If this is always true, why can we feel pain when we have not injured ourselves? 

For example, we feel neck or back pain after sitting for a prolonged periods or a trivial action like reaching for a towel causes severe back pain?
How is this possible if pain = damage? This is confusing.

What The Research Shows

The research tells a different story:

One study ( Brinjiki et al) showed a high rate of ‘pathology’ in lower back MRIs in over 3000 subjects without any pain or dysfunction – and this was in people ranging from 20 to 80 years old.

In the shoulder, many studies have painted a very similar picture. One study (Grisih et al) found that a remarkable 96% of subjects who reported no pain or issues had at least one identifiable ‘pathology’ on their ultrasound scan. 

So you can see that tissue damage does not lead to pain in many cases, and pain can arise without  evidence of tissue damage. This is precisely why we constantly remind our patients that ultrasound scans don’t tell the full story.

The general understanding of pain and injury needs to be updated so that people can overcome pain more easily and get back to living their (best) lives.

A New Understanding of Pain

The new understanding of pain is that it is an output signal created by the brain, as a warning sign. It can be out of proportion to the injury. This serves to change behaviour to prevent further damage, which is often required to fix the problem.

The issue is that most people don’t understand this, and remain stuck with a painful condition because they are fearful to move in case it causes more tissue damage. The problem with this is that people are thinking about local structures, not the whole body. There are compensations and protective mechanisms that can develop in other areas of the body that can contribute to your pain…. Where your pain is located is not necessarily where it comes from.

For example, someone can get knee pain because they had a recent back pain episode that affected the way they walked. The back pain improved, but the knee persisted because of secondary protective mechanisms that have not resolved.

A Whole Body Approach

This is why we look at the whole body and how it works together. We want be as thorough as we can and find all the contributors, both local and remote for your pain. This will enable you to get back to the things you love doing without the pain you have been suffering.

We use a 7 step process (the ridgway method) that will find the main drivers of your pain and fix them quickly. It is scientific, objective and based on the latest neuroscience research. 

If you’re not open to a new understanding of pain, you will remain stuck and restricted by your pain and fear of movement. Are you really willing to let your pain dictate your quality of life? 

Or are you looking for a new approach to regain your lifestyle, independence and get on top of your pain long term?

If you’re ready to take control of your life, book an initial consultation with us. We’d love to help you!

References

Brinjikji W et al; Systematic literature review of imaging features of spinal degeneration in asymptomatic populations. AJNR Am J Neuroradiol. 2015 Apr;36(4):811-6. doi: 10.3174/ajnr.A4173. Epub 2014 Nov 27.

Girish G et al; Ultrasound of the shoulder: asymptomatic findings in men. AJR Am J Roentgenol. 2011 Oct;197(4):W713-9. doi: 10.2214/AJR.11.6971

Nick and Andre are 2 AFL field umpires that were referred to our clinic by word of mouth last year (July 2022) due to recurrent calf injuries. They both had similar presentations, with multiple calf tears over several years, which would often occur more than once in the same season. Each time, they would have to miss 3-4 games while they were recovering and rehabbing their injuries. The cost to both of them was lost income, as well as loss of conditioning and opportunities to progress as umpires and secure finals positions. The emotional cost was also significant, with a loss of confidence in their bodies, and a sense of frustration and confusion…”why does this keep happening?”

The management of each injury was with standard sports medicine protocols, including MRI scan to confirm a tear and the grade, rest/deload, local Physiotherapy ( including massage, dry needling, ice, electrotherapy modalities) and a graduated strength and conditioning program and return to sport.

So why wasn’t this approach working for them and why were they having recurrent calf injuries?

Taking a Broader Whole Body Approach

To work out why Nick and Andre were having recurrent calf strains, we had to use a whole body problem solving approach known as the Ridgway Method. The team have all had extensive training in this method over the last 10 years.
This involved performing a whole body assessment looking for muscle knots, joints that don’t slide and nerves that don’t glide. It also involved assessing posture, strength, motor control and importantly a running video analysis.

The main principles of the Ridgway Method are:

1. Where you feel your pain may not be where the problem is located.
2. The structure that produces the biggest and most consistent gains in movement restrictions connected to your problem, is likely to be a primary contributor to the condition.
3. Behavioural change and motor control are important to reduce load on the primary contributor.

