Injury Free Life: Calf Stretches

Hi, it’s Rob from New Leaf Physiotherapy in beautiful Kelowna, British Columbia, Canada.  Today Iam going to go over calf stretching and two different calf stretches.  The reason I am going to give you two different calf stretches is because you a two different calf muscles!  One calf muscles it starts above the knee attaches into the Achilles tendon, the gastrocnemius, and the other one starts below the knee and attaches into the Achilles tendon, the soleus.  If you have tight calves either those muscles can be causing the tightness.

The first stretch I like to do is a kneeling stretch.  You can use a yoga mat or a carpet to knee on.  I’m going to stretch my right leg, first on the video, I am kneeling on my left.  I’m bringing my right foot back as far as I can, making sure to keep the right heel on the ground.  I put my bodyweight on the right leg.  The stretch is felt in the right Achilles area and it is a subtle stretch.  I’ll hold it 15 to 20 seconds and then I will switch and do it same on the left leg.  This is stretching the deeper, shorter muscle called the soleus.

The next stretch stretch the longer muscle the gastrocnemius, or gastroc for short.  I use is downward dog.  Walk you hands out, bum up in the air and try keep the heels on the ground with the knees being straight.  You are stretching both calves at the same time.  Hold for 15 to 20 seconds.

That’s cash stretching thanks for watching.

Injury Free Life: Eccentric Calf Exercise

Hi, it’s Rob from New Leaf Physiotherapy and we are here in beautiful Kelowna, British Columbia, Canada. Today, I’m going to go over the eccentric calf exercise. I give this exercise to a lot of people with pain around their Achilles tendon/ heel area.

I personally find that this is one of the best exercises that people can do to help with pain in the Achilles tendon area.

What is eccentric exercise?  It is when the muscle lengthens under tension.  This means that when you are doing a calf exercise it’s not the going up onto the toes, it’s the action of coming back down off the toes to having your foot flat on the ground, that is helpful.

When you’re doing an eccentric exercise I always get my people to only do the down phase of the calf on the injured leg,  How do I do that?  Let’s say that it is my right calf/Achilles that’s bothering me.  I’m going to go up on my left toes, then transfer my weight onto my right toes, taking my left foot off the ground, only standing on my right foot.  I slowly lower my right heel down to the ground.   You can hold on to a wall or kitchen countertop for balance.  Try not to put any weight through the hand, only balance.

So up on the left foot, and slow, controlled lowering on the right foot.

In my practice, this is one of my go to exercises for helping my clients with pain in the Achilles area.  I find that it helps to reduce their pain and get them back into action quickly.

Level 2 Upper Kelowna Physiotherapy course

Vince is half sitting on a physiotherapy plinth. You can see the screen behind him with a slide on nerve mobility
Vince chatting about neurodynamics.

The first weekend in March, the 3-5th, I had the pleasure of working with Vince Cunnan, @funsocksphysio on Twitter, on a Level 2 course.  This time the course was not in Vancouver, it was in Kelowna!  This course was spearheaded by Vince in the fall of 2016.  He sent me an email asking if I would be interested in helping him out in a course in the spring of 2017.  I agree and then he set to work trying to set the course up with the BC Orthopaedic Section.  It was a close call because we did not get the numbers that we needed to get the course going at first. It was postponed, then we had a couple more physiotherapists sign up for the course and it was a go!

The course started on Friday afternoon, did I mention the course was in Kelowna?  Vince started off with talking about the course and where it fits into postgraduate learning.   Transitioning into the upper quadrant scan.  We use this type of scan to make sure that us, physiotherapists, do not miss some of the subtleties.  Basically, it is a quick scan from the head down the arm and hand.  We get the clients to do the basic moves to make sure that we are getting the information we need.  We go through head/neck, shoulder, elbow, wrist and hand movements.  We check to see if there is anything that our client did not tell us because it did not seem important to them.  For example, when dealing with neck or shoulder pain, the client will almost always tell us about one or the other.  In reality, they are so closely related that it is very difficult to have shoulder pain without neck pain or vice versa.

