Total Care Facebook Total Care Instagram Total Care Linkedin Total Care Youtube

Lumbar Fusion by Thomas Andrews (Physiotherapist)

lumbar fusion diagram
lumbar fusion diagram

What is it?

In people with severe back pain or nerve referral down the leg, a lumbar fusion may be recommended. A lumbar fusion is a surgery that permanently connects two or more vertebrae of your spine together.  This is done with metal plates, screws and rods in the vertebrae. This technique holds the two vertebrae still and stops any movement at this area of the spine. Often during this surgery, the surgeon may release or trim areas that are compressing nerve structures to relieve pain.

When is it indicated?

Lumbar fusions are usually indicated for those people who have persistent high levels of pain despite trialling conservative treatment. For example; Physiotherapy, medication and injection therapies. Usually this occurs in people who have the following conditions:

    • disc herniations (disc bulge)
    • spinal scoliosis (irregular curves in the spine)
    • sciatica or nerve irritation
    • severe arthritis of the back (stenosis)
log roll
log roll

What to expect in the hospital:

After the surgery, you will be in hospital for at least the next 4 days to allow time to recover. During this period, physiotherapists and nursing staff in the hospital will assist you getting out of bed, walking and completing daily tasks.  Your surgeon will likely recommend that you do not to bend or twist following surgery for a number of weeks.

Getting out of bed after lumbar fusion or with severe back pain can be difficult. It is recommended that you use the log roll manoeuvre as shown in the diagram.  This reduces movement at the spine, which may help reduce pain and protect the area.

What to expect once your home:

After discharge from hospital, the first six weeks post surgery includes basic exercise, walking, and other light activities. It is not recommended that you avoid heavy house-hold duties during this time. After surgical review at 6 weeks, your surgeon may recommend Physiotherapy. Due to the screws and plates and the pain in your back, you are likely be stiffer in that region, making simple tasks such as putting on shoes and socks difficult. Physiotherapy following a lumbar fusion is recommended to assist in activating muscles in the back, core and legs and to support the injury area.  Treatment may also include nerve stretching, Clinical Pilates and manual therapies.

How can we help you:

Physiotherapists can use hands-on techniques to help improve movement of your back, reduce pain and facilitate muscle activation. Physios can also develop a tailored exercise program dedicated to your needs, to assist you in getting back to activities that you want to do.

Below are some exercises that we often give patients immediately after lumbar fusion to help get you started.

Transversus abdominus muscle activation.

The transversus abdominus is a deep core muscle that helps support the both the abdomen and the spine. After lumbar fusion surgery, this muscle has some difficulty working and supporting the spine. This exercise is aiming to jump start this muscle again to get it working. This may help to decrease pain after lumbar fusion and help to ensure the spine is supported.

To complete this exercise, you slowly draw your lower abdomen in, hold it for 3-5 seconds and then release.

Hip abduction

This exercise aims to build up the strength in the hip muscles to create a stable and strong foundation for the back.

To complete this, bring one leg to the side whilst standing upright. Hold this position for up to 3 seconds and then bring it back in.

Chair squats

This exercise is aimed at improving leg and hip strength. It also works on coordination of the lower back muscles.

To complete this, stand whilst holding onto a back of a sturdy chair or kitchen bench, keeping your back straight, bend your knees making sure they don’t go past your toes. Make sure you don’t squat down too low and return back. You can progress this exercise by removing the chair and completing a squat to the same height.

Book an appointment today for your assessment!

Ankle Sprains

What is a sprained ankle? – Blog By Kara Giannone

An ankle sprain occurs when your ankle ligaments are overstretched. They can vary greatly in severity from a minor “rolled ankle” to a complete ligament rupture with or without bone tendon or muscle injury. They are graded as 1, 2 or 3 depending on the severity.

 ankle-sprain-1

Anatomy of the ankle

The ankle, referred to as the talo-crural joint or true ankle joint, consists of three bones – the tibia, fibula and talus and is responsible for plantarflexion and dorsiflexion of the ankle. The subtalar joint lies underneath the true ankle joint and is the articulation between the talus and calcaneus. It assists the talo-crural joint in inversion and eversion. Most ankle sprains occur from an inversion mechanism of injury (rolled in).

anatomy

The most commonly injured ligaments of the ankle are the lateral ligaments which sit on the outside of the ankle. These include the anterior talofibular ligament, calcaneofibular ligament and posterior talofibular ligament. The ligament on the inside of the ankle is called the deltoid ligament which is much stronger and hence more difficult to injure.

anatomy3

High ankle sprains refer to injury to the inferior tibiofibular ligaments and syndesmosis which bind the tibia (shin bone) and fibula (calf bone) together above the ankle. A high ankle sprain is a much more debilitating injury, requiring a longer recovery time.

What causes an ankle sprain?

