April 7, 2009

Ask Physiotherapy, all questions taken from PT Forum

Posted in physiotherapy at 6:50 am by Edwin

Any injuries, pain or discomforts? Ask me about them and I will try and answer you to the best of my knowledge what could be going on. Hi Ronny A few months ago I fell on my knee – direct patella, full weight hit, also twisting the knee at same time. Ive had x rays and scan and consultant says theres nothing he an do but I cant walk far and to walk on that leg gives me sharp pains in my heel! Any advise? Claire Hey Claire, What did the scans tell you about your knee? So in your case, a direct trauma to the knee from a fall may create a syndrome called “patella-femoral syndrome” that causes the knee cap to not track properly when you bend and straighten the knee. In addition, twisting the knee as well can cause some issues when you walk because the tibia bone (i.e. the bone below the knee) may be stuck in a rotation which therefore makes you walk on the foot improperly which may cause some pain in some areas of the foot and ankle regions. This is obviously all theoretical because I would need a lot more info from you. Go see a physiotherapist. Rule of thumb, a good physiotherapist is one that deals with the body globally. A trauma to the knee will definitely cause problems above and below the knee (i.e. ankle and hip/pelvis/back). So make sure the physio you choose thinks GLOBALLY and not just at your knee!!!! I hope I helped you out… Hey Ronny The scan results showed that all ligaments and cartliage was ok, and had possibly repaired since the injury, but the base of knee and tibia showed some “strain” (their words). What you mention about the twisting of the knee resulting in walking improperly is exactly as it is. I tend to use the outside of my foot and roll the ankle to relieve pressure from the patella, which has not done my foot / ankle any favours now! Thank you for your advise and hopefully I may get a referal back to another physio as my consultant thinks that just exercising that I did with the last one probably didnt help me much! He mentioned Ultra sound! Many thanks Claire Hey Ronny, I went running thursday night with no incidents, but about an hour after I got home, my leg (outside – about 45 degrees from the front, a few inches below the knee and sort of shin near top) started hurting.By the time I went to bed (after icing it and everything) I was limping. Friday morning I woke up and thought I needed crutches. In the end I didn’t because once I got some blood in my legs I was limping but I could at least walk. It is of course worse when I first wake up, and I can now walk OK, but it even hurts when I extend the leg and put no pressure on it sometimes. At first I had no clue, now I’m thinking shin splints, even though it is much higher and more localized than shin splints I have had in the past. What do you think, and what do you suggest I do to make it better and do you think that biking would be bad for it if it doesn’t really hurt when I bike (didn’t try yet). Thanks Hey Mitch… Long time… Hope family is doing well. As for your knee, it is hard for me to pin point where the pain is. A few things can be happening in that area. Meniscal damage (since you for sure have a lot of wear and tear in there because of how active you are), Patellar tendonitis, patella-femoral syndrome (poor knee cap tracking), or yes, even shin splints (or compartment syndrome). Is there any swelling? Is it tender to the touch? Do you have full range in the knee (bending and straightening)? Has this happened before? Try to get these questions answered and I could help you out more. If not, I could always see you at the clinic… might be worth it. For the biking, my rule of thumb is whatever doesn’t hurt you could do… Also, if it does hurt when you do it but when you stop the pain goes away right away, that activity is ok to do within moderation. Keep icing… Thanks Ronnie, I’m no trained physio, but experience with many, many injuries does teach you a few things about your own body. So: 1- It is not a knee problem. It is below the knee. Not sure exactly how far up you consider it to be shin splits, but i think it is kind of that. Feel like that type of injury. I just did teh elliptical trainer with zero pain (icing now). Funny, I have a bad history of IT Band injuries so I have been stretching that a lot. One stretch that I do is standing on one foot I but my other foot on my knee/quads and get into a sitting position (but not actually sitting on anything) and stretch the IT band of teh elevated leg. When I just went to do that, it pulls on the outside leg below the knee as well…and it hurt..so i stopped immediately. I wonder if doing that stretch aggressively added to this injury. Stretch one thing to avoid injury and cause another… I don’t see any swelling but the muscle is a bit sensitive. Like I said, outside of leg, a few inches below the knee, about 45 degrees from the center. I do have a full range of motion. No problem. Thanks and