Foot and Ankle
There are four main ligaments that provide stability of the knee joint – the medial and lateral collateral ligaments on either side of the knee, and criss-crossing deep inside the joint are the posterior and anterior cruciate ligaments. The anterior cruciate ligament (ACL) is a thick ligament that attaches from the lower surface of the femur (thigh bone) onto the upper surface of the tibia (shin bone) in a way that will resist the tibia from slipping too far forward or rotating too far inwards on the femur. If – as can happen during sports that involve twisting, jumping, or pivoting – the knee twists too far with a lot of force, then part of all of the ACL can be torn.
ACL injuries are one of the most common knee injuries and they are managed in different ways depending on the severity of the injury and the age and activity level of the person.
Non-operative management consists of physiotherapy treatment with focus on reducing the inflammation and working through a strengthening protocol in order for the muscles around the knee to support the knee joint as much as possible. In these cases the surrounding muscle support is crucial as the knee will be lacking some stability if the ACL hasn’t been repaired. A knee brace may also be useful to provide extra support once the person is taking on more activity at the end of the rehab and beyond.
In many cases surgery will be required. The repair is normally made with a graft taken from the persons own hamstring or patellar tendon. Once the surgery is done, the rehab begins immediately. Whereas in the past the knee might have been put in a cast and rested, current protocols involve early weight bearing and range of motion exercises. It is very important to regain the knee range of motion early on otherwise it can be hard to progress and achieve goals further down the line.
A strengthening program, developed by your physiotherapist, will be started post operatively in order to begin to regain some of the knee strength and stability. The strengthening program for ACL reconstruction rehab is quite specific because the exercises need to strengthen all of the important muscles without placing too much stress on the healing ACL graft. A gradual progression of strengthening is done, beginning with simple light exercises and building up until eventually more complex exercises that are specific to your sport can be achieved.
By the end of the rehab the goal is to have sufficient strength in the muscles and ACL graft to give the knee the functional stability it needs to cope with the demands placed on it during activity. A return to sport is typically achieved in around 9-12 months following surgery.
Shoulders
It’s well known that pain in your neck, radiating down the arm can be a result of an irritated nerve root in your neck. What’s often overlooked, is that compression can occur further down the nerve continuum as they bundle together and exit the neck. These nerve bundles are partnered with major blood vessels as they travel through the shoulder and further into the upper arm. As they exit the neck, these neurovascular structures become susceptible to compression. Knowing this, we now consider the possibility of compression of not just the nerves, but the blood vessels too.
Thoracic Outlet Syndrome (TOS) is a complex presentation of signs and symptoms that result from compression of the neurovascular bundle as it emerges from the thorax and enters the upper limb. The thoracic outlet is the space bordered by the scalene muscles, first rib, and clavicle. The neurovascular structures pass from the neck and thorax into the axilla (arm pit region), and continue to branch further into the upper arm, to forearm, and hand. TOS is more common in women, particularly those with poor muscular development, poor posture, or both.
In the office, we assess and diagnose injuries related to repetitive upper extremity use or trauma. Swimming, baseball, tennis, and volleyball, are common sports that may bring on symptoms of TOS. Functional and biomechanical assessment of these patients who engage in repetitive and extreme abduction (out to side) and external rotation (outward rotation) of the shoulder, often demonstrate TOS signs and symptoms. Other patient populations who may develop TOS include those who are in sustained poor postures in their activities of daily living and work, and tend to develop shortened chest and shoulder structures, and weak/lengthened neck and upper back structures.
Anatomically, TOS can be a result of bony and soft tissue factors. Bony causes often involve rudimentary or “extra” ribs which increases the risk of compression, e.g. cervical rib. Soft tissue factors can include muscular tightness or hypertrophy related to sport. Trauma or mechanical stress to the neck, shoulders, upper back, or upper extremities can bring on signs and symptoms.
The common presentation of TOS includes a high degree of variability. Most people describe a vague and often confusing source. Pain can originate from the root of the neck and radiate to the entire arm. Strength loss can occur. Depending on the structures being compressed, people can also experience numbness, swelling, tingling in the arm and hand, heaviness in the arm, loss of movement, rapid fatigue, dull aching, cold and discolouration.
Our challenge as physical therapists is to distinguish by specific testing, whether or not you present with a true TOS. From the comprehensive list of signs and symptoms above, we can easily see how TOS can mimic neck injury (disc, nerve root pain), and even shoulder and elbow injury.
Physical therapy treatment addresses postural abnormalities and muscle imbalance, in order to assist in alleviating symptoms by relieving pressure on the thoracic outlet. We work to minimize tension directly around the nerve entrapment points. Manual therapy and exercise strategies would assist in correcting muscles that have shortened or lengthened because of poor posture. It is also important to take into consideration a patient’s activities of daily living, work environment, sleep positions, etc. Surgical intervention is often considered in severe cases of blood vessel compression and compromise.
