is debate over what the side effects of having an ab separation are. Most commonly you may notice a bulge appear in your belly when you try to sit forward, stand up or lie down. Often described as a ‘pouch’. After pregnancy, you may be left with a bulge in the belly region that may give the impression you are still pregnant. Evidence for anything else is limited, but you may experience abdominal pain, postural issues, bloating or constipation. Not so fun! Many people believe having an abdominal separation increases the risk of pelvic or low back pain, but while we see this in our clinic, there isn’t any hard evidence supporting this claim. Having a separation could also impact your core stability, which could lead to other problems like breathing issues or low back pain.
Can it be treated?
The short answer is yes, but it may not have to be. Some minor abdominal separations require very little intervention. A more severe separation may well require the help of a trained physio (ahem, why hello there!) and giving of rehab exercises. It’s not just a simple case of doing a load of sit-ups or crunches to get those abs back. Sorry! Did you know sit-ups and crunches will increase your intra-abdominal pressure? So, these exercises are not a good idea at this stage as they could make things worse… But that’s not to say you won’t get back to them!
Rehab requires working on your pelvic floor and deeper abdominal muscles. We will also address any breathing problems you may have with breathing exercises, as getting your diaphragm muscle and ribs to function correctly is also very important.
It is not always straight forward and not every exercise will be suitable for every person with an ab separation, so we recommend you book an appointment to see us first. We will be able to assess you accurately and get you on the ideal program for you, as well as advise you on all the do’s and do not’s about movement, lifting and general exercise.
Iliotibial Band Syndrome
Runner’s outer knee pain is a common injury. The term used to describe the lateral knee pain is often iliotibial band syndrome (ITBS). Some twelve percent of the running community will experience knee pain felt above the outside of the knee joint. A physiotherapist will need to do an examination of muscles, ligaments and the knee joint. This newsletter will focus on the ITBS.
Where is the Iliotibial Band (ITB)?
The ITB is a thick band of connective tissue that arises at the top of the hip, from the tensor fascia lata and gluteus maximus muscles. It runs down the outer thigh from the pelvis to the shin bone of the lower leg (tibia). The ITB provides lateral stability to the hip and knee joints.
What is Iliotibial Band Syndrome (ITBS)?
The prime cause of ITBS remains debatable. The most accepted theory is when the knee flexes or bends, a tight ITB creates an irritating friction force at the outer femoral condyle, which leads to irritation and pain at the lateral knee. However, current thinking proposes that a layer of fat, with a rich nerve and vascular supply, is compressed between the ITB and outer femoral condyle, causing inflammation and pain. We await further research to confirm this theory.
What causes ITBS?
The classification of ITBS being an overuse injury means training error is often the primary cause of the inflammation and pain. How much you train, how hard you train and how often you train will determine the loading capacity of tissues. When the load on tissues is too great an acute inflammatory response at the outer knee can occur.
Gluteal muscle weakness and poor movement control in the running activity can contribute to further tissue strain. Also if the knee rolls in (valgus) whilst running, greater compression and loading of the ITB at the knee joint will occur. Poor stability at the hip and/or ankle may add to movement control issues around the knee when running.
ITBS Treatment Options with Physiotherapy.
The first option is settling the acute inflammatory response with rest and ice packs. It is important to stop the aggravating activity, such as running, brisk walking or cycling, to allow the healing response to occur. Ice packs to the painful area on the outer knee and thigh can be helpful.
Manual therapy including soft tissue massage, trigger point release, ultrasound, and dry needling may be required to reduce muscle tension in the ITB or quieten areas of pain and inflammation.
When the symptoms have settled, exercising the weak muscle systems efficiently is important. This means your physio will choose exercises for you with progressive, graded loading. These exercises will help to reduce the strain on compromised tissues along the ITB and at the lateral knee when you return to running. The exercises will focus on strengthening core muscles, gluteus maximus, hip abductors (gluteus medius, gluteus minimus and tensor fascia lata) and hip rotators.
Finally, treatment will need to correct movement control in the aggravating activity of running. This can involve movement at the knee, ankle, foot, hip, pelvis and lumbar spine. The physio’s assessment will determine what areas of your body need to be addressed.
Stretching is now not believed to be a reliable, initial treatment approach, as the ITB’s tensile strength is like steel. However, stretching and mobilising the ITBS with a roller may be helpful in self- maintenance, once muscle strength and movement patterns are rehabilitated. A gradual return to running is then advised.