keep well! Most likely then we are dealing with an ITB syndrome… Try finding the spot that is sensitive and rub perpendicular to the muscle fibre direction for 5-8 minutes. Rub deep to the bone not superficial to the skin. The Pain should numb out after 2-3 minutes of rubbing over the same spot. Most likely yuou have some scar tissue development over that area. I would be surprised if it was shin splints. A good way to help shin splints however is to tap your foot on the floor 20-30 times… 2-3 sets. Hey Ronnie, Can it be ITB if it is BELOW the knee??? I thought that muscle was only from the knee up to the hip. This pain is definitely below the knee by a few inches. Thanks ITB attaches below the knee into the tibia on the lateral side… if tight enough, it can actually rotate the tibia bone laterally…. Check out this webpage… http://www.spinalhealth.net/inj-itb-pix.html Hi Ronny, Thanks for the link. I see what you are saying. However, I think my injury was still lower. i just took a photo of my leg and it hurt most where my fingers are touching. I’ll try to post it on your group site somewhere. Based on that, what do you think it is? It is much better now. But I still don’t think it would be a good idea to run yet. Thanks, keep well. Happy spring. me again, You know what, I just moved my leg and realized that it actually hurts where I put my fingers in the pic, but also continues along that line almost all the way up the just below the knee….right where you showed me that the ITB wraps around. So, it seems that you are very possibly right about the ITB thing, even though I was hoping it was not ITB because it was below the knee unlike my usual ITB pains that are on the side of my knee. What can I do, aside from stretching, to avoid this recurring injury? Thanks again. Listen…. when it comes to the ITB and the surrounding structures (i.e. PELVIS, HIP, KNEE and ANKLE) it is a complicated issue. Stretching is good, but very hard to get that area to stretch out. Some people like to take somethig like a rolling pin and use it to “deep tissue release” the ITB by putting it under the leg and using body weight as the pressure. Most of the time however, it is the body giving you and indication that something biomechanically is not working very well. You must think as the body GLOBALLY… We compensate everyday up until the body cannot handle it. A lot of active and even inactive people get ITB problems. Because you are very active, I think you will need to get “check ups” to make sure that your body is working as effeciently as possible. It is defintely not working as well now that is for sure. These things tend to get better on their own but then you are getting involved with layers of problems your body adapts to… This in my opinion is definitely not good for the future… I would recommend massage and/or physiotherapy. Bonjour Doctor, I tore my achilles and it’s been nine weeks since the surgery. The actual damage occured one month prior to that (misdiagnosed three times). Because my calf muscle had that extra month of non-usage (and deterioration), does that mean I should do more excercises to strenghten it (currently using the theraband twice a day and toe raises under my desk through out the day)? Also is being active during this phase recommendable? I’m a little confused as to whether to rest or to be active, and when should I be able to run, what would expedite the process? Thanks Doc First of all… Have you seen a physiotherapist at all for the problem? Do you know how the surgery was done? Are you still in a boot? Give me some answers to those questions because every surgeon has there own protocol… Some protocols say that you should still be in a boot but ++weight bearing until 10 weeks… If you are 9 weeks, by now you should have been doing a lot of stregnthening at the knee, hip and very importantly the CORE!! Your physio should be able to take the boot off and begin light to moderate mobilizations on the ankle to increase mobility. Get back to me with some answers to the questions above. Oh yeah the boot came off quite a while ago (4 weeks ago). I go to physio twice a week and I’ve been using the bike, the wobble board for balance, and I’ve been walking a lot (focusing on pushing off on my big toe? As for how the surgery was done, I’m not too sure what you mean. I was completely anaesthetized and there’s a six inch scar starting from two inches above my heel upward. As far as I know they had to suture or staple the tendon back together and then re-sew. I’m still wearing one heel lift. I walk a fair bit, at least 45 minutes a day. My physiotherapist has recommended that I start rocking back and forth on both feet to a standing tippy toe position. Does your physio actually work on your ankle manually trying to increase mobility? Manualy therapy is very important for the ankle at this stage especially… So your boot came off 5 weeks POST-OP? Most protocols ask the patient to keep the boot on 8-10 weeks slowly weening off of it. Was it your