A bunch of physiotherapists working on each other
The practicing and questioning begins

Then we go onto the neurological scan of the assessment.  This is one of my favorite parts!  It tests the integrity of the nervous system and the ability of the muscles to get the nerve impulses.  We, as physiotherapists and doctors i.e. GP and neurologist for example, know that the nerves from the arms entangle with one another, in the brachial plexus, and come out as different nerves, with a little bit of multiple different origin nerves.   For example, the C5-T1 nerves go into the brachial plexus and come out at the radial, median, ulnar and axillary nerves.   The axillary nerve has components of the C5 and C6 nerve in it.  Continuing on with my little story, there are certain muscles in the arm that even though they get multiple nerve inputs, there is a primary nerve going to that muscle.  That is called a key muscle.  Testing the nerve and muscle is called key muscle testing.  It tests for weakness in the muscle that is NOT painful!   The test is basically an isometric contraction of the muscle that is held for about 5-10 seconds.  If the muscles do not lose strength, everything is good and move to the next muscle.  If there is some weakness, the muscle should be retesting immediately, within 1 second, to see if the weakness is present and or getting worse.  This can be a sign of the nerve having some pressure on it.  A lot of people immediately think, it is a disc bulging, that puts the pressure on the nerve.  It can be, but it does not have to be.  There are many places along the path of the nerve that can add some extra pressure that may change the strength of the end muscle.  

The conduction of the nerves can also be tested by doing the reflexes of the nerves.  Yes, the classic sitting on the table and having the physiotherapist hit your knee with a reflex hammer and watch your leg swing forward.  In fact, in the upper body we can do that down the arm.  We can get reflexes in following different muscles, levator scapula (back on the shoulder blade), in the deltoid (shoulder muscle), biceps, triceps, thumb and little finger sides of the hand.  Each one of those reflexes tell something to the physiotherapist or doctor about the integrity of nerve and the nerve pathway.  Very cool.  

Friday night was finished off with a talk on neurodynamics.  I think I did another blog post about this.  Neurodynamics includes the movement of the nerves and how they interact with the tissue around them.  It is always interesting.  

 

The young physiotherapists are assessing each others CV region
Assessing the CV region of the spine

Saturday morning, I was up and we started discussing the CV region of the spine.  That is the area of the body where the head sits on the neck.  There are two joints up in this area, the OA and the AA joint, Occipital-atlantal and the axial-atlantal joints.  The skull is known as C0, top on the cervical spine, aka the neck.  The first cervical vertebrae is called C1 or the atlas.  C2 vertebrae is the second cervical vertebrae aka axis.  

The top joint, C0-1 or the OA joint causes the ‘yes’ chin nod motion of the head.  The AA joint, causes the head turning, ‘no’ motion of the head.  We went through the biomechanics with the physiotherapists, i.e. how do these joints in theory move.  What muscles get them to move and what muscles, or other structures, restrict their movement.  That always brings up some good conversation between the instructors and students.  

Just before the morning break we started into the assessment of this area of the body.  This is usually an area of the body that is not covered well in the their normal training in university.  A lot of hands on training for the physiotherapists.  Lots of questions and questioning their techniques.  And most importantly, lots of learning and stimulation of conversation between physiotherapists and instructors.  We went through stability testing in this area of the spine because this area can be injured with trauma.  For example a fall or a car accident.  What I tried to teach, which is more important than stability testing, is when not to stability test and send the client back to their doctor or the emergency room.  It is not often that occurs, but it is really good to know when to do it.  

We finished off the second day of the course, only 10 more to go,  with how to treat this area when there is something wrong.  

  

Vince is seen standing at the front of the room talking about the C-spine to students
Vince discussing the C-spine

Sunday morning started off with me again, going over the anatomy of the upper and lower cervical spine.  Then Vince jumped right in and started off with the biomechanics of the cervical spine, how the bones in the neck move.  There are two different ways of looking at how the bones move, arthrokinematically or osteokinematically.  Arthrokinematics deal with what type of movement happens that the joints, between the bones, while osteokinematics deal with the how the bones move but ignoring the joint movement.  Very interesting indeed!

Vince then went on to teach assessment of the cervical spine.  There are a lot of little subtleties that occur with the assessment of the neck.  The younger physiotherapists did a great job with trying the different skills and adding them to their arsenal of assessment techniques.  

Treatment of the cervical spine was just getting started and the day ended.  One thing that Vince and I did was video some techniques for the physiotherapists taking the course.  I am going to try to add them to this blog post or maybe try to embed them with YouTube.  

PPIVM OA joint bilateral, flexion and extension

PPIVM OA joint unilateral, flexion and extension

PPIVM AA joint, rotation and side flexion

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Total hip replacements

Last year, I did a blog post about total knee replacements.  I fiugred that I better do about total hip replacements.  This operation is another very common one that happens in Canada.  There were 24,253 in Canada in 2006-2007 and the number keep rising annually.  There were 310,800 total hip arthroplasties, THA’s, done in the USA in 2010.

