Lower back pain and lumbar disc bulge
Hello readers! This month we are going to talk to you about a common low back complaint. Let us paint you a picture. You’re a busy mum that tackles the same daily challenges of getting the kids through their morning routine, school drop off, housework and a day job. It’s hard work, not to mention having this niggly, nagging low back pain to deal with at the same time. Sound familiar?
It’s a scenario we are all too familiar with here at Physiotherapy for Women. We see so many busy mums who are struggling with low back pain, but are just so caught up in the daily grind that they don’t find the time to come get checked out. Usually the pain carries on for some time, then one day they’ll bend down to tie up a shoelace and bang… Crippling pain! It’s often at this stage that people come to the clinic barely able to move and in a very distressed state.
So what has happened?
The scenario of long-standing low back pain followed by a single episode of acute pain (often following a seemingly trivial movement) is common with a lumbar disc bulge. Let us explain what it is, how it happens, and what we can do to help get you back to being super mum again.
The spine is broadly made up of bones called vertebrae and discs that sit between them. The discs are responsible for allowing movement, whilst being strong enough to hold the vertebrae together. They also act as shock absorbers for the varying forces that our body must withstand on a daily basis when we move. Each disc has an outer and inner section. The outer section is a tough and fibrous material (aka the ‘Anulous Fibrosus’ or AF), whilst the inner section is more gel-like (aka the ‘Nucleus Pulposus’ or NP).
A lumbar disc bulge occurs when the NP pushes through the AF and the disc material moves into a space in the spine that it would not normally reside in. This causes inflammation and depending on the severity of the bulge, can press on nerves that run down to the legs. It’s important to point out that discs don’t just spontaneously bulge for no reason. The NP will slowly push through the AF over a long period of time (hence the long standing niggly pain), usually because we have spent this time doing lots of bending and lifting (who doesn’t with kids, right?!), which places high amounts of stress on the discs. Then there is the ‘straw that broke the camel’s back’ moment when things turn worse suddenly (in the example above, it was the tying of shoelaces).
Signs and symptoms
The signs and symptoms of a disc bulge will depend greatly on the level of the spine that is affected. Most commonly, it affects the lowest two discs in the spine. The nerves that exit the spine at each level have a specific role and will run down to serve different parts of the legs. Broadly speaking, you may experience any or all of the following:
- Low back pain (especially when bending and sitting)
- Pain that travels down one or both legs
- Pins and needles, tingling or numbness down the legs
- Weakness with certain leg movements
A severe disc bulge can lead to more serious signs and symptoms which include problems with your bowel, bladder and sexual function. These are rare but can occur.
Recovery from a disc bulge usually takes 3-6 months, depending on the severity. That doesn’t mean you’ll be in pain for that long. Generally speaking, the acute pain from a disc bulge will start to settle within a few days to a week. Inflammation is a process the body goes through when injury occurs and it is vital for our recovery. So the early stages will definitely be the worst, but the good news is things will start to feel better quite quickly with some treatment and by following some simple rules. Coming to see us early on is important because we can educate you from the word go. It is normal in the early stages of an injury like this for people to want to stop everything, including moving, through fear of injuring themselves further. However, it is very important to keep moving! The worst thing you can do is to lie down on a lounge and do nothing all day. They say motion is lotion, and that’s true when it comes to disc bulges. Doing things like heavy lifting and bending is off the cards to begin with, but walking and mobilising the spine regularly is allowed and encouraged.
The injury will have left you with restricted joints and muscle tightness. We will use massage and joint mobilisation techniques to free you up and get you moving again. We will also give you some exercises to start following which we will progress slowly. These will aim to restore full movement to your spine and limbs, muscle tension to normal levels, and strength to the trunk and limb muscles that have been affected.
Many mums we see with this issue have poor core stability, most likely stemming from pregnancy and poor movement and breathing over the years. Being unable to stabilise through the trunk and pelvis during movement will have been the main reason the disc has bulged in the first place. So, it is natural for there to be some core strengthening needed for full recovery and to reduce risk of re-injury in the future. Over time we will start to re-introduce full movement, including bending and lifting. But this time round you’ll be moving well and safely.
