Coming into 2021, I’m sure the new “COVID-normal” has many people brainstorming ideas to keep fit. One way that has increased in popularity over the past year is recreational running. There are numerous health benefits to running, most commonly stronger bones, stronger muscles and improved endurance.
As with any sport, a balance needs to be struck between keeping active and over-training. One common consequence of overuse in running is pain around the knee. This is broadly defined as “Runner’s Knee”, otherwise known as Patellofemoral Pain Syndrome (PFPS).
What is Runner’s Knee?
Runner’s Knee is commonly classified as an overuse injury. Despite its name, it can also occur in athletes that need to bend and straighten their knee frequently. This means cyclists and soccer players are also frequently affected. Pain can come about from irritation of the kneecap on the thigh bone (femur). It can be caused by many things, like increasing your running distance too fast, uneven running surfaces or even improper training and footwear. The pain experienced can vary, from a dull ache all the way to a sharp shooting pain. Pain generally arises around or underneath the patella (kneecap) with this injury, and can get worse with knee bending, climbing stairs or walking on uneven surfaces. Other common signs noted are swelling and crunching within the knee joint. Patellar tracking (how your kneecap moves) can be one of the contributors towards this.
What should you do?
If you encounter this, the best way to manage an acute flare-up of knee pain is to follow these steps over the first week:
Rest: It is important to avoid repetitive overuse and stressing of the knee. This can be completed with relative rest – you may reduce the running distance to one where there is no flare-up of knee pain after the session. Additionally, reducing exercises with significant knee bending like lunges and deep squats can reduce the stress placed on your knee joint.
Ice: This helps reduce localised pain and swelling, Apply an ice pack onto your knee for 30 minutes at a time, and ensure it is wrapped with a towel to avoid ice burns.
See a Physio!
Physiotherapists can assess and get to the bottom of what exactly is causing this knee pain. Due to its nature, risk factors that affect patellar tracking and load bearing around the area can increase the incidence rate of Runner’s Knee.
Some common risk factors are:
Weak Quads: Your thigh muscles are responsible for straightening the knee, and are an essential muscle group to help load the knee appropriately. Weakness, particularly of the inside quads, can also cause the kneecap to track along the outside of your knee. This further contributes to knee pain.
Tight Iliotibial Band: The ITB is a thick fibrous layer of fascia that runs along the outside of your thigh, attaching onto the lateral aspect of your knee. It normally assists in knee stabilisation and movement of the lower extremity. However, if it gets too tight, it can pull the knee cap laterally, thereby influencing knee pain.
Loading changes: Sometimes, changes to intensity and volume of your training can contribute to knee pain, especially when combined with insufficient recovery. The best thing to do with loading changes is to only change one variable (eg. Speed, duration or frequency), and ensure a gradual change instead of a rapid increase.
Knee Cap position: Patellar positioning is different on each individual. Some are more predisposed to knee problems due to where it sits. If it sits to far to the side, this can increase contact with the groove, and hence knee pain. A good method to counter this is to train the muscles around the knee and optimise the patellar positioning.
How can we treat it?
Physiotherapy is an evidence-based, effective treatment for Runner’s knee. There are many ways we approach treatment and prevention of this:
Education: Discussing the nature of your injury and how to prevent recurrence is a crucial component of your treatment. Reflecting on your training and loading is the first step in reducing your pain.
Taping: Taping or bracing can help relieve pain in the short term, and may allow a continuation of running. This is because the tape helps the patella track more on the inside, helping reduce its contact with bony grooves and therefore reducing pain on running.
Exercise: Targeted strength and activation training is needed, given the dynamic nature of running. This will likely involve work with the glutes and quads. A common example of an activation exercise is VMO activation. The VMO is the inside quad muscle, and plays a role in keeping the kneecap in place. A common sign in people with Runner’s Knee is weaker VMOs, so strengthening this muscle may help improve pain and biomechanics of running as well. Other exercises can target different muscles, movement patterns or muscle activation. These include single leg squats and lunges. It is important to ensure you work within a tolerable threshold, as pain can be a big barrier to training.
Soft tissue work: Many people present with tightness in their major muscle groups in their legs. This can be worked on with stretching or soft-tissue work. Additionally, foam rolling or kneecap and ankle mobilisations may be of some benefit. However, the main contributing factors are more likely to be related to strength and motor control. Therefore, soft tissue work is considered a short-term form of treatment, and unlikely to resolve your Runner’s Knee for long.
If you are pulling up with increased soreness, and it is interfering with your everyday life, book an appointment with our expert practitioners. Most of the time, one or more of the above causes can contribute to your Runner’s Knee, so we can help tailor an appropriate treatment plan for you to achieve your goals.
Book an appointment today for your assessment!