The diagram is of the right hip joint. The femoral head is seen in the acetabulum, of the pelvis. The labrum, cartilage around the acetabulum, as well as the cartilage of the femoral head and acetabulum are seen
The hip joint
Taken from American Academy of Family Physicians

The hip joint is where the top of the femur, the femoral head, attaches to the acetabulum, socket in the pelvis.  The femur is the longest and strongest bone in the body.  The top part of the bone is part of the hip joint, the bottom part of the bone is part of the knee joint.  The hip joint is a ball and socket joint.  There is a lot of mobility in the hip joint.  In the buttock and the groin area are where the muscles that support the hip joint are located.  In the buttock, the muscles that typically support the hip are the glutes, gluteus medius, gluteus minimus and a multitude of small hip external rotators, like quadratus femoris, they turn the leg outwards.  In the groin area, the main muscle that supports the hip joint is pectineus.  Pectineus almost aligns perfectly with one part of the glute med muscle.  Together they are thought to be orientated along the neck of the femur, to pull the head of the femur into the acetabular socket.  The acetabular socket is lined with cartilage as well, the femoral head is covered with cartilage.  There is a joint capsule around the hip joint.  The joint capsule keeps the synovial fluid in the joint, which helps to lubricate and give nutrition to the cartilage.

This picture shows the details of the deep posterior muscles of the hip
The small posterior muscles of the hip
Taken from: ww.med.uio.no

When is someone ready for a THA?  One criteria, is when your doctor does an xray of the hip joint and they do not like what they see.  What is normal?  The femoral head with a good pocket of space around it then the acetabulum.  The radiologists will usually compare the xray of the painful side to the non painful side.  If the space around the femoral head is minimal, most common is the superior aspect of the acetabulum and femoral head, then there is degeneration of the cartilage in the joint.  Another aspect possibly getting a hip replacement, is where the client is having their pain.  I see many people that complain of ‘hip’ pain and the pain is their buttock.  That is not the area for hip joint pain to occur.  Pain in the buttock area can be caused by the low back, sciatic nerve or the muscles of the buttock, i.e. the glutes.  Pain that arises from the hip joint itself is most likely to be found in the groin area, almost along the groin crease.  These are a couple of the things that surgeons look for when deciding if the client is in need of a hip replacement.

The picture on the let shows the xray of a normal hip joint. The xray on the right shows a hip joint that has degeneration in it
Hip xrays
Taken from: WebMD

What happens in a total hip replacement surgery? Honestly, I am not completely sure.  I have never seen a THA surgery.  I have seen multiple total knee replacement surgeries but not one in the past 10 years.  There are a number of different techniques when doing the hip surgery.  There is an anterior, lateral and posterior approaches.  With an anterior approach, the incision is done on the anterior part of the hip area.  The main complication in this technique is the possible cutting of the femoral nerve.  The femoral nerve supplies the sensation and motor function to the groin and anterior thigh muscles.  I have rarely seen this approach, as the risk of that complication is simply too high.  The lateral approach is much more common, in fact, I think the vast majority of the clients I see have had the lateral approach.  The surgeon comes in and cuts the gluteus medius muscle and separates it to get access to the hip joint.  There is also the posterior approach to the hip.  This is when the incision is made on the posterior aspect of the hip, the client may be lying on their front during the operation.  The main complication of the posterior approach is the increased possibility of hip dislocation.  To combat this, there is more of a restriction of hip flexion, post op than normal.  I have seen a few clients that have had this approach, one of the orthopaedic surgeons from Penticton, I believe does this approach.  I believe his clients are restricted to no greater than 70 degrees of hip flexion.  Below is a video of a total hip arthroplasty (this a video of a real person getting their hip replaced, if you are squeamish, you may not want to watch this video).