The main test movements we noted that were most guarded and restricted with both Nick and Andre were:

1. Lumbar flexion
2. Thoracic rotation
3. Hip flexion
4. Hamstring length

For both of them, there was one side of their body that was most restricted, and this did correspond to their symptomatic side.

After whole body assessment and treatment trials to find the best structures to continue to work on, their body charts looked like this below. These charts only show the unhappy structures that when trial treatment was performed, improvements in key tests were observed.

The Findings

We found the most dysfunctional structures that made the best gains in the movements signs for both Nick and Andre were actually remote from their calfs! In fact they both had segments in their lower back that were very stiff and painful, and working to release these made significant improvements in their movement signs and also released tension in their calf muscles. We labelled these segments, both from the front (anterior) aspect of their lumbar spines, the PCF or primary contributing factors to their calf conditions. For Nick their was also a secondary contributor in the thoracic spine, and for Andre the secondary contributor was the right sacro-iliac joint (SIJ).

The WHY?

So if working on these lumbar segments made the best improvements in key movement tests and also released calf muscle tension, why were these joints so stiff and problematic?

We performed a number of other tests, including strength tests and a video analysis of their running techniques.
Both Nick and Andre had some postural and control issues that we had to correct.
For Nick it is was about being too extended through his thoracic spine, with some rib flare. Nick also ran like this, with his chest up, which loaded his thoracic spine, and put him more in a lordotic posture which increased load on the lumbar spine. Nick also had some strength deficits in the left hip abductors and adductors, hip flexors and latisimus dorsi muscles, as well as poor gluteal activation.

For Andre, he stood in anterior pelvic tilt with knees locked back into extension. He ran with an anterior tilt also and an increased forward lean. This loaded up his lower back and SIJ. Andre also had a left limb apparent shortening, and we had to provide a heel lift for his left leg to regain symmetry through his hips. This was likely the reason his right SIJ was being loaded and had become stiff. Andre also had strength deficits in his right hip abductors and reduced gluteal activation also.

For both Nick and Andre, there were some mindset obstacles we had to address, which were mainly based around a loss of confidence in their bodies and a fear of re injury.

The calf injuries were then just a symptom of a more central problem, which when identified and treated with all contributing factors addressed also, resulted in no more calf strains and greater confidence in their bodies for both Nick and Andre.

The Results

After going through the Ridgway Method problem solving process late last year, implementing all the strategies we identified to be specific for both Nick and Andre, and adjusting their training, they have both made it through the 2023 season without missing any games. Yes, there were a couple of hiccups, but not with calf issues. Mid season, Nick got bowled over by a ruckman during a game, which jolted his body. Andre had an episode in his right lateral leg from a period of increased sitting. We were able to manage both of these incidents and keep Nick and Andre on track.

They both umpired in the finals and went as far as the preliminary final Carlton vs Brisbane at the GABBA (16th September, 2023), which is further than they have gone any any previous year… a real success story!

Other Factors That Contributed to Their Success

1. Both Nick and Andre were dedicated professionals, who attended all appointments including tune up sessions, followed through on all advice, and worked hard to keep their bodies in the best state.
2. They both had a team of support people around them, including AFL medical and physio staff, masseurs and pilates instructors, and their partners.
3. After meeting with their strength and conditioning coach in August 2022, their running training was modified to increase the amount of easy volume in their program. The research based 80/20 rule was adopted, where the percentage of high intensity training above 80% maximal heart rate represents a smaller fraction of their overall running. This is important for recovery from harder sessions/games and building resilience and conditioning in soft tissues. The amount of easy running (long slow running) was tracked and measured.
4. The AFL changed the amount of umpires per game from 3 to 4 during the 2023 season, which meant that each umpire had less ground to cover during a game.

In summary, this highlights the benefits of using a whole body problem solving approach for any injury, particularly persistent or recurrent conditions. The whole body is interconnected in ways that we are still coming to terms with, and local pain, eg in the calf in this case, can have a remote cause or primary driver, in this case, the lumbar spine.

But why is it so common? It all comes down to swelling. Pregnant women have a tendency to retain more fluid. This leads to generalised swelling across the body, meaning less space in the carpal tunnel, which then compresses the nerves in the forearm and hand. The result is numbness, tingling, and pain in the hands.

We have a complete Women’s health physiotherapy service here for you.