Brachial Plexus by Marco Cheung (Physiotherapist)
The brachial plexus is a network of nerve fibres that allows movement and sensation in our arms. It forms five major branches as shown in the image pictured.
Occasionally, these nerves may be compressed by muscles or bony structures around it. This can cause symptoms like numbness and tingling to occur, so a Physio can help assess and understand what’s going on in the arm.
When you book in with a Physio, they will complete a series of assessments on you. Upper Limb Tension Tests (ULTTs) are ones that evaluate your nervous system. They are performed by placing tension on your arms or legs. This blog will look at neural assessment for your arms, and outline their use in assessing neurological structures like the Brachial Plexus within it.
Why use these tests?
Use of the ULTTs are indicated when :
Neural symptoms (tingling and numbness) are around the head, neck, thoracic spine and arms
Symptoms are not severe and not easily provoked
The tests are valid for detecting peripheral neuropathic pain (PNP), and can detect neural sensitivity associated with this (Née et al., 2012). Common PNP conditions include cervical radiculopathy and carpal tunnel syndrome.
What are they?
ULTTs are split into 3 common types: Median nerve, Radial nerve and Ulnar nerve. They are completed on the unaﬀected side first, applying pressure from the shoulders to the fingers, or until pain is replicated.
An outline of each step for the 3 ULTTs, as well as a video, is available for reference. Video: https://youtu.be/rir6x6Iiqc4 (Physiotutors)
What a positive result looks like
You will feel a stretching and tingling sensation when your arm is put on stretch. At this point, stretch on the hand will be reduced. If a reduction in symptoms is experienced, then this is a positive result, and treatment techniques called sliders and tensioners may be used.
Tensioners and sliders are eﬀective techniques in treating conditions like neck and back pain. They can reduce the sensitivity of the neural tissue by allowing more movement within. Tensioners are used more commonly, and involve stretching the nerves more. Sliders work by moving the nerve forwards and backwards. Sliders are less forceful than tensioners, and may be more useful in acute and post-operative management. Meanwhile, tensioners may improve intraneural pressure and improve circulation by pumping the nerve.
To perform them, first complete the relevant test to place the nerve on stretch. For tensioners, add lateral neck bending towards the opposite side. For sliders, add lateral neck bending towards the opposite side and oﬄoad the nerve at the fingers.
The video below demonstrates how to complete the tensioners and sliders of the median, ulnar and radial nerves.
Basson, A., Olivier, B., Ellis, R., Coppieters, M., Stewart, A. & Muniz, W. (2017). The Eﬀectiveness of Neural Mobilization for Neuromusculoskeletal Conditions: A Systematic Review and Meta- analysis. Journal of Orthopaedic & Sports Physical Therapy, 47(9), pp. 593-615.
Coppieters, MW. & Butler, DS. (2008). Do ‘sliders’ slide and ‘tensioners’ tension? An analysis of neurodynamic techniques and considerations regarding their application. Manual Therapy, 13(3), pp. 213-221.
Nee, RJ, Vicenzino, B, Jull, GA, Cleland, JA & Coppieters, MW (2011). A novel protocol to develop a prediction model that identifies patients with nerve-related neck and arm pain who benefit from the early introduction of neural tissue management. Contemporary Clinical Trials, 32(5):760–770. doi: 10.1016/j.cct.2011.05.018
Nee, RJ., Jull, GA., Vicenzino, B. & Coppieters, MW. (2012). The Validity of Upper-Limb Neurodynamic Tests for Detecting Peripheral Neuropathic Pain. Journal of Orthopaedic & Sports Therapy, 42(5), 413-424.
Book an appointment today for your assessment!
Understanding Pain by Louise Holland (Physiotherapist)
Understanding your pain
Pain can be a confusing and complex time for anyone especially when it becomes chronic. But before you can effectively tackle your pain, you need to understand how it works, what it is for, and what you can do to influence your perception of it.
Your body consists of various tissues that have specific neurons which are designed to respond to harmful stimulus – whether mechanical, chemical or thermal. When they are activated, they send a warning signal to your spinal cord, which in turn sends a signal to your brain. This activity in neurons is called ‘nociception’ and it’s happening all the time. But this does not always translate to the sensation of pain. Most of the time, the brain protects you with other things like movement – such as when something is hot and you move your hand away quickly. Once the warning signal reaches the brain, the brain makes sense of it based on the information arriving and the vast amount of learned responses that it has already learned. If there’s reason to think protection is required, then your brain makes pain.
Pain could be thought of as a protective fire alarm. There could potentially be a fire at the pain location or elsewhere within the body, or it could be a false alarm. Pain can become influenced by strong emotions to a trauma, such as the death of a death of a loved one or even in response to stressful situations at work. Pain is not always just a physical injury especially if there is no specific event that has occurred. Your brain is a miraculous structure, and retains a memory bank of emotions regarding old injuries or painful areas. Your brain will “remember” these triggers of pain, and can be conditioned to experience this pain at especially vulnerable or stressful times.