So when pain in the outer knee is debilitating and making it difficult for you to be active, there is hope. ITBS can often be a cause of this lateral knee pain, which must be carefully assessed and then treated according to examination findings. It is good news to realise that this presentation can be effectively treated with a variety of physiotherapy treatment options.
Chronic pain: What you need to know
At the end of this month, we celebrate National Pain Week. So, this month we’re going to look at chronic pain – something that 3.24 million Australians live with day in, day out. When you are living with chronic pain, life can be difficult. Getting out of bed in the morning, going to work, parenting… Pretty much everything can become very hard work. Being in pain for a prolonged period can be debilitating and can have huge impact on a person’s life.
In 2018, the total running healthcare costs relating to chronic pain across Australia topped $139 billion! And unfortunately, it is predicted that by 2050, more than 5 million Australians will be living with chronic pain. And, as research tells us, women experience chronic pain more than men. Women are generally more sensitive to pain and report more widespread and higher intensity of pain than that of their male counterparts. It is interesting though that women tend to accept their pain and get on with things, whereas men tend to become more depressed when in pain. So, man flu is a real thing!
As physiotherapists, treating chronic pain is part of our daily working life. Understanding chronic pain is complicated and requires some in-depth training. So, to make things a little easier to understand, we’ve put together this blog to help break it all down and give you a little introduction to what chronic pain is all about.
So, what is pain?
This seems like a good place to start. Pain is something us humans and other animals on the planet are fortunate enough to experience. Fortunate? Bear with us. Pain is so crucial because it is our body’s protection mechanism. Interestingly, sometimes we can even feel pain before we get to the injury stage – it can act as a red flashing warning light! Once injured, pain will hang around for a little while to remind us that we need to protect the injured area from further damage – so that we can heal. It’s probably the most state-of-the-art alarm system you’ve ever come across, and the answer is sitting inside your skull. Yes, you guessed it, you have your brain to thank for all of this :).
So, I hear you ask, ‘why are we so fortunate to feel pain?’ Well, there are a small minority of people on this earth who cannot and have never felt any pain at all. These people may have one of a group of very rare conditions called Congenital Insensitivity to Pain (CIP). Some people might think this is pretty cool, but this is a very serious condition, and many who are born with it have a shortened lifespan because potentially fatal injuries and illnesses can go completely unnoticed. People with CIP wouldn’t know they had just stood on that rusty nail, or that they have just sliced open their arm or leg. Pain is literally a lifesaver.
For ease of understanding, pain tends to be categorised based on time. ‘Acute’ pain is pain that is felt any time from injury up to the six-week mark. ‘Sub-acute’ pain (a sub-category of acute pain) is pain felt anywhere between six weeks and three months. ‘Chronic’ pain is pain that is felt for three months or longer. Let’s have a quick run down …
We feel acute pain when we fall and graze our skin, twist on the netball court and sprain our knee ligaments, or when we slice our finger with a knife when cooking. When this happens, special sensors around the injury site detect that all is not right and send a message along the nerves to the spinal cord and up into the brain. Your brain processes this information at lightening quick speed and then sends a message back to the injury site as a pain signal and you wince or yell out (and possibly curse). As time progresses over the following days and weeks, the injury heals, and the pain disappears. Along the way, your brain forms a memory of the unfortunate event. This makes you more aware and helps you to avoid similar dangerous situations in the future. State of the art indeed!
Remember the definition for chronic pain – pain that is felt for three months or longer. This pain is also sometimes called ‘persistent’ pain, because it is just that – persistent! In many instances of chronic pain, it is pain that is felt beyond the bodies normal tissue healing times. As an example, a mild to moderate knee ligament sprain takes approximately six weeks to heal. Sometimes people who have injured their knee still get pain months after the injury has healed. They have entered the realms of chronic pain. Things become more complex because by this stage there may well be involvement of different bodily systems. And, most importantly, the person’s belief about what pain is has a huge impact on their recovery. There may also be unrelated issues, such as arthritis that is impacting on recovery or hasn’t been previously diagnosed.
The development of chronic pain is a complicated process. In a nutshell, the healing of tissues has already occurred (as discussed above), yet the brain still thinks there’s a threat. This is due to changes in the nerves carrying signals to the spinal cord, and changes in the spinal cord itself. Basically, these nerves become highly sensitised and end up sending misleading information to the brain. The brain perceives this information as still threatening, and the result is ongoing pain. Ultimately your nerves are ‘tricking’ your brain into thinking you’re injured. We would like to point out that it is much more complicated than that, but this gives you the basic idea of what is happening.