[An important note: Not all swelling in the hands is normal during pregnancy! If you have a sudden increase in hand and feet swelling, it’s important to check in with your midwife or obstetrician ASAP, as this can be an early sign of pre-eclampsia.]

Carpal tunnel syndrome usually starts in the 3^rd trimester and 85% of cases resolve within 2-4 weeks after the baby is born. Management during this time often involves soaking the hands in cold water before bed and wearing a soft splint overnight.

But what happens when it doesn’t resolve? Let’s explore an interesting example of this by looking at Ms X’s case.

When Carpal Tunnel Syndrome Doesn’t Go Away

Ms X presented to our clinic with carpal tunnel syndrome affecting her right and left hand. It had started several months ago during her 2^nd trimester. She had been told by her doctor at the time that it was related to her pregnancy and would resolve after her baby was born. Unfortunately for her, her baby was now two months old and the problem had not gone away – in fact, it was getting worse.

What did we find?

When I saw her, her symptoms were constant numbness, stiffness, and pain in both hands, especially on her right side. In addition to waking up to feed her newborn, she was waking up 1-2 times a night due to pain and numbness. Fine movements like doing up buttons and changing the nappy were difficult. Pushing the pram with her newborn for a walk made things even worse. As you can imagine, experiencing this painful condition on top of adjusting to life with a newborn was a lot to handle!

I assessed Ms X and found:

• Significant nerve tension in both arms
• Rounded shoulder posture
• Muscle tightness and joint stiffness across both shoulders
• Weakness in hands and arms, especially with gripping
• Overall weakness in her core muscles

Returning to full pain-free function

Ms X’s improvements were slow in the beginning. With disrupted sleep, having to constantly pick up her baby, and breastfeeding, getting the rest required for her carpal tunnel to settle was an uphill battle. But little by little, changes started happening!

The tingling gradually reduced – there was less spread, less intensity, and finally, less frequency. The left resolved first, then the right. We’re now at the point where the pain is much less severe and only occurring at night (usually when the baby sleeps on her right arm). She feels stronger overall and able to do many of her daily tasks without the weakness and pain that limited her before.

So what did we focus on to get this result?

First of all, most of the problem was coming from excessive tension around the neck and shoulders further upstream from where she was feeling her pain. This impacted the nerve pathways and led to the symptoms in the wrists and hands. We released this region in our sessions together as part of a whole body approach, which helped improve her flexibility and grip strength week by week.

Next, we made corrections to Ms X’s posture. Keeping her wrists in a neutral position while breastfeeding and carrying her baby were paramount. We also adjusted her posture while pushing the pram – keeping the pram closer to her body, lower the handle height, and squeezing her shoulder blades together helped support her hands and protect her nerves while walking.

We encouraged the use of ice and anti-inflammatory gel nightly over her forearms to reduce swelling and inflammation.

Lastly, the key thing that helped Ms X improve was a gentle program of strengthening her shoulder and core stabilising muscles. We started off with gentle holds and gradually progressed to resistance bands. This proved to be one of the most significant factors to her condition – the stronger she became, the less symptoms she had.

Why Was Strength So Important in Ms X’s Case?

Unfortunately, the advice she had been given regarding strengthening exercise during pregnancy had been unclear. Was it safe? What were the dos/don’ts? Without clear guidelines, she decided it was best to err on the side of caution and pause exercise until after the birth.

This is not an uncommon story, as many pregnant women receive conflicting or even no advice at all about exercise. Unfortunately, this meant she was much weaker following the birth of her child and the initial carpal tunnel problem was able to linger and become a chronic issue.

What Can We Learn From Ms X’s case?

If you experience any pain or problems during pregnancy, it is important to get a full assessment as soon as you can. There’s no reason you should suffer with persistent pain and discomfort during this special time in your life! A Women’s Health physio can help assess the factors contributing to your painful condition, fix them, and guide you in ways to stay well during your pregnancy.

Lastly, aerobic and strengthening exercise is encouraged in uncomplicated pregnancies! If you are pregnant and you’re not sure about what’s safe for you, arrange an appointment today to see our Women’s Health physio. Nicole can help demystify the dos/don’ts, treat areas contributing to your pain, and tailor your exercise to your specific needs. This will help you stay mobile, pain-free, and enjoy your pregnancy journey!

She is a mum in her early 40s who had been suffering a 5 year history of neck, shoulder pain and headaches. The headaches were at the base of her skull and would occur twice weekly and last for several hours. While there were no features of migraine, Mrs P found the headaches quite debilitating, as often her neck and shoulder pain would worsen with them.