This brings me to my next topic, restrictions post THA.  There are typically three restrictions.  First, no hip flexion past 90°.  The reasoning for this is that the majority of hip dislocations occur posteriorly, or out the back of the hip joint.  The more the hip is flexed, think of knee to chest, the better the chance that the hip could ‘pop’ out the back of the joint.  Typically this is for 3-6 months, although some surgeons put restrictions on for life.  The second restriction post THA is no pivoting on the surgical leg.  The reasoning is similar to above, to decrease the chance of dislocation.  The muscles of the hip joint are very weak post surgery and it takes, 6 – 10 weeks to get them stronger again.  In reality, it takes someone very dedicated to strengthen the hip/glute/groin muscles the weeks following the surgery.  The third, and final restriction post THA surgery is no crossing the midline with the surgical leg, meaning no crossing the legs.  This thought to be because it places stress on the lateral incision of the hip and makes it possible to dislocate the hip.  There was a review article done in 2015, I believe that reviewed these restriction and what they found was the number one chance of dislocation was a poor surgery performed by the surgeon.  An interesting note, is that in Kelowna, the orthopaedic surgeons have gone from 3 restrictions to 2 restrictions, post op.   They decided to allow clients to cross the midline with their leg, post op.  That got me thinking that typically we get the clients out on their surgical leg side, as it does not cause the leg to cross the midline.  The downside of getting clients out on their surgical side is that they pivot on the surgical hip when getting out of bed.  Now with that restriction gone, I have started getting clients out of bed on their non-surgical side.  This way, they pivot on the non-surgical hip side, much less painful.  In addition, the Kelowna orthopaedic surgeons only keep the restrictions on for 6 weeks.  Pretty cool.

Clients that get a THA do not complain of pain in the same way as clients that get a total knee replacement.  Clients with a TKA complain of pretty severe pain, however, clients that have a THA still complain of pain, don’t get me wrong, but they complain almost more of stiffness.  Many of the clients once they start doing the exercises find a lot of relief with them.

The top photo shows someone lying on their back with both of their legs straight. The bottom photo shows the person still lying on their back but their right knee is bent up and the right heel is still touching the surface of which they are lying on
Heel slides
Taken from WebMD

The operation itself takes about 90 minutes and the client typically stays in the recovery room, 2-3 hours. We see the clients up on the floor, 4W, three to four and half hours post operation.  After the client comes up to the acute surgical floor, is when the physiotherapist gets involved.  Typically the day of the surgery is counted as day zero, same as a total knee replacement.  As long as the client can feel their surgical leg and can wiggle their toes we can work with them.  If the client cannot feel their leg or wiggle their toes, I try to just pop in and say hi to them and go over the exercises and let them know what to expect.  As well, I might get them up standing and possibly ambulate using a two wheeled walker.  How many times has someone asked me to get them up and when they stand up they just about pass out?  Way too many times, it is very common.  For this reason, I am not eager to get people up standing day zero.

The drawing has someone on their back and they are taking their right leg away from the midline of their body.
Supine Hip Abduction
Taken from: www.allianhealth.org

There are typically four exercises we do with the client, post op day one.  Day one is the first day after their surgery.  For the first couple of days, the client does need some help with the exercises.  For example, doing a heel slide while lying on their back, I help to lift the knee and guide the heel.  This exercise seems to be one of the most helpful for eliminating the ‘stiffness’ in their new hip.  Second exercises is supine, lying on their back, heel slide then lift their leg off the bed.  Again, some help is needed with this exercise.  Thirdly, supine abduction, moving the leg away from the midline of the body out to the side.  And finally quads over a roll.  After they do the final exercise, I help them get out of bed and we go for their first walk.  Most of the time people with hip replacements are WBAT.  WBAT = weight bearing as tolerated.  I make sure to let the clients know that just because it hurts does not mean that they are doing any harm to the new hip.  Many people are happy to hear that because they have associated pain with damage to the old hip.

two photographs. The top photo shows someone lying on their back and a rolled up towel is underneath their knee. Their foot is on the bed. The second photo shows the person in the same position but they have activated their quads and straightened their knee lifting their foot off the bed
Quads over a roll
Taken from mysurgery.nshealth.ca

Day two, is when the rehabilitation assistant, RA, comes to see the client.  The RA’s will do the exercises with the client, get them up walking and do the stairs with the client.  Some clients do not want to do stairs because they live in a condo without any stairs  or they live in a rancher style house.  I tell them that we live in a world of stairs.  Their house may not have stairs but just wait until you have to step up on the curb or to go to a restaurant…  The vast majority of people with a total hip replacement go home on day two or three post op.  Clients with a total knee replacement usually go home day two post op.

If you have any questions about total hip replacements of THA’s, please leave a comment or contact New Leaf Physiotherapy.  We would love to discuss your upcoming or recent THA with you.