doctor that told you to take it off or the physio? At the stage you are at, whch seems quite advanced for 9 weeks, do you have a lot of PAIN? The doctor told me I no longer needed to use the removable cast. There was a lot of pain immediately after I took off the cast, but it has decreased. There’s still a bit of discomfort when I walk. My gait’s getting better, but I still have a bit of a limp. Whoops, re: manual stimulation: we usually start the session with the cryocuff–>she elevates my foot with the ice-water filled boot to decrease the swelling. Then she looks for my range of motion and uses her hand to apply resistance while I push it in different directions, and sometimes she massages it to push the swelling away from my ankle. Is this what you mean? Actually, it is what I mean. I was hoping that the physio would get more into mobilizations of the small joints in the foot and in the ankle using techniques called GLIDES. Basically, improving the small movements to benefit the bigger movements. I don’t want you to think that your physio should be doing more… every physio is different. The most important thing is that you are improving. However, #1 thing is strengthening the joints above the ankle (knee, hip, pelvic floor, core…). My view on the body is GLOBAL!! One should not only focus on improving the “problem site” but also the other joints around it because they definitely got affected by your NWB and being in the boot… COMPENSATIONS ARE PRESENT IN YOU!! So make sure that you are getting the strengthening you need. Do you play any sports? Currently no (still using the elliptical and the bike at the gym..and I’m doing Pilates) regularly I play soccer, run and blade. What does NWB mean? NWB = Non Weight Bearing So I don’t really know what else to tell you except that you should ask your phyiso how and when you are expected to progress to general strengthening. Thank you for your help. A couple weeks ago I was starting to get depressed because I felt like it was taking a long time to heal. Now I feel like I’m progressing. Thank you! I do have another question I guess..how am I going to be able to lift my body weight on my toe? (How would you progress this injury?) Well, that I will not answer since I have not evaluated you and this is something very important to evaluate and advance… Have your present physio do this with you… GRADUALLY!!! Hey Ronnie, I have a question about an injury I sustained about 1.5 years ago. I sufferred a sub-talar dislocation and fractured my navicular bone (actually powdered some of it which was unrepairable) for which I underwent surgury. There was no need for any permanent hardware to be installed just one pin which was later removed. I was in a cast for 4.5 months (NWB) and then started physiotherapy for my injury. The treatment was primarily strenthening exercises for my ankle/calf with some PNF stretching for the area. my treatment fell into a routine that I could do at home so I stopped seeing a professional (I Know this was a bad idea but I’m stubborn and was broke at the time from not being able to work for so long). I now have rather sharp pain and a severe limp after spending a long time on my feet, especially @ work since I’m walking + carrying ~50 lbs most of the day. I’m wondering if going back to physio would be of any benefit this long after the injury or if there is anything you could recommend that I could do @ home to help strengthen the area, allow me to get a better feel out of my one ankle (I cannot jump properly or especially land properly anymore with my one foot) and possibly reduce the pain/strain I feel at the end of the day. Any help would be appreciated. Hi Nick… This is a very common thing to occur to most people unfortunately… It is always a question of money and time. It is something definitely respected by me however… To answer your question briefly, I would go back to see a physio because you will most likely require some mobilizations or even manipulations to unlock whatever is going on. The only thing I would recommend is that you find a physio that deals with sports injuries and is quite veteran to the field. A rookie physio might not know where to take this problem. There is not much else i could tell you to do at this point excpet go find that physio that will be somewhat aggressive with you and perhaps get another X-Ray or even more specific, an MRI of the ankle to see what it looks like in there. Most likely a lot of scar tissue and perhaps some arthiritic changes because of everything you went thru… Sorry but that is the best answer i could give to you… Hi Ronny, I hope all is well with you. So, my latest problem: I just looked up the definition of sciatica and it pretty much describes exactly the pain I’m feeling. When I make certain movements standing/walking, I get a shooting pain down my right leg that starts at the junction between my butt and my back (but no back pain), and goes down the outside of my leg almost all the way to my foot. No numbness. I’ve been