Ankle sprains occur most commonly by a sudden twisting or rolling action of your ankle often on unstable irregular surfaces. The ligaments affected is determined by the direction the foot rolls. The most common ankle sprain is the ligament on the side which occurs when the foot is turned in as shown below.

Certain factors can put a person at greater risk of spraining their ankle including poor footwear, previous injury, reduced strength, poor biomechanics or poor balance receptors.
rolled-ankle

What are the symptoms of a sprained ankle?

  • The mechanism of rolling your ankle is a clear indicator that you are likely to have sprained your ankle
  • You may hear a popping or cracking sound at the time of injury
  • The injured ligaments will be quite tender to touch in that initial phase
  • Swelling and bruising
  • Generalised ankle pain
  • In the cases of a severe ankle sprain, you may have difficulty walking and may require the use of crutches to mobilise.

How is a sprained ankle diagnosed?

Physiotherapists will take a thorough history and conduct a comprehensive clinical examination to effectively assess and diagnose ankle sprains. Furthermore, to exclude certain fractures or ligamentous injuries, it may be required to refer for imaging like a X-RAY, MRI or CT scan.

 

Management of an ankle sprain

A person who sprains their ankle is up to 70% more likely to re-sprain their ankle without the correct post-injury rehabilitation.

In the initial 72 hours post injury, it is essential to use the principles of R.I.C.E – This include rest, ice the affected area every 2 hours for 20 minutes, compress the ankle with a compression bandage and elevate in order to manage pain and swelling.

Physiotherapy is crucial in the management of ankle sprains. It is important in managing pain and improving range of movement, strength, proprioception, balance and assist in return to your pre-morbid level of activity.

Physiotherapy treatment may include:

  • Education
  • Gait re-training
  • Biomechanical correction
  • Exercise prescription including sport specific training
  • Taping
  • Soft tissue massage
  • Mobilisations
  • Sport specific training
  • Electrotherapy and more!

 

At Total Physiocare Heidelberg, Reservoir, Camberwell and Footscray, we specialise in accurate assessment, management and return to sport or level of activity for clients presenting with ankle sprains. 

Book an appointment today for your assessment!

Blog post by Kara Giannone

Anterior Cruciate Ligament (ACL)

 

ACL

What is an ACL?

The Anterior Cruciate Ligament, commonly known as the ACL, is an important ligament of the knee. Along with the posterior cruciate ligament (PCL) the ACL forms a cross (cruciate) between the shin bone (tibia) and to the thigh bone (femur). Together these ligaments provide stability of the knee joint, with the majority of ligamentous support of the knee coming from the ACL.

ACL3ACL2

 

The ACLs two main roles are:

(A) Prevent the forward translation of the tibia on the femur

(B) Assist with rotational stability of the knee

Prevalence:

The rate of ACL injury is highly common in the sporting population. It is often associated with sports that require cutting, pivoting and sudden deceleration such as Australian Rules Football, netball, basketball, soccer, gymnastics, hockey and downward skiing.

ACL4

Risk Factors:

There are multiple risk factors that may influence the incidence of an ACL injury, as listed below:

Non-modifiable risk factors:

  • Genetics: athletes with an ACL tear are twice as likely to have family history of ACL tears
  • Females: There is approximately a x6 times greater incidence of ACL tears in females. This is likely attributed due to anatomical variations, hormonal involvement and neuromuscular deficits.
  • Previous ankle or knee injury with residual joint laxity

Modifiable risk factors:

  • Muscle strength imbalance (low hamstrings to quadriceps strength ratio)
  • Poor neuromuscular control and coordination
  • Bio-mechanical factors such as poor hip and ankle control, reduced core strength, reduced ankle range of motion and a deficit in lower limb strength
  • Reduced sport specific fitness/conditioning
  • In-proper technique and body positioning for sport specific skills
  • Environmental conditions: playing surface and wet weather
  • Inadequate shoe wear
  • Increased Body Max Index (BMI)

Mechanism of injury:

Two thirds of ACLs injuries occur in a non-contact situation, which often involve the athlete landing in knee hyperextension, a side pivoting motion and/or decelerating suddenly. In footage of ACL ruptures, the knee is commonly seen to track inwards compared to the foot (valgus moment) and is accompanied by a knee inwards rotation motion.

During an ACL rupture, an athlete will often describe an audible “pop” or “crack” and a feeling of the knee giving way or instability. The majority of complete ACL tears are often followed by few minutes of severe pain and the sportsperson will be unable to continue their activity. Often the athlete will have a reduced range of knee motion, particularly extension, following the incident.

Judd

Assessment:

The best time to exam an ACL tear is within the first hour following the injury, as following the first 24-72 hours, hemarthrosis (bleeding into the joint space) and swelling occurs and may limit the examination findings.