It is important to understand that when someone is in pain for long periods of time, they can start to become affected in other ways. Depression and anxiety resulting from chronic pain is very common. A person’s beliefs about pain will begin to affect their behaviour also. For example, a netball player with the knee ligament injury, once playing again, may avoid certain movements due to fear of re-injuring themselves. In psychological terms, this is known as exhibiting fear avoidance behaviours, and can keep the cycle of pain going for longer than necessary.
Treating chronic pain
The longer the cycle of chronic pain persists, the more difficult it becomes to treat. Unfortunately, treatment is not as simple as applying first aid principles. Of course, treating someone’s movement dysfunctions and getting their strength and flexibility levels right are very important, but treating the resultant depression and anxiety, and educating the person on what changes have occurred in their body so they can change their beliefs about what pain is, is just as important, if not more.
Until all contributing factors of a person’s chronic pain cycle are dealt with in some way, it is unlikely the cycle will be broken. Therefore, treating chronic pain rarely comes down to just one profession or practitioner. In most cases, it requires a multi-disciplinary approach to treatment. We as physiotherapists play a crucial role, but a person may also require the services of a psychologist, their GP and possibly other specialists too. Pain medications may be prescribed by your GP to help control pain levels, but the debate on how effective strong pain medications are in the instances of chronic pain is still out.
Your physio is an expert at re-training your body to move properly and get stronger and more flexible. We will use our hands to affect your muscles, joints and skin, as well as prescribe you exercises to get you on the path to optimum movement and health. These will include exercises relating to strength building, flexibility, posture and breathing. We may also give advice on how to improve your sleeping and diet, to make sure your body is getting the correct amounts of rest and nutrition it needs to function. Most importantly though, we will sit you down and educate you on what exactly is going on with your body so that you can begin to understand it yourself and start the process of beating chronic pain. It will be a big team effort, and the results will be totally worth it.
We hope you found this blog a worthwhile read. If you would like to know more about chronic pain or National Pain Week, please visit http://www.nationalpainweek.org.au.
Afraid to laugh out loud? Incontinence help is here!
Hello ladies, it’s blog time again! To celebrate World Continence Week (17th-23rd June), we thought what better topic than the pelvic floor and incontinence. For those of you who are not familiar with this condition, incontinence is the term used to describe uncontrolled loss of urine from the bladder or faeces from the bowel. It’s a tricky problem to get people to speak out about because as you can imagine, for the majority it is quite an embarrassing thing to have to admit.
Let us assure you, if you are experiencing such a problem, you share this problem with over 5 million other Australians. In fact, 1 in 4 people over the age of 15 are incontinent, and females account for 80% of cases of urinary incontinence alone. Shockingly common right?! Well the good news is, help is at hand. The majority of cases of incontinence respond very well to conservative, non-surgical treatment and can often be completely resolved. Interested to know more? Then please read on…
Types of incontinence
It is important to know that there are different types of incontinence, and the management for each is different based on the cause. Briefly, the different types of urinary incontinence include:
- Stress urinary incontinence (SUI) – the most common form, where small amounts of urine leak due to small increases in pressure on the bladder during physical activity, or from coughing, sneezing and laughing.
- Urge incontinence – where you get an unexpected, strong urge to urinate with little to no warning. This is usually as a result of an overactive bladder muscle.
- Incontinence associated with chronic retention – where your bladder cannot empty fully, and you get regular leakage of small amounts of urine. There are many causes for this, including an enlarged prostate in men, or prolapsed pelvic organs in women, as well as medications and certain conditions, such as diabetes and kidney disease.
- Functional incontinence – where you are unable to get to the toilet, possibly due to immobility, or wearing clothes that are not easy to get off in time.
Faecal incontinence is when you have a lack of control of bowel movements and you may accidentally pass a bowel movement, or even pass wind without meaning to. This may be due to weak muscles surrounding the back passage (ladies, unfortunately this can be following pregnancy and childbirth), or if you have severe diarrhoea.
Why so many females?
In short, babies and menopause! The most common type of incontinence that we see and treat is stress incontinence. Although seen across both sexes, women are three times more likely to experience it than men. It is very common in women following pregnancy and childbirth (when the pelvic floor muscles get overstretched, and sometimes even damaged), and during menopause (due to hormonal changes).
Pregnancy, birth and menopause can affect our pelvic floor. The pelvic floor muscles sit at the bottom of the pelvic bowl, spanning from the pubic bone to the tailbone (front to back), and from one sitting bone to the other (side to side). Imagine a trampoline stretched out and attached to each bony point and you kind of get the gist. When these muscles are strong, they help to support our internal pelvic organs (i.e. the bladder and bowel, and uterus in women) and wrap around the openings of the front and back passages, allowing us to control when we decide to do a number one or two. Following pregnancy for example, they may become weak and dysfunctional, and we can lose that ability to control voiding. It only takes something as small as a cough, or an activity like jumping or running (things many of us take for granted) that may cause a person to lose a small amount of urine.