Her neck movement was severely restricted also, finding it hard to reverse the car, check blind spots and also to look up with activities like hanging the washing and reaching up to cupboards. Mrs P played netball and found shooting in netball was also painful, and so she had stopped playing. In fact, her enjoyment of life had really taken a hit. She couldn’t enjoy playing with her young daughter as she wanted. She was frustrated and felt down.

She was otherwise in good general health.

Mrs P had also tried other practitioners, including other Physios, with no long term help.

Examination Findings

On initial assessment, we found lots of unhappy areas in Mrs. P’s body that could contribute to her problems. Most notably she had neural tension in all 4 limbs and through the upper cervical spine. This had to be treated first to ensure she responded well to further manual therapy and her results would hold.

There were several muscles in the neck, shoulders, jaw and lower back that were tight and in a protective state, as well as joints in the neck and thoracic spine. The main movements that were restricted were neck rotation (we haven’t shown these for privacy reasons), shoulder internal and external rotation, shoulder abduction and passive neck flexion/rotation. The last test has been shown to correlate well with the incidence neck related headaches.

Below are the pictures of limb range before and after nerve clearing. All tests are performed to the first point of resistance/muscle guarding.

Problem Solving Process

Through a systematic process of treatment trials and clinical reasoning, we narrowed down to a list of 15 structures that were affecting Mrs P’s neck and shoulder movements. With further treatment we narrowed down further to the primary contributor to Mrs P’s condition. This was a segment in her upper neck which was essentially ‘’stuck” (C2) and not gliding to the right as it normally should. There was a secondary contributor in her left shoulder (infraspinatous).

Treatment to this structure made significant changes to Mrs P’s movements, and all other problematic structures.

Results

Over a period 4 weeks (interrupted by Covid!), Mrs P’s movements returned to an optimal state. Concurrently her headaches ceased, her neck and shoulder pain resolved and she was able to finally enjoy playing with her young daughter, as well as move normally and return to netball without pain!

We gave Mrs P strategies to manage her condition long term, including postural, strengthening and motor control exercises, as her posture affected her neck tension and head position.

Postural Corrections

These postural corrections were made for Mrs P, as the corrected position reduced strain and tension on the primary contributors in the neck. Thees new postures will require practice and awareness over time to become natural postures. Mrs P was shown how to check for tension in her neck and whether she was in the correct posture.

Mrs P was overjoyed and quite emotional with her result. She felt that after so many years, she had finally found an approach that worked. She felt confident in her body, and empowered to prevent the condition recurring. She was relieved and excited about enjoying her upcoming holiday, finally being painfree.

This is an example of how a thorough, whole body, systematic problem solving approach can work well for persistent long term musculoskeletal problems.

I want to talk about the challenges I faced and how I have managed to maintain a level of activity and exercise despite the injury, as well as some lessons I learnt along the way.

I had been lucky to avoid injury in my youth playing cricket, squash, and footy competitively plus loads of social sport with friends. I’d seen the cost of injuries in my nine years as an AFL physiotherapist. We had a brilliant rover at the Bulldogs called Brian Royal. He represented Victoria many times, but during his 199th game against Essendon at the MCG in 1992, he tore his Achilles tendon. At his age, it was career over.

The first thing I realised about my own injury was that, although it was limiting and painful, there were no signs of serious injury or red flags. However, there were times when I was severely incapacitated by the pain. At one stage I lost power in my triceps and I couldn’t even lift a 2 kg dumbbell overhead. Later I got excited about chin-ups. After a session of preparation work (not even doing a full chin up), the resultant pain stopped me from sleeping for 2 nights. I tossed and turned and would maybe get some slight relief before a deep shoulder ache came back with a vengeance.

Working with a team of physios was a great opportunity for me to have treatment and work through a prescribed rehabilitation program. I was a living case study. However, I wasn’t consistent with my treatment, only seeking help when the shoulder became particularly painful. Most of the time, I could get on with my life and put up with the discomfort. There weren’t signs of serious pathology, so we decided not to go down the path of further investigation and scans.

I had a chronic annoying shoulder injury that only episodically became severe. I think this is a story that many people can relate to. As Ridgway Method practitioners, we recognise the importance of finding the main drivers of your pain and restriction. These can be addressed by changing movement patterns and habitual postures, and improving tolerance to load with strength and mobility exercises.