It is important to present for medical assessment as soon as possible following an injury, even if significant swelling has occurred. Your physiotherapist will perform a comprehensive physical examination and perform special tests to diagnose your injury.
It is important to undergo a thorough physiotherapy assessment as other knee injuries such as damage to the meniscus and/or medial and lateral collateral ligaments of the knee may accompany an ACL tear.Often an investigation or imaging may be required to confirm an ACL tear and conversely rule out other injuries. You may be referred by your physiotherapist, doctor or surgeon for knee MRI scan. Occasionally an X-Ray may also be indicated if an avulsion fracture (small component of bone pulled away by ligament) is suspected during the mechanism of injury.

Management;

In the acute stage following an ACL tear it is advisable to follow the RICER principal for the first 48-72 hours. This involves Rest, Ice, Compression, Elevation, and a Referral for medical management. In addition to this it is advised you follow the No HARM protocol to further limit bleeding and swelling into the joint: No Heat, Alcohol, Running or Massage.

brace

A torn ACL can be managed in several ways including conservatively, with bracing, or via a surgical reconstruction. The benefits and associated risks of all methods can be discussed with your treating physiotherapist or healthcare professional in order to tailor a treatment plan specific to your presentation and future goals. In short; young, active individuals aiming to return to a pivoting sport or activity are often candidates for ACL reconstruction surgery.

During ACL reconstruction surgery, the torn ACL is replaced with a graft that aims to replicate the normal functions of the ligament. Several graft options may be explored in discussion with your surgeon, most commonly including:

(A) Bone-patella-tendon-bone (BPTB): where part of the middle third of the patella tendon (knee tendon) and a piece of the tibial bone (shin bone) are taken to make the graft

(B) Hamstring tendon graft: where the semitendinosis (hamstring) tendon is bundled and looped (+/- gracilis (groin) tendon) to form the graft

(C) Quadriceps tendon graft (less common)

(D) Taking the above tendons from the uninjured leg

(E)  Synthetic grafts such as the LARS ligament graft, however this is rarely utilised in modern practice.

ACL Reco

Rehabilitation:

Rehabilitation for a reconstructed or conservatively managed ACL tear should be under the direct supervision of a physiotherapist. This is integral as there is a 6-30% recurrence rate of ACL injury in the years following an ACL tear, and this risk can also affect the opposite knee.

The aims of physiotherapy are to:

(A) Restore knee joint range of motion

(B) Improve knee and lower limb strength

(C) Address poor biomechanics and improved jumping/landing strategies

(D) Skill retraining

(E) Facilitate return to sport or activity

(F) Prevent re-injury rate

At Total Physiocare we treat hundreds of knee injuries and work closely with multiple orthopaedic surgeons in order to accurately diagnose, manage and rehabilitate clients following an acute knee or ACL injury. Call us now to make an appointment!

treatment treatment4 treatment3 treatment2

Femoroacetabular Impingement

What is Femoroacetabular Impingement?

Femoracetabular Impingement (FAI) is a hip condition that occurs when the ball (femoral head) and socket (acetabulum) rub abnormally creating damage to the hip joint. The damage can occur to the articular cartilage (smooth white surface of the ball or socket) or the labral cartilage (soft tissue bumper of the socket) resulting in painful hip movements. Research suggests that there is an association with FAI and development of hip osteoarthritis.

Types of Femoracetabular Impingement

cam lesion

Cam Type

In Cam type FAI the usually spherical femoral head (ball) is abnormally shaped resulting in jamming of the femoral head against the rim of the socket (acetabulum).

This type of FAI is most commonly seen on young athletic men.

Pincer Type

In Pincer type FAI bone spurs formed on the end of the cartilage on the socket of the hip joint (acetabulum) cause painful pinching during activities where the hip is flexed. This occurs in the area of the thigh bone (femur) just below the ball, called the neck of the femur, may bump into the rim of the socket. This type of impingement is more commonly seen in middle aged women.

Mixed Type

In many cases there is a combination of both Cam and Pincer impingement and this is called mixed impingement.

What Causes Femoracetabular Impingement?

FAI occurs when the hip bones do not form normally during childhood. Over time the deformity of a cam bone spur, pincer bone spur, or both, leads to joint damage and pain.

Studies suggest that many people who have no symptoms of hip impingement show findings of FAI on X-Ray. This suggests that the hip needs to be aggravated in some way for symptoms to develop and this explains the tendency for athletes, sporting professionals and active people to be more susceptible to this form of injury.

Sports that may commonly aggravate FAI include: gymnastics, cycling, football, soccer and dancing.

Symptoms

  • Pain is typically felt deep in the groin (at the front of the hip) but may be felt to the side of the hip or in the buttock.
  • Restricted or painful range of hip motion
  • Onset is often insidious, and may be associated with increased activity.
  • Onset can be acute or following injury.
  • Typically pain is provoked by: prolonged sitting, walking, crossing legs, getting in and out of the car and pivoting in sports.