There are a number of treatment options that could help. What is most important is that you come and see us first, so we can understand the issue and figure out the best course of treatment. Some treatment options include:
- Pelvic floor and strengthening exercises
- Manual therapy
- Biofeedback (to monitor your muscle activation)
- Weight loss
- Reducing caffeine or alcohol
- Fluid altering
- Bladder training
- Quit smoking
- Surgery or other procedures
We hope you have found this blog interesting and helpful. Please join us in celebrating World Continence Week and help us to raise awareness for people living with incontinence. If you, or someone you know is looking for answers or advice on the management of these conditions, then please get in touch. We are ready to offer professional advice and/or treatment. No more leaking when laughing!
Healthy hips are here to stay
April is here, and with that comes Healthy Hips week (1-7 April), so we thought we’d write a blog about some of the common hip issues we regularly see in clinic, so you can ensure your hips stay healthy, and keep your body moving for longer.
The hip is a pretty complex joint, with numerous muscles, tendons, ligaments and other tissues attaching in and around it to provide support and movement. Because there are so many structures, it means there are lots of possibilities for things to go wrong. And therefore, lots of potential sources of pain when something does go wrong. Fortunately for us clinicians, the common things are common, and the rare things are, well, rare! This helps us to work out quickly what’s going on, so we can put you on the road to recovery.
Do I need a scan?
One common issue we are faced with in clinic, is that our patients will often come to us having seen their GP, following a scan on their hip, and have been told that they have ‘bursitis’ or ‘arthritis’, and this is what is causing their pain. This can be a little problematic for everyone sometimes, for a few reasons. Firstly, many people that have reports that suggest bursitis, or hip osteoarthritis, do not even have pain from that condition – sometimes these findings are simply incidental and have no bearing on our patient’s issues… Secondly, it plants a seed. What we mean by this is that people tend to trust what they see. So, if they see suggestions of bursitis, or arthritis, they suddenly start to believe that this is what must be the cause of their pain, rather than something else (like muscular weakness). Getting the patient to understand that their scan’s diagnosis may not be the cause of their pain (if it is indeed not the cause of their pain) is part of our job as educators of the body, and this can sometimes be difficult!
Common causes of hip pain
In our experience, the most common cause for hip issues in our clinic is muscular imbalance and gluteal weakness. Muscle imbalances are very common throughout the body, throughout the population. We all live different lives, playing different sports, having different hobbies and working different jobs. Look at an example of a desk worker who sits for their job, plays tennis left-handed, and is a keen candy-crush game addict. It’s easy to see over time how their body might develop muscular imbalance from favouring certain positions and sides of the body over long periods of time. Our bodies are rarely 100% symmetrical and can adapt extremely well, but there is always a point where it can no longer keep adapting. This is generally when you start to feel pain. Your body is telling you to do something about it. And this is where we come in!
Weak gluteal muscles are a really common problem for the general population. Why you ask? It’s because a large amount of people now sit more than move. People are more sedentary than ever. Technology is advancing and feeding our need for constant entertainment. And you can actually see it… The world is growing more obese and Type 2 Diabetes rates are continuing to grow. All this being sedentary malarkey is not good for our poor gluteal muscles. When we sit, they don’t get used, and when they don’t get used, they get weak! And they have a pretty important role to play, being responsible for several hip movements, helping to keep the pelvis stable when we walk, and allowing you to advance forward when walking, running and jumping. You see, they want to move you! Weakness in these muscles then leads to bio-mechanical changes around the hips (which spills over into the lower back, knees and ankles), and those fundamental movements suddenly become difficult to perform without major compensation and adaptation occurring. And we know what adaptation over long periods can lead to don’t we? That’s right – pain. Good… You’ve been listening!
Some of the effects of weak glutes include hip, knee, low back or heel pain, poor/slouching posture, and a change in the way you walk (your ‘gait’). If you’re a runner, you may even notice an increase in the number of blisters you are getting, due to the change in your running style (of course, you may also need new runners, so worth getting these checked too!).
What should you do?
If you are experiencing hip pain, please come in and see us… We’ll assess you to see where your imbalances are, and what is causing the pain. Whether it’s down to muscular imbalance, weak glutes, or any other cause, we’ll teach you how to put it right and get those glutes firing properly in no time.