Ankle injuries

Ankle pathologies
From: www.jcmgpodiatry.com

We are going to discuss a number of different injuries that can happen at the ankle joint.  I did a lecture a few weeks ago on this for a course in Vancouver.  I think the lecture was well received as there was some participation from the group of new-ish physiotherapists, I was helping to co-instruct the course on.  

In this post, I will discuss; lateral ankle sprains, osteochondritis dessicans, achilles tendinopathy, shin splints and high ankle sprains.  

 

Lateral Ankle Sprains

This injury is one of the most common injuries out there.  Why is that?  Did you know that the number one predictor of having an ankle sprain is having a previous ankle sprain!!  One reason is because we do not take the time to rehabilitate ourselves after an ankle sprain.  Have you ever, stepped off a curb, thinking it was 3 inch drop only to find it was a 6 inch drop and you turn your ankle?  You mutter a few curse words and ‘walk it off’.  That is an ankle sprain that will not get rehabilitated.  If you end up doing that a few more times, you can really turn your ankle badly, sometimes surgery is needed if a fracture occur.  

From: www.myphysiosa.com.au

The most commonly injured part of the foot is the anterior talofibular ligament (ATFL).  It is a long band about 24-25 mm in length and about 7 mm wide.  It attaches from the fibula to the talus.  It resists the typical ankle sprain.  The second  most common injury is to the calcaneofibular ligament.  This ligament is stronger than the ATFL.  

What do ligaments do for us, other than protect our joints.  Ligaments have some pretty cool nerves in them.  They are called proprioceptors.  Google defines a proprioceptor as ‘a sensory receptor that receives stimuli from within the body, especially one that responds to position and movement’.  Basically, they tell our body where our body parts are in space.  Have you ever climbed up stairs in the dark?  How do you think our bodies know how high to lift our feet?  It is the nerves in the ligaments, and muscles, that let our brains know how we are moving… Fascinating!

When we turn our ankles numerous times, our proprioceptive input from those nerve is not as crisp as it was previously.  Those nerve tell our brain that our ankles/feet are in a certain position but they might not actually be in that position.  Which is why it is much easier to sprain your ankle a second time.

How do we treat it?  Treatment should include some sort of balance exercise.  Starting on two feet, then progressing onto the one leg, the injured ankle.  Taping, either tradition white tape or K-tape, can be used to help protect the ankle.  Wearing an ankle brace can to help prevent the ankle turning again.  I really like the ASO brace, it was designed really well.  How does a brace work?  We now think that it works through increased proprioception.  Basically, the brace pushes on the skin, which can cause the nerves to fire, telling your brain there is a brace around the ankle joint.  This increase in subconscious awareness we think helps to keep you from turning your ankle again.  The same effect can occur with tape.  Very interesting…

 

Osteochondritis dissecans

The top left hand corner of the talar dome is flaking off. It has the potential of coming off and causing the talocrural joint to get stuck.
The top part of the talus is flaking off with the cartliage due to an injury.
From: houstonmethodist.org

What the heck is this?  It sounds like something scary.  Osteochondritis = inflammation of the cartilage.  Dissecans = desiccate or to dry out.  Putting those two words together = flaking dried out cartilage.  How does this happen?  There is some traumatic injury to a small part of the bone.  The bone chips stay underneath the cartilage.  There is no blood supply to a bone chip, so the bone dies aka avascular necrosis.  With the piece of bone dead under the cartilage, the cartilage can start to flake away.  This will let the bone chips float around in the joint.  The bone chips can sometimes get stuck in the joint, almost like a door stopper.

What do you do if you get a bone chip stopping the movement of your joints?  You can try a loose body manipulation from your physiotherapist.  Another very viable option is to go to the emergency room at your local hospital.  While it is not a true emergency, you may see an orthopaedic surgeon.  They can decide to go into the joint and remove the bone fragment.  

 

Achilles tendinopathy

A black and white picture, looking at the posterior lateral aspect of the foot. The Achilles tendon, where it attaches to the heel, is the only thing coloured red.
Achilles tendinopathy frequently occurs in this area.
From: www.physiocomestoyou.co.uk

What is it?  Localized pain and stiffness in the Achilles tendon area that is usually worse after a period of inactivity or after activity.  An interesting point is that activity can make the symptoms get less while doing activity, i.e. walking or running.