Diagnosis

Assessment of hip pain involves the physiotherapist taking a case history and then performing a thorough physical examination. This will include assessment of functional activities such as walking and sitting as well as range of motion, strength and screening of other joints including the lumbar spine.

In the clinic the most accurate test to diagnose FAI is the hip impingement test. This test involves the physiotherapist moving your hip into hip flexion, adduction and internal rotation. A positive test occurs when pain is reproduced.

Your physiotherapist may also refer you for a radiograph (X-Ray) or MRI of your hip to confirm the diagnosis of a FAI.

Treatment

In most patients it is recommended that a period of conservative (non-operative) management is trialled before considering surgical correction.

Techniques your physiotherapist may use to help treat this injury include:

  • soft tissue massage and joint mobilisation
  • dry needling
  • the use of crutches (if the pain is very severe)
  • ice or heat treatment
  • biomechanical correction (e.g. the use of orthotics)
  • activity modification advice
  • weight loss advice where appropriate
  • education
  • progressive exercises to improve flexibility, balance and strength
  • clinical Pilates, hydrotherapy or gym based rehabilitation
  • a gradual return to running program
  • a gradual return to sport or activity program

Your physiotherapist may also recommend you consult your doctor for advice regarding anti-inflammatory medication and pain killers to help manage your pain, particularly in the early stages.

Hip Surgery for Femoroacetabular Impingement?

If a period of conservative management fails to improve your symptoms then a referral to an orthopaedic surgeon may be indicated. You will need to see your GP for a referral to an orthopaedic surgeon.

Surgical treatment for FAI is most commonly performed arthroscopically, but sometimes involves open debridement. Surgery for FAI aims to correct any bony abnormalities to the ball or socket of the hip joint as well as repairing any associated labral tear.

Following surgical correction of FAI you will need to undergo a supervised rehabilitation program with your physiotherapist.

Your rehabilitation time will depend on the level of activity you wish to return to but most patients resume normal activities after FAI surgery within six weeks. Full recovery and return to sport will be guided by your surgeon and physiotherapist and may take up to six months. Studies show that 80-90% of patients return to athletic activity after surgery.

For more advice about femoroacetabular impingement, book now with one of our Physiotherapists at Total Physiocare!

Post compiled by Claire Devos (Physiotherapist)

Shoulder Dislocation & Stabilisation

The shoulder joint (also known as the glenohumeral joint) is the most commonly dislocated joint in the human body. This joint is the most mobile joint in the body with an extended range of motion which allows the arm to move in many different directions. Shoulder dislocation occurs when the head of the upper arm (humerus) is forced completely out of its socket (glenoid labrum). The humerus needs to be relocated as soon as possible in order to achieve the best possible outcome in the future. The most common form of dislocation is anterior dislocation where the humerus is forced forwards out of the joint. This injury is commonly seen in young adult men who have sustained high energy injuries to the shoulder joint. Most commonly these injuries occur in contact sports including basketball, football and wrestling.

shd

Management after a dislocation differs and is dependent on a range of factors including age and participation in sports. People under the age of 20 are 68% more likely to experience a future dislocations and therefore this needs to be taken into consideration when determining the appropriate course of treatment.

Best current evidence demonstrates that immobilisation of the injured shoulder in a sling after relocation for 2-6 weeks combined with physiotherapy is the best course of treatment following a first time dislocation. Physiotherapy treatment can be commenced immediately after the injury and involves:

  • Postural retraining
  • Strengthening of the shoulder muscles
  • Range of motion exercises (reducing stiffness)
  • Taping
  • Facilitating return to sport/ function

Surgery is an option and recommended only in cases where the ligaments or bones within the shoulder joint are damaged. Common associated injuries within the shoulder include:

  • Bankart lesions: a tear in the ligaments in the front of the shouldershd2
  • Bony Bankart lesions: fracture of the front of the shoulder socket
  • Hill Sach’s lesion: fracture of the top of the humerus (arm bone)

Surgery can also be performed for patients who experience recurrent dislocations. In these cases surgeons will perform key hole surgery to tighten the ligaments in the shoulder in the aim of increasing the stability of the shoulder.

  • Capsular plication: tightening of the capsule to bring the humerus closer to the socket
  • Capsular shift: tightening of the capsule
  • Bankart lesion repair: repair of the torn ligaments in the front of the shoulder joint
  • Hill Sach’s lesion repair: fracture in the humerus is filled in with ligaments, bone or metal implants

There are different post-operative protocols after the above surgeries and all involve intensive physiotherapy management following the procedures. At Total Physiocare we can assist you in your recovery and rehabilitation following shoulder dislocation and these associated surgeries.

Post compiled by Alice Smith.