Using the Ridgway problem solving approach, Nicole identified my left biceps and anterior deltoid muscle as the main contributors to my shoulder pain. I also have a nerve component to my pain with increased nerve tension in the upper and lower limbs. Now I have treatment on a regular basis with Nicole and have seen consistent improvement in my pain levels, range of movement, and strength.

When she treats these structures, this always improves my shoulder movement by reducing pain and guarding. More importantly, I have an exercise program to build on the improvements made during the treatment sessions. At the beginning, I couldn’t do a push up with proper technique with my left shoulder – but now I can do 3 sets of 15 push ups with good form.

With consistent treatment, specific exercise, and Nicole’s guidance, the movement control of my shoulder has steadily improved and with that, the level of chronic pain and tightness in the shoulder has also reduced to the point where I’m not even aware of my shoulder most of the time. Now I continue with the strength and motor control exercises on a daily basis.

My take-aways:

1. Recovery from injury is never a smooth linear process. There will always be setbacks and obstacles to overcome.

2. Persistence trumps all. To move forward you can’t give up. Always try to find the best pathway forward. Ask questions and get the best understanding you can.

3. You may not get 100% recovery and that may be an unrealistic expectation. You want to be as independent as possible but also know your limitations so you don’t overdo it. I look at my pain as a reminder. It keeps me on track.

4. Always look for guidance and assistance. This can come from your therapist, supportive friend, or family member who can check on your exercises and keep you accountable.

5. There is a difference between pain and suffering. One does not automatically lead to the other. We can get caught up in the emotions, and the negativity of pain does not help our recovery. We always have a choice.

A few years ago I started to notice some mild tingling in my feet, which would come and go, but was more apparent after a long run or a hard training session around Princess Park( I was in a running group back then, and our coach liked to push us!).

As a Physio, I sort of knew what this may be, but it wasn’t affecting me much so I just kept doing what I was doing.

Then in 2019 we renovated our house. Most people who’ve been through this know how stressful it can be, and although we had a great builder, I was quite involved in the whole process. There was a lot of physical work to do, like moving and getting rid of furniture, putting together flat packed furniture( I will outsource this next time!) painting and landscaping, as well as the stress of moving out temporarily and managing the budget. I was still running a lot at this time, because I felt it helped me relax and I enjoyed it.

But soon I started to develop back pain, which would often radiate down the back of my legs on both sides. I remember coming home from work back then, and feeling much worse than the clients I was treating! I also remember umpiring at my son’s tennis games and having real difficulty standing for a set of tennis…my back and legs would be aching, and often my feet would be tingling.

The pain was also affecting my running, in fact I had to stop completely and go to walking on several occasions due to acute episodes. I remember one weekend after a flare up, I couldn’t walk more than 2 km, whereas 1 week earlier I had run 18km! ( 18km is not that far when you’ve done 6 marathons!). I was often tired and cranky at the end of the day, and it was even affecting my relationship with my wife and kids… mainly because I was tired and in pain… and a pain to live with!
 

I had an xray in 2019 and later in 2020 an MRI of my lumbar spine. The results of the latter are below. It looks pretty bad doesn’t it? Essentially I had a forward slip of the L4 vertebral segment on the L5, severe facet joint degeneration at that level, and stenosis(narrowing) of the spinal canal due to disc bulging and swollen facet joints. This really did explain most of my symptoms, especially the tingling in feet and legs, which was nerve irritation.

My doctor had referred me to a spinal surgeon, and cortisone injections were on the cards.

So what did I do:

1. I didn’t panic or catastrophise! With my knowledge of pain and the body, I knew there are a lot of contributors to pain signals being created by the brain, and stress/anxiety is a big factor!
2. I made more time for meditation and managing my mental health, and was more conscious of overdoing and overthinking! This calmed my central nervous system( completing the renovation and settling into a beautiful house also helped!).
3. My colleagues assessed my posture at work and found that I was over straightening my thoracic spine(mid back) when  was leaning over to treat. My back was too straight because I thought this was the right thing, but it was placing more load on my spine, contributing to my pain. Making some postural changes here, working on motor control (thoracic flexion movements) and having my thoracic spine treated regularly made a big difference.
4. I reduced my running volume, slowed down my pace, focussed on more recovery between sessions and worked on my core, back and gluteal strength.( I also started drinking Mangosteen juice daily, known for its anti- oxidant and anti inflammatory properties).
5. I had regular tune ups with the team and regular massage, which prevented strain in my body accumulating, and allowed me to slowly build more strength and capacity for load.
 