How do you get it?  There is really no one way to get it but there are multiple ways to get you there.  For example, decreased  range of motion at the talocrual and subtalar joints, increased pronation, decreased plantar flexor (calf) strength.  Abnormal tendon structure is a funny one.  Do they get the Achilles tendinopathy because they have a different tendon structure or does the tendon structure change once they have the tendinopathy?  Hypertension, obesity, hyperlipidemia, diabetes these might be because people get these from being inactive and they try to get up and do too much and get Achilles tendinopathy? Training errors = too much, too soon, too fast = won’t last.  Environmental factors were that more recruits got Achilles tendinopathy in the winter vs. summer.

What kind of symptoms do people get?  There can be local tenderness to palpation with possibly some palpable thickening, nodule or gap in tendon continuity.  Swelling and redness might be present.  Pain on resisted plantarflexion or repeated plantarflexion in the Achilles tendon area.  Pain can occur with stretching and some people notice a decrease in their range of motion.

How do we treat it?  Eccentric loading there is strong evidence for this.  There is actually some evidence for  Low Level Laser therapy and Iontophoresis, not as good evidence as for the eccentric loading.  Stretching, foot orthoses/ orthotics have weak evidence supporting their usage.  I, personally, get my client to do a lot more strengthening then stretching.  It helps to control their pain much faster.  The use of orthotics, it does not seem to matter if you get over the counter or custom orthotics.  The main difference between the two are  price, $50 vs $450, respectively.  You should only wear the orthotic for a few weeks as well.  There are experts in the field of physiotherapy that agree on the use of manual therapy and taping to help with the pain.  There is conflicting evidence about heel lifts, some studies say they help others say that they do not help.  Finally, the use of a night splint is not recommended.  They tested the use of a night splint vs. eccentric exercises for pain relief.  The eccentric exercises won hands down…

 

Shin Splints

The two different locations for shin splints. The right leg has a red spot on the front part of the shin for anterior shin splints. The left leg has a red spot just above the inner ankle bone for posterior shin splints.
The two different locations for shin splints.
From: www.myfootdr.com.au

There are actually two types of shin splints.  Anterior (front of the shin) and posterior or medial (inside of the shin).  

Anterior Shin Splints

How do you get it?  Anterior shin splints are from tibialis anterior tendon irritation.  This can be caused by increased foot pronation.  It can possibly be caused by overuse, i.e. sudden increase in kicking a ball for example.  The tibialis anterior muscle lifts the foot up (top of foot comes toward the shin) as well as help to support the arch of the foot.  If the calf muscles are tight, this muscle has to work harder.  I typically treat many runners, think of running 30 minutes with a tight calf.  180 steps/minute x 30 minutes = 5400 steps.  About 2700 steps with each leg.  If the calf is tight and makes that tibialis anterior work harder and strained.     

How do we treat it?  One thing to do, especially if the calves are tight is to stretch out and loosen up the calf muscles.  The stretching can be done with  a couple of classic calf stretches or downward dog (if you know yoga).  In addition, get a massage or use a foam roller on your calves.  They will both hurt with tight calves but it will pay off in the long run.

Posterior Shin Splints

How do you get it?  Posterior or medial shin splints might be caused by tibialis posterior tendinitis. This can be caused by overuse.  I used to see a lot of Highland dancers when I worked in Halifax.  Every year when the  Royal Nova Scotia International Tattoo, a military show, which featured a number of Highland dancers, I would see many tibialis posterior tendinitis’.  The dancers would step up their game and practice more = more jumping.  

What kind of symptoms do people get?  The signs and symptoms of posterior shin splints are pain along the path of the tibialis posterior tendon from 3-4 cm above the medial malleolus to slightly distal.  There can be pain with walking in mid-stance and the heel lift stages.  Along with over pronation in hindfoot or midfoot.  Pain with plantarflexion and inversion movement of the ankle and when testing the strength of these movements.

How do we treat it?  Working directly on the muscles and tendon.  In addition, adding some strengthening exercises. As with any type of tendon issue, I really like to use eccentric exercises (you can see above in Achilles tendinopathy).  

High Ankle Sprains

This xray shows the separation of the inferior tibiofibular joint. There is normally no space between and tibia and fibula.
This xray shows the separation of the inferior tibiofibular joint. There is normally no space between and bones.
From: www.drchiodo.com

How do you get it?  This type of ankle sprain occurs in the inferior tibiofibular joint.   This occurs when the talus is forced upwards and backwards very abruptly.  Another way the injury can occur is with the foot planted, on the ground, and a forceful twisting motion occurs at the ankle.  This can happen when a hockey player goes skate first into the boards.  That type of impact may force the foot into more dorsiflexion, top of foot forced toward the front of the shin, and injure the ligaments.  