The sensation of pain is also personal to each individual and different from one person to the next. Individuals will respond in different ways, but everyone still needs to break the same pain cycle. If consistent change doesn’t occur in your daily routine/pattern, then the pain won’t change either.
Some of the most common questions that clients tend to ask include: How do I know if my pain system is being overprotective? How can I retrain my pain system to be less protective? How do I know if I’m safe to move?
Pain is a habitual response that the body becomes use to defaulting to it because it becomes the new normal – which can escalate very quickly! Breaking this learned response is the ultimate goal when to break the repetitive pain.
So be brave and have hope! And while you probably have well thought out coping strategies, it’s time to take a new approach to dealing with and reducing your pain – one that focuses on retraining your pain system. This may mean testing yourself physically and moving more than you normally would.
1. How do I know my pain is being protective?
Practice makes perfect! If you have had pain for more than a few months then your pain system will be more effective at producing the sensation of pain. This response develops over time and your system becomes more sensitive. As it becomes accustomed to responding in learned ways, and it becomes “normal” to produce pain in response to a particular stimuli. Nerve cells in your spinal cord and brain physically alter their makeup to be more responsive. The same principle applies when you learn a new skill such as playing the new sport or riding a bike – Nerve cells change their properties to be more responsive. The process is the same, it is the nerve cells which are involved that are different.
You will know your pain system is becoming overprotective when:
Your body becomes more sensitive than it was before.
Activities that used to cause a little pain now cause a lot of pain.
Activities that were usually not painful, start to become painful.
Other signs of over protection include:
Your pain may begin to spread to other parts of the body or to the other side (referred pain).
Your movement starts becoming stiffer and it becomes more difficult to move. Remember that movement is another great way to protect yourself!
You may get muscle spasms. These can be really frightening, especially if you don’t understand what caused them. Spasms are another way your body protects a painful area, and are almost never a sign that you have damaged something.
You may even find you become more sensitive to things that don’t seem related to your body – loud noises, unusual smells or people beginning to irritate you more easily.
All these symptoms indicate that your system is ‘on alert’. Pain can be greatly influenced by your thoughts, feelings and other events going on in your life – things that actually have nothing to do with the painful body part!
One thing that we know absolutely for certain 100%, is that an over protective pain system is NOT a sign you have a weak personality or a weak mind. It does NOT mean you are going crazy and it does NOT mean your injury is getting worse or your body is falling apart.
It means your body is doing too good a job of protecting itself.
2. How can I train my pain system to be less protective?
There are many ways to retrain your pain system, but they all begin with understanding your pain. Many people say that their pain begins to reduce as soon as they understand it better.
The goal is to re-train your pain response system back to providing protection when you need it, but not when you don’t.
Start by developing an accurate understanding of this system and how it can become overly protective. Sometimes when injured tissues heal, they don’t look the same as they did before your injury. Think of a scar from an old cut. You can still see it, but the site can still adapt to being stronger, fitter and less painful.
Understanding is very important because pain can be a relatively subjective experience. If you can change the perception of your pain, then you can change how you experience the pain sensation!
Knowledge is power and understanding that your system can be overprotective and be influenced by your thoughts, feelings or moods is the first step to overcoming the cycle of pain that could be preventing you from living your best life. Once you have the fundamental understanding of pain being be turned up by anything that can trigger a protection response and turned down by anything that makes your system feel safe, you can discover a renewed confidence to move – even through the sensation of functional pain.
Find a good coach. At Total Physiocare, are are trained to help you understand your pain better and to identify the triggers that make your perception of pain worse or better. We will guide you through a week by week plan of movement with a controlled action plan aimed to improve your pain responses.
You can start without a coach too. By altering your daily routine to include little lifts your heart rate, you can begin to train your system to be less protective. Remember pain is protecting you, not telling you that you have damaged yourself.
Never forget that your brain is always looking out for you. Even thoughts and feelings, social interactions and life’s day-to-day events can powerfully influence your pain. Remember too, the trick is not to avoid all life’s challenges but to retrain your system to be able to cope effectively with them.
Sounds challenging right? Well it is, which is why you might need some coaching. Take a long-term approach – this is a journey and there are no quick fixes.
3. How do I know if i can safe to move?
Movement is the most critical pathway to recovery and it is almost always safe to move.
At Total Physiocare we can provide you with a thorough assessment to ensure that you the ‘OK’ to move. We will determine if you are the very rare case for whom it is not safe to move. We can discuss with you why it is safe for you to move even though you have pain. We can guide you in how much you can push, and how you can start to ‘recognise the signs’ that you are getting close to triggering your pain system. Remember – the pain system will protect the tissues of your body!