slowly getting back into running since takling a couple of months off after my last message to you. I very slowly worked up to an hour run (only on flat surfaces, and usually not pavement) and last week, after a run, is when I first felt this. I stretched it a lot (stretching the gluts (gloots πŸ˜‰ and it seemed to go away after a couple of days. But then I ran again 3 days later and it is back. I didn’t feel it right after the run. I’m also biking a lot. I biked 125 km saturday (hilly) with zero pain, and ran Sunday with pretty much no pain, but yesterday just getting on my bike and pedaling hurt a bit at first. Also no pain on the elliptical machine. After getting some blood into it, it seemed to go away a bit. So that’s my big story. I do think it is sciatica, so I was wondering what advice you can give me regarding treatment and what can and can’t I do? How long do you think this will last? What do you think caused it? If it doesn’t hurt too much can I still bike? Run? Thanks Hi again. Just to be clear, I have ZERO back pain. All butt and leg. Thanks Hey man… Well Sciatica is a very over-used term… But your problem might very well be that… For things like this I find it hard to give advice because it can be coming from so many different areas… It could be back (even though there is no pain there). It could be buttock (piriformis syndrome). It could be a mix of the two or even just a poor posture thing that needs fine tuning. This is a toughy and as an ethical physio, I cannot give any real feedback on this without a thurough evaluation. Call me if you want… (514)485-9292 to make an appointment. Hi Ronny In February i slipped in the mud and did rather a lot of damage to my ankle and leg. My primary diagnosis is “Weber C # Right Ankle” for this I had “Open Reduction and Internal Fixatin Right Ankle” following what the hospital describe as a “Fall (Mecanical.) Now then, as they explained it to me or from what i remember in my morphine/ketamine/pethadine fuelled haze of two weeks in an orthapeadic ward was that i broke my ankle and the thinner of the tib/fib bone (can never remember which is which) and disloctaed the break as well as damaging nerves, soft tissue, muscle etc I was told in terms of them putting me back together again the break/s was pretty hideous and would be on a difficulty level as peicing someone back together who had smashed their ankle due the angle of my breaks and dislocation. I have had two operations and still have some screws and a rod in my leg which are all remaining unless i experience problems with them. The second op was to change big screws for smaller ones. When they took my cast off following second op they said i was not having physio, i couldnt even walk so i taught myself how to do that and i do the small amount of exercises they gave me. Its now amost 2 months since i taught myself to walk again but i am still having problems my ankle and foot swell up massivly each night and i am still taking a lot of pain killers. The hospital discharged me so now i have to go to my health centre/general practitioner and they wont refer me for National Heath Service Physio (oh England is great isn’t it) and I cant afford a private physio as it is so expensive and i dont have that money.i dont know how it works where you are but here its NHS or private treatment which many cant afford! anyway was wondering if you have any advice for me, i swim each week gently but i still swell up after each session and it hurts me and i am still walking with crutches (when hospital discharged me 6 wks ago they were surprised i was still on them!) is my best bet just to keep harassing my doctor for a referral or do you know anything i can do at home?I just feel im in such a mess with it and i dont know what to do and the medical people dont seem to want to help. Thanks Hannah Hi Ronny: What a nice idea for a group! About 7 yrs ago, I tore my ACL playing basketball. I sustained the initial injury cutting to the basket and turning to receive a pass. I went to my doctor who diagnosed an LCL strain. So about 3 weeks later, I was back playing because he cleared me to play. The second injury occured as I was making a two-foot jump stop lay-up. My knee was unable to sustain the force of me coming down on it and just gave out…worse pain ever. It was after this incident, my coach set me up with PT and it was the PT who diagnosed my ACL tear. I did PT for about 3 months after the injury. I have never had it repaired and continue to do exercises to strengthen the muscles around the knee. However, lately I have found that I am beginning to have problems..i.e. It gets sore quite easily. Especially after I play any sort of sport…I usually have to wrap it and ice it for a bit. Could this be a sign that I have further damaged the knee? Is there anything I can do to help with the pain? to the doctor) I am not able to either jog or do many of the sports I am used to (climbing, badminton). In the x-rays two exostoses can be seen (on the heel and the