How does these types of forces injure the ligaments?  The talus is wider in the front, by about 6mm, than the back.  This causes the inferior tib-fib joint to be splayed really quickly or get wedged apart, injuring the ligaments that hold it together.  The ligaments that can be injured are the anterior tibiofibular ligament, interosseous membrane and the posterior tibiofibular ligament.  

What kind of symptoms do people get?  People with a high ankle sprain will complain of anterior ankle pain usually a pinching sensation.  The client might complain of a giving out sensation on the front of the ankle.  In addition, pain with squatting, getting the talus moving backwards into the ankle mortise.  Which causes splaying of the mortise while stretching the inferior tibiofibular joint ligaments, mentioned above.  Also, the front of the inferior tibiofibular joint can be tender to touch.

There is a minimal space in the inferior tibiofibular joint. Above the joint, you see a screw that is holding the joint together.
This is a high ankle sprain that has had surgery. Notice the inferior tibiofibular joint is very close together, minimal space.
From: www.drchiodo.com

How do we treat it?  These can be difficult to treat as there are no muscles that help to keep this joint together.  In an ideal world, the patient would be non-weight bearing for 4-6 weeks with a compression cuff/tape on the ankle to help the ligaments tighten back up.  I remember treating a hockey player with taping up his leg every 2-3 days to try and keep the tibia and fibula pushed together.  In addition, educating your client on what happened and why you are putting the restrictions on them can be very useful.  Educating my clients is an essential part of the my practice as I know it is for many other  physiotherapists.  In addition, doing some proprioceptive exercises for the client and their ankle can be useful to make sure that when they are back in their sport, they have minimized the risk of this happening again.  If there is a large spreading of the inferior tibiofibular joint, they might actually do surgery!  They put a screw through the inferior tibiofibular joint to help the ligaments tighten up.  

 

 

 

That is a lot of information about different ways that we can injure our ankles.  If you have any question about this post, please leave a comment!

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The Ankle Joint

The outside view of a left lower leg, ankle and foot.
The ankle joint joins the leg to the foot
From: www.pafootdoctors.com

The ankle is the joint in the body where the foot meets the leg.  Just like many joints in the body, we do not seem to care much about it until something goes wrong.  This blog post I am going to talk about the ankle joint and in my next post, I will discuss some of the ankle pathologies or injuries that can occur in this area.  

The ankle joint is made up of three bones.  The bones are the tibia, fibula and the talus.  The tibia and fibula are the bones in the leg and the talus is the bone on the top of the foot.  The tibia and fibula make up ‘the mortise’ and talus sits in ‘the mortise’.  

The two ankle bones, that we think of, on the inside and outside of the ankle are the tibia and fibula, respectively.  ‘The mortise’ is an arch formed by the tibia and fibula.  The intersection of these bones connect is called the inferior tibiofibular joint, at the ankle.  Around the knee, they meet again at the superior tibiofibular joint.  

This is the inferior tibiofibular joint. The fibula is on the right and the tibia is on the left. The front ligament, anterior tibiofibular ligament has been cut.
This is the inferior tibiofibular joint. The front ligament, anterior tibiofibular ligament has been cut. From: clinicalgate.com

The inferior tibiofibular joint is held together by ligaments only, no muscles.  There is the anterior tibiofibular ligament, in the front.  The posterior tibiofibular ligament, in the back.  And in between those, is the interosseus membrane.  This is the strongest ligament to hold the joint together.  

The inferior tibiofibular joint is called a syndesmosis joint.  That means that there is no joint fluid to lubricate the joint.  But the joint is held together by connective tissue instead.  

The talus is an interesting little bone in the foot.  Just like the inferior tibiofibular joint, there are no muscles that attach onto the talus.  

 

This is the talus bone in the ankle joint. The front of the bone is facing the left, the back of the bone is to the right. You are looking at the outside of the bone, where the fibula attaches.
This is the talus bone in the ankle joint. The front of the bone is facing the left, the back of the bone is to the right. You are looking at the outside of the bone, where the fibula attaches.
From: fpnotebook.com

The talus has a funny shape.  It is convex, from front to back, looks like half a circle.  While it is concave side-to-side, looks like an indent in the side of the bone.  It is what is called a modified sellar joint.  A modified sellar joint can only move in one plane of movement.  For your ankle, that is top of your foot to the shin = dorsiflexion.  And pointing your toes away from the shin = plantar flexion.  Basically, this joint can only move the foot up and down.  The talus is about 6 mm wide in the front than the back of the bone.  