It did take some time for things to settle and to build load capacity again, but if you give your body the right conditions(including your positive thoughts and beliefs), and have the right guidance…you can overcome many physical conditions. This also shows that you cannot make decisions about your health based only on scan results, because often they do not correlate to symptoms. There is now lots of evidence to support this. If I had another MRI now the results would not be much different… the same degenerative changes would be there… but I’m essentially pain-free, enjoying my running again…. and my wife and kids are happier!:))
 

If you have recently had a spinal or joint scan and are a little concerned about it, feel free to contact us at the clinic and we’ll be happy to discuss it with you.

She had suffered some trauma to her head and neck region when she was 15 years old, and she had traced the start of her problems to after this event.Mrs D suffered with 2 migraines a month generally, but lately she had been experiencing headaches on a daily basis around this. Her symptoms were usually aggravated by stress.

Her headaches and migraines were in similar areas, usually around the left eye and into the back of the skull on the left, and she had associated pain into her left shoulder and the top of her arm.

Mrs D had been under the care of a neurologist, and had seen other Physios and Chiropractors with good but short to medium term relief only.Her good result was:

What we found

1. Reduce or eliminate the constant headaches.
2. Reduce migraine frequency, duration and intensity.
3. Feel less stiff in the neck and shoulders.
4. Improve energy levels.

We took Mrs D through a whole body assessment, because we know through experience and research that where your pain is may not be where the cause of your problem is.

What we did

Summary of assessment findings:

1. Muscle tension/knots in many of the neck and shoulder muscles on both sides.
2. Adverse nerve tension in the upper limbs.
3. Stiffness in many joints around the neck, thoracic spine and lumbar spine.
4. Restricted passive neck flexion/rotation test, worse to left.
5. Weakness in the deep neck flexors and scapular stabilizers.
6. Poor pattern of shoulder movements, left worse than right.

We trialed treatment on the the unhappy muscles and joints that we had found on the initial assessment, and used a single test movement(passive flexion/rotation of the neck) to measure the response of each intervention. we also monitored other key movement tests related to Mrs D’ condition, especially shoulder and neck range/quality of movements.
From this we made a list of structures that had made good changes to Mrs D movements tests.

We then worked on that list to narrow down further the main dysfunctions that were contributing to Mrs D’s condition. This involved a process of elimination and clinical reasoning.

We finally narrowed down to the left infraspinatous muscle in her shoulder, that was continuing to make differences to all of Mrs D’s relevant movement signs. Working to release this muscle also improved the stiffness in many of the neck joints.

Results

The graph below shows the improvement in Mrs D’s key movement tests over the course of treatment, which involved 7 x 1 hr treatment sessions.

The objective improvement matched improvements in Mrs D’s symptoms:

1. General headaches were largely eliminated between migraines, except for times of high work related stress. In these cases headaches were much less severe, and of shorter duration.
2. Migraines were also less frequent, less severe and shorter duration, on average 1 very 4-6 weeks.
3. Mrs D was very satisfied with her results, feeling more energetic and more in control of her condition. she had simple tests she could use to self monitor her body, to know when muscle and joint tension was increasing, and a range of strategies that she could use to manage her condition long term.

Why was the left shoulder contributing to Mrs D’s condition?
The left shoulder had a large trigger point/knot in the infraspinatous muscle. This was adding to the level of noxious input to her central nervous system, sensitising the main receptor nuclei(trigemeni cervical nucleus) in the brainstem that trigger headaches. Reducing tension in this muscle reduces the level of this noxious input, thus making it harder for a headache/migraine to be triggered.

This shoulder dysfunction related to weakness to of the shoulder stabilisers, poor posture in sitting at her desk, and poor movement control, problems we addressed as part of a long term solution for Mrs D.

This case study highlights the importance of looking beyond the neck in the management of headaches.

It is unlikely that such a result would have been achieved by treatment of the neck alone, as the shoulder release work improved the neck stiffness when re- assessed immediately afterwards.

Heel pain or plantar fascitis, can be a real nuisance, stopping you from putting your best foot forward! In our experience, the 2 biggest myths around this condition are:

1. That where you feel your pain is where the problem is.
2. That the degree of damage on your scan results will determine your ability to recover.