instep), the doctor couldn’t say if they are congenital (i have never had a problem with my feet before and i have been jogging for around 10 years), or if they are caused by overuse. The treatment recommended was to keep the foot quiet, bandage it and use anti-inflamants. Has anyone had this kind of injury before too? How did you deal with it? How long till you could use the foot normally again? How long till the pain stopped? Any alternative exercises? I am trying to do some push ups keeping on the knees and trying to keep the lower part of the legs inmobile. Thanks πŸ™‚ Hi , Ronny The Most Useful Group on the face book πŸ™‚ ,,, sorry my english is not so good i study spanish ….. i fell on my knee in the bavement i didn’t feel pain i continued playing but after i went home my knee be came larger than before and i take some medicines pls if u have any solution for fast recovery cuz i play foot ball and the team needs me 1/7 Thanks πŸ™‚ Trigger point Glut med. Ice attachment of ITB and work on strengthening VMO Hi there, I play soccer and I got a neck injury about 3 years ago. I performed a so called bicycle kick and unfortunately landed on my neck (shoulder height). I have seen several doctors since and all they can tell me is that it’s a ligament problem and that i need to rest and see a physio. Radiography showed that no damage was caused either to the backbone or to the vertebra. To be honest i don’t really trust that result because every time i move my neck it causes multiple crunches and if I try leaning my head backwards it’s as if something was pulling was pushing the other way. It really hurts though, especially when I sit down, I can’t last longer than 5 minutes on a chair and it also gives me a serious sensation of nervousness. I really hate pills and I’ve had some digestive problems with painkillers also. So if you have any suggestions I would really appreciate !! Thanks a lot ! Claudiu Roman Over the past couple of months I have been pondering whether or not to start seeing a physio again for an old ankle injury. Two years ago I broke my left ankle – open fracture dislocation, three breaks in my fibula and a piece off the bottom of my tibia. Now I have a plate on my fibula and two screws in the bottom of my tibia, I was lucky and had an excellent surgeon to do the repairs. Obviously there was a lot of tissue and joint damage at the time. I saw a physio regularly for about 6 months after I started walking again and managed to get pretty active and walk without a limp quite quickly. It generally feels okay good now, but I still find it quite uncomfortable to run and occasionally I will get pains up the side of my leg where the plate is. I walk a lot, swim regularly and in the summer do quite a bit of hiking, rock climbing and rollerblading – and I try not to push beyond what is comfortable. Although it feels okay now, I am starting to have horrible visions of gradual damage that I won’t notice until later. What would you recommend and any advice? Well, good on you for getting yourself active again. Did the surgeons ever give you the option to remove the plates from the site at one point? Sometimes this is done when there is pain felt due to the plates and screws. Who was the Sx? Questions like this are very hard to answer because after a while (i.e. 2 years), one must think how much more can you improve? On the other side of the coin however, as a physio I tend to think quite globally and you would be surprised how much compensating you have done since the Sx and how much you ar estill probably doing now. The compensations are due to weakness and perhaps habit that you have developped over the past 2 years. It is very fair to say that your ankle is not the same ankle you used to have. So if it was up to me, I would evaluate you back, pelvis, hips and knees to further advance you and perhaps educate you on the wonderful world of compensation. If you are interested in this theory, you should come by the clinic for an evaluation… I did have one larger screw removed about 6 months after the injury because it was going through both bones and I didn’t want it to affect my flexibility. As for the rest I haven’t really gotten a conclusive response as to whether or not its worth it. The surgeon was at VGH in Vancouver and I haven’t seen him recently because I moved away in 2005. I appreciate your holistic approach – this is something I’ve been looking for (I have been less than enthused by previous physios and wary of randomly choosing one that I don’t know). I probably will stop in sometime soon. Thanks!



  1. Hi it was delightful to read your blog.I was particularly relieved to see you stress on focusing on the body ‘GLOBALLY’,people usually only focus on the injured area and don’t realize that treating the other areas can be very helpful as well.

  2. Hi, interesting post. I have been pondering this issue,so thanks for writing. I will certainly be subscribing to your site.

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