We can also help you understand that many things found on scans are perfectly normal and common, even in people who do not experience pain.
Start with something slightly more intense than you currently do. If you are like many people with persistent pain, you are not doing much in the way of activity and movement. It is usually best to start gently with a simple movement such as walking. Some people with chronic or uncontrolled pain already do a massive amount of exercise (some are Olympians!). In this case, mixing exercise with other cues and ‘training smart’ will enhance your exercise experience and build up your personal learned responses to functional pain.
Injuries heal, and your body’s tissues adapt amazingly well to the demands of life. Even if things don’t heal perfectly, they nearly always return close to normal function. This does not mean that we stop feeling pain. Back pain in particular can be particularly severe even when there is no detectable tissue damage at all!
Here are some facts that have helped other people gain confidence to get moving:
‘Disc bulges’ are so common in people WITHOUT back pain that many scientists have concluded that they are not abnormal but a common and normal part of ageing!
50% of 40 year olds WITHOUT back pain have a disc bulge!
The most natural movement of our spine is the bend/ flex over, so why shouldn’t we be able to pick up our grandchildren or return to our job?
If you were injured more than two months ago then a vast amount of healing has already happened. Don’t underestimate how magnificent our body is in healing itself.
Knowing and believing that you are safe needs repetition and practice as you teach your overprotective pain system that it does not need to be so protective anymore.
4. Will I get better?
Many people don’t realise how much patience, persistence and courage it takes to recover from learned pain. But if you stick to your treatment plan, remain patient and be brave when you need to be, then all the evidence we have tells us that a majority of ailments will slowly heal or improve. Building your own sense of optimism about the future is an integral part of your recovery.
The most common culprit that traps you in the pain cycle is by either avoid everything that trigger the sensation of pain, or by do everything regardless of how much it hurts until you ultimately give up. The first is known as the the ‘avoidance pathway’, and the latter is referred to as the ‘boom-bust cycle’.
The third option is the the most effective. Understand your pain. Develop an action plan to slowly increase what you are doing and remain consistent with your endeavors. Remain patient and persistent to give yourself the best chance at your achievable recovery.
5. Will I re-injure myself?
No one can completely eliminate all risk of injury, but unless you are either very unlucky or taking unnecessary risks, then your chances of injuring the painful body are actually very low. Remember, even if injury does occur, your body is designed to keep healing and re-adapting again and again. Consider sportspeople who have multiple injuries and re-injuries, and yet in most cases return to their sport.
As you begin to challenge yourself physically it is important to realise that an increase in pain does not necessarily mean an increase in injury. An overprotective pain system will often alert you as you try new tasks, but remind yourself that it is protective, not a sign of damage. If a flare-up lasts longer than usual or you have had a significant accident and you are concerned, ask your health professional to give you the all clear.
Rest and avoiding activity and movement tends to make an overprotective pain system even more protective. The chance of ongoing pain is higher if you stop moving – your system adapts to being stationary. Exercise and movement are the best way to reduce your pain. Our Bodies are designed to move and get grumpy if we avoid it completely. As you load your tissues you will become stronger, and your stronger body will be more resilient to injury. Exercise and movement turns down your protection setting.
6. How can I speed up my recovery?
Your body has an in-built recovery system – you just have to help it along. “Speeding up” your recovery is more about avoiding things we know slow it down. For example:
Don’t go looking for a quick fix magic pill, injection or online gimmick to fix your body for you. You need to retrain your system and no one else can do that for you. You need to put the hard work in and change the bad habits.
A good healthy diet and limiting your sugar intake helps. Vegetables are anti-inflammatory. Sugar slows down recovery.
Get enough sleep and develop a good sleeping pattern. Sleep is also anti-inflammatory, and poor sleep slows down recovery.
Learn new ways to reduce stress. Anxiety and depression slow recovery. A good psychologist can give you effective methods to reduce anxiety and depression.
Stick to your plan.
Discuss with your doctor the possibility of slowly reducing pain medications as you heal. Some pain medications actually slow your recovery, but always seek a doctors approval before changing any medications yourself.
Keep testing your new sense of what’s possible. Aim to be active on most days. Track your progress, set some goals, and think about the things you will be able to do when your pain is better. People recover at different speeds, but with persistence most people will either get better or at least improve their situation.
Is all this learning new skills and information really helpful?
Amazing as it sounds, learning new things – skills and information – is anti-inflammatory! Keep up your journey of understanding of pain by reading new things, and learning new concepts! And book an appointment in with us at TOTAL PHYSIOCARE to help you start your journey to a better life.