Through a thorough assessment, we often find other areas in the body that contribute to heel pain.

Research shows that scan results are not consistent with your functional restrictions and are not an accurate predictor of recovery.

This case study is a good example of this.

History

Miss C is a 30 year old nurse who presented to our rooms on 28/3/18 with a 5 month history of right heel pain and plantar pain. This had began while overseas and walking a lot in high heel shoes. It had slowly worsened and the plantar foot pain had started in January 2018.

Miss C was a keen runner and this pain had stopped her from running. As the pain worsened, she found walking difficult and would often limp after an exercise class or walking a lot. She had seen a podiatrist, had 3 bouts of shockwave therapy, dry needling and had seen a specialist who had ordered a cortisone injection.

All this had not helped and Miss C was becoming increasingly frustrated and down about not being able to walk properly let alone run.

Scan Results

An MRI of the foot had confirmed plantar fascitis with a small split tear in the plantar fascia, as well as significant degeneration (osteoarthritis) of the sub talar joint (heel joint).

Assessment findings

We used whole body systematic problem solving approach to treat Miss C and get her back to running as soon as was possible.
On examination we found a poor gait pattern with a significant limp and reluctance to take weight through the heel. She was unable to perform a heel raise, and knee to wall lunge was 4cm on right and 6cm on left.  The the sub talar joint was “locked”, ie it was not able to be moved side to side. This movement is referred to as a passive accessory glide of the joint, and all healthy joints in the body should have a certain amount of “passive glide” when tested. The cuboid joint in the foot was also very stiff, as well as the deep calf muscle(tibialis posterior).

Remote assessment revealed Miss C held a lot of tension in her neck and shoulders, especially the left shoulder, which had reduced internal rotation (hand behind back). There were also stiff joints in the thoracic and lumbar spines.

Treatment

Through a process of trial treatments and elimination, we found that release of the left shoulder (subscapularis muscle) was making significant changes to the assessment signs around Miss C’s right foot. Treatment here improved the knee to wall lunge range and heel raise, as well as the mobility of foot joints, when retested immediately after release of the muscle.

Local release was also performed, and as Miss C’s pain and movement signs improved we gradually increased her walking and load bearing exercises. Within 4 sessions, Miss C’s knee to wall lunge had improved to 12cm and she could heel raise without pain x10 on the right leg.

At this point, Miss C started to increase the load on the foot by alternating walking with short periods of running. We progressed the running intervals and reduced the walking intervals over a few weeks until she was running continuously for 30min. We then added faster pace interval sessions to her training.

Miss C emailed us after approximately 2 months telling us that she had just completed a 10km charity race, coming 6th in the field of women! Her foot had held up well, and she was not sore afterwards! As you could imagine, we were absolutely amazed and impressed with her recovery.

We posted her result on our Facebook page.

How do we explain this?

To understand this we need to think about pain in a different way. Modern neuroscience research tells us that pain is an output signal created by the brain to warn the individual and protect them from further damage.

Pain is not in the “tissues” of the body. These tissues have receptors in them that pick up excessive strain or inflammation, but it is the brain that decides whether this is important enough to warn the individual. If the brain is receiving lots of nerve impulses from other tissues in the body, which may be remote from the site of pain, these add to overall level of “danger” signals the brain is receiving. If the sum of these signals exceeds what the brain determines as a safe threshold, then it will create the warning of pain. The brain then allocates an area for the pain based on what is most likely to change the behaviour of the individual, so that they will either take a rest or seek treatment that will restore the body’s balance.

This is why working on other primary areas of the body that are under strain can lower the overall level of  input signals to the brain, and hence reduce the output signal of pain and the associated protective responses in the body.

More information is available at Why do Whole Body Assessment.

Mr M is a 64 year old lawyer who presented with a 5 day history of worsening low back pain which had become so severe that he attended the ED of John Fawkner Hospital. The pain had developed insidiously without any particular incident or change in routine. There was no radiation of pain into the legs, but the pain was worse in standing and walking, and eased by lying down.

Mr M was managed with medication in ED and referred for Physiotherapy with us by his attending emergency physician.

No red flags. General health good. Walks and goes to gym regularly. Meds: Anti- inflammatories, Codeine, Paracetamol as required.

He had a history of intermittent LBP of similar but less intense nature, generally aggravated by gardening.