If you have low back pain, we recommend you come to see us at the earliest possible convenience. Don’t wait for the big bang as recovery will be longer. Give us a call today on 08 8443 3355.
Wrist and thumb pain after pregnancy?
It has been a long journey and you’ve been through a lot over the last 10 months. You’re already exhausted and you’ve only just started your life with a new addition to the family. Life doesn’t get much busier than this, right?! How frustrating then that you’re having to battle through this new period with a sore wrist and thumb. If it’s any consolation, you’re not alone. One study from 2017 reported over 50% of women experienced wrist pain following delivery of their baby, and over 80% of those still had pain two months on. Read on to find out why.
The most common cause of wrist and thumb pain after pregnancy is a condition called De Quervain’s Tenosynovitis. That’s a bit of a mouthful so let us explain simply. There are a few different tendons which run from muscles in the forearm along the thumb side of the wrist, which act to move the thumb away from the hand when the palm is held out flat. The tendons are covered in a thin ‘sheath’ of tissue which provides important lubrication to allow for smooth movement. On their journey from the forearm, the tendons and their sheaths have to pass through a little tunnel, made up of bone and soft tissue. In De Quervain’s, the tendons and/or sheaths become thickened and this leads to problems with movement through the tunnel.
It is thought that new mums are at higher risk of developing this condition due to the repetitive nature of lifting and holding their baby. These movements put the hand, thumb and wrist into a compromised position and increases strain through those tissues. It has also been suggested that increased fluid retention and hormonal changes following pregnancy could also be involved in the development of this condition.
Another common cause of wrist and hand pain following pregnancy is Carpal Tunnel Syndrome. This condition involves the pinching of a nerve as it passes through the wrist. This is different from De Quervain’s in that a patient will experience pins and needles and/or numbness in the hand as well as wrist pain—a blog topic for another month!
Signs and symptoms
If you develop this condition you can expect the following:
- Pain and/or swelling around the base of the thumb, and thumb side of the wrist
- Pain increased by thumb and wrist movements
- Pain associated with gripping, lifting and twisting objects
- Popping/clicking with wrist movements (in severe cases)
If you are reading this and alarm bells are already ringing, then you may want to consider giving us a call to book an appointment. We can help you with this problem so read on to see what treatment we offer.
As this is a busy time of your life, our aim will be to get you out of pain and functioning as soon as possible. After all, you have a little one to prioritise now and it’s not like you can just stop parenting to allow your body to heal. Fortunately, you don’t have to. Our treatment for De Quervain’s may include any or all of the below options:
- Rest and splinting: In the initial stages, you may need to alter how much you do with your wrist and thumb. Getting some extra help around the house from friends and family may help to take the load off. Using feeding pillows to support the baby during meal times is another way to reduce your ‘holding’ time. Wearing a splint or brace can help to reduce aggravating movements in key areas of the wrist whilst still allowing you to move and perform your everyday We may fit you with one of these if we think it is necessary.
- Massage and joint mobilisation: To release tight muscles and restore range of motion to the hand, wrist and forearm joints.
- Taping: To support the wrist or aid with drainage of the wrist area back up the limb towards the heart.
- Stretching: To combat any tightness of the hand and forearm muscles. You’ll also need to do some of these at home.
- Graded strengthening exercises: Evidence is pointing more towards gradual loading exercises to rehabilitate the tendon and restore full movement and strength to the tissues.
Other treatment options include therapeutic ultrasound and corticosteroid injections for pain relief. For severe or persistent cases that don’t respond to a more conservative approach, a surgical opinion may be required. We will always work hard to ensure you don’t reach that point because the recovery is always longer and it means a time period where your function will be much reduced, which is always difficult when you have a little one.
Our advice to you is to not let it get to that in the first place. No matter how trivial you think it is, if you start to feel pain in your wrist in the early days of motherhood, please get in touch with us here at Physiotherapy for Women. We can put all of the above in place straight away to avoid your pain getting out of control. That means more time for you and your baby. What could be more important at this time?
See you next month!
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.