Symptoms often resolve with conservative physical therapy in 90% of individuals, with good ability to return to previous lifestyle with little difficulty.
Vince Cunanan is a registered physiotherapist and associate at Sun City Physiotherapy. He can be contacted at our Downtown St. Paul Street location or email downtown@suncityphysiotherapy.com
Shoulders
Ever had pain radiating from your neck to your shoulder and down your arm? Perhaps losing strength in your arm or a feeling of numbness or tingling in the fingers? Chances are that you have irritated a nerve in your neck and that nerve is sending these painful or distressing symptoms down your arm.
The neck, or cervical spine, is comprised of the top seven vertebrae of the spine. These vertebrae form a solid yet fluid structure – solid to encase the spinal cord which runs down the centre of the spine, and fluid as the vertebrae move on each other as the neck bends and rotates. In between each vertebrae there is a opening called the intervertebral foramen, and it is here where the nerves that branch off the spinal cord exit the spine. These are called the nerve roots and the ones from the lower half of the cervical spine combine to form a group of nerves that travel into the arm, giving us sensation and muscle power.
Each nerve will follow a specific pathway from the neck to the arm, and nerves like to have space to slide and glide along that pathway. If at any point the nerve is compressed or pinched, then the nerve signal can be affected and as a result we can experience some of the symptoms mentioned above – pain, altered sensation, or reduced power in the arm.
There are certain areas where the nerve is more likely to become pinched in the neck. The intervertebral foramen that it travels through to exit the spine is the first. Anything that encroaches on the foramen such as a disc bulge or a bone spur can reduce the space available for the nerve causing compression. Then once it is through the foramen, the nerve travels between some tightly packed muscles in the neck so any increase in tension in these muscles can also cause compression of the nerve as it moves through this area.
If these symptoms ring a bell with you, a physiotherapist can perform a series of tests that will determine exactly which nerve is irritated and exactly where it is getting pinched. The location of your symptoms or the specific muscles that have lost power will help to determine the area of your neck that needs to be treated. There are several treatment options to resolve your symptoms, and which treatment will be most effective for you will depend on the findings from the assessment. Some common techniques used to treat cervical radiculopathy are manual therapy to create more space for the nerve, traction to take the pressure off the nerve, and acupuncture to stimulate the nerve in order to fully restore the nerve signal. Once there is no compression on the nerve and any inflammation around it has settled, then your arm symptoms should subside and full function should be restored.
Vestibular Rehabilitation (Dizziness and Vertigo)
An area of concern that I often hear about while working with an older population is the fear of falling. It is also fairly common that I will assess and treat an injury that is the result of a fall. A fall may occur due to poor balance, an unsafe walking pattern or general deconditioning.
Many older people tell me that they simply avoid physical activity due to the fear of falling and the risk of an injury. The problem with this approach is that as we become less active we experience a gradual decline in muscle strength, endurance, flexibility and balance. This gradual deconditioning puts us at a greater risk of suffering a fall. Also, as we become sedentary and weak, the recovery process if an injury does occur is often much slower than it would be for someone who is fit and active.
In the clinic we will look at functional measures including walking, standing on one foot and a sit to stand test to help us determine walking pattern, balance and lower extremity strength. While walking, we want to see that the leg swinging through is lifted high enough to fully clear the ground. A shuffle pattern can result in catching the toe quite easily. As well, since a large portion of walking is spent standing on one foot while the other leg is swinging through, we want to assess balance and stability on the stance leg.
To avoid tripping while walking, it is important to develop a safe walking pattern. The swing through leg should be lifted high enough to properly clear the ground. We also want to see a pattern of striking with the heel and pushing off the big toe with each step. If unsteadiness is noted while standing on one foot, a walking aid such as a cane or walker should probably be used while walking. A physiotherapist can adjust a walking aid and demonstrate how to use it correctly.
A cane or walker is especially important when walking outdoors where there are many obstacles including uneven ground, curbs and other potential tripping hazards. A walking aid should also be kept close to the bed in case it is needed when getting up during the night. A physiotherapist can teach safe and effective exercises to help improve walking pattern and endurance for those who feel weak or unsteady while walking.
It is also very important to stay active and keep moving. Daily physical activity is essential to maintain aerobic endurance, lower extremity strength and balance. It is never too late to start an exercise program. It is important to find an activity that is enjoyable to stay motivated to keep active. This may include walking, hiking, cycling, swimming, golfing, tennis, Tai Chi, yoga or Pilates. In addition to aerobic activity, a physiotherapist can design an appropriate home exercise program to help improve endurance, balance, coordination and strength.