No obvious psychosocial factors or limiting beliefs.

Important client values:

1. To understand the cause of the condition and how to prevent recurrence.
2. To regain full painfree function to return to normal lifestyle again and enjoy gardening.

We performed a whole body assessment with Mr M and found several restrictions, not only in his back movements, but also the hips, hamstrings (worse on the right), as well as the neck and shoulders. He also had nerve tension (adverse neural tension) in the left upper limb, both lower limbs and the upper cervical region.

Joint signs, ie local stiffness to passive accessory movement, were detected in the lumbar facets on the right L1-3, L5 -S1, as well as T9-12 on the right and the C3/4 facet joint on the left (neck).Hip flexon R= 90deg; L= 115deg

Hamstring range (tested to R1- first point of reactive resistance): R= -50deg; L= -40deg.

According to patho-anatomical classification criteria (Ford et al, 2011, 2012) Mr M’s condition would be classified as a lumbar facet joint condition. This would be treated with local manipulation/mobilising of the lumbar facet joints, then exercises to address strength, flexibility and motor control impairments.

However, we wanted to determine which dysfunctional structure needed treatment to give the best result for Mr M, and we did not assume that it would be the lumbar facets because there were a host of other structures that may have been also contributing to his condition.We needed a movement test to demonstrate changes in Mr M’s condition as a response to treatment.

We chose, in consultation with the client, and based on research and guidelines for effect re-testing,  that hamstrings range would be a good test to use. This also related well to his low back condition (Halbertsma et al, 2001).

We performed treatment trials to all of the problematic areas we found on Mr M’s initial assessment, including lumbar, thoracic and cervical facet joints, using the limited hamstring range (tested passively to R1).After the first round of treatment trials, Mr M’s hamstring range had improved from -50deg to -20deg, a great result.

On follow up the next day, there had been some regression in Mr. M’s movement signs. Further treatment to eliminate contributing structures revealed that the C3/4 facet on the left was continuing to make the best changes to Mr M’s right hamstring range, as well as right hip joint flexion.

Further treatment to the C3/4 followed by reassessment revealed that the thoracic and lumbar joints had also improved, in response to mobilisation of the C3/4 joint. All lumbar movements also became full and pain-free.

At the start of the session on Day 4 of treatment, Mr M’s LBP had resolved, and he rated himself as 90% in terms of function and recovery. This treatment was administered in the same week.

At this point, Mr M’s lumbar joint signs had also resolved, and given the left C3/4 facet was more mobile but still not in an optimal state of passive resistance(ie it was still stiff), we labelled this as the primary contributing factor to his low back pain. Working on it further continued to improve the hip and hamstring signs.

Why was this neck joint such a problem for Mr M? After we had discovered this, he revealed that he had had a long history of neck pain which preceded his back pain, but he generally managed this himself. Looking further into his sitting posture at work revealed some static loading issues, ie the way Mr M was sitting at his desk was creating tension in his neck, and his neck was contributing to his back pain.

Postural correction and client awareness was required to then  achieve a long term result and prevent recurrence, as well as exercises to address neck tension and habitual postural adaptations.

If Mr M’s neck was contributing significantly to his back problem, as we found it to be, not addressing this important part of his condition would suggest that he may be more vulnerable to relapses and recurrence with his back condition. It would also suggest that we are not fully addressing what was important too him at the start, which was to find the cause of the condition and understand how to prevent it.

On 3 month follow up, Mr M had been reasonably diligent with his exercises. He reported an “occasional twinge” in his lower back that did not eventuate and improved quickly with exercise. He was unrestricted and pain free in all his daily activities, including gardening and gym. His objective signs had regressed a little and further work on the neck continued to improve these. Mr M’s self management exercises and postural strategies were progressed.

6 month follow up was better, where Mr M reported he had been “generally good.” Again, hamstring and hip flexion range had regressed but lumbar range was full and pain-free. Further treatment to the neck and some local work to the lumbar spine also improved his signs again to earlier levels.

Mr M has been very satisfied with his result and is now aware that his neck tension and posture contributes to his back pain. 12 month follow up is pending.

This case really highlights the value in not making assumptions and looking at the whole person and how their body is interconnected to achieve the best long term result for the client.

If you are struggling with this pain, this whole body approach could work for you. Contact us and speak to one of our experienced Physiotherapists.

References

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