Why is the talus wider in the front than the back.  When we bring the top of our foot towards our shin, the talus wedges itself between the inferior tib-fib joint.  By the way, the talus and the inferior tib-fib joint = the talocrural joint.  Anyways, back to the wedging.  When the talus wedges itself between those two leg bones it makes  the joint much more stable.  So stable in fact that it does not need any muscles to act on the stability of that joint.  

This picture shows the tibia, fibula, talus and calcaneus bones. The ankle mortise is made up of the tibia and fibula, on the top, and the talus fits between the two bones underneath.
This is view of the talocrural joint. It shows the ankle mortise.
From: www.pt.ntu.edu.tw

When you move your foot up and down, with your leg straight as you sit on the sofa, you do not need a bunch of stability.  However, if you are walking, lifting, carrying any weight, you would not want your talus to accidentally slip out of place.  That would be bad… actually very bad.  Same thing with squatting, as you squat down, the shin will travel forward, essentially bringing the top of your foot towards the shin.  If you are squatting and putting something down, again, you want that joint to be very stable.   

If there are no muscles holding the talus in its place, why does it not dislocate?  There are a lot of ligaments that hold it in place.  Ligaments are like pieces of rope.  Unlike muscles, ligaments cannot contract to hold the talus in place.  Ligaments are little bands of collagen that are very tough.  There are multiple ligaments on the inside and outside of the ankle.  

 

The deltoid ligament components anterior tibiotalar, tibiocalcaneal and posterior tibiotalar ligaments. You are looking at the inside of a right ankle.
The deltoid ligament components.
From: corewalking.com

On the inside of the ankle are three ligaments that blend together to make one large ligament, called the deltoid ligament.  The ligaments have big, scary names but their are mostly named from where they start and end.  For example, tibiotalar ligament, starts on the tibia and ends on the talus.  The ligaments that form the deltoid ligament are the anterior tibiotalar ligament, tibiocalcaneal ligament and the posterior tibiotalar ligament.  They all interact with one another and overlap.  Therefore it looks like one big ligament.  The deltoid ligament is not nearly as frequently injured as the counterparts on the outside of the ankle.  

You are looking at the outside of a right ankle. You can see the anterior talofibular, calcaneofibular and posterior talofibular ligaments..
The lateral ankle ligaments.
From: danceinjurydvd.com

There are also three ligaments on the outside of the ankle.  They are not blended together like the deltoid ligament.  From front to back, the ligaments are the anterior talofibular ligament, calcaneofibular ligament and the posterior talofibular ligament.  The most commonly injured ligament in the ankle is the anterior talofibular ligament (ATFL), followed by the calcaneofibular ligament (CFL).  

These ligaments and muscles from the tibia (shin bone) that go into the foot keep this joint moving properly.  Something else that keeps this joint moving is the joint fluid.  The talocrural joint is a synovial joint.  That means it has a joint capsule that has synovial fluid inside the capsule that helps to lubricate and give nutrition to the cartilage.

 

I hope you enjoyed learning about the ankle joint.  If you have any questions or comments about the ankle joint, please leave a comment below.  

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Level 2 Lower Vancouver 2017

Looking down the middle of a road with cars pared on each side. The sky is blue with some white puff clouds.
Beautiful Vancouver, down in Kits.

This past weekend, I was lucky enough to help Christine teach the Level 2 Lower course in Vancouver.  We were not alone though, we had Tricia as a teaching assistant.  This was going to be a tough weekend of learning for the physiotherapists on the course as we were going to talk about the foot.  Yikes!

Most people think that the foot does not have much to it.  Well let me tell you that there are 26 bones in the foot which = 33 joints.  We were going to not only touch on the bones, but also the muscles (and how to test them) and ligaments.  

We started off this weekend with doing the last half of the case study.  The case study was a good one, made by Christine.  The class was broken up into 3 groups and we discussed the objective findings for this ‘client’.  There was a lot of good discussion in the group I was leading.  We talked about why we do a case study in that format.  

Years ago, when I was going through these courses, we did a test at the end of each course.  Much like this course.  There were two components to these exams, a written exam and a case study.  We never did a case study during the courses.  It was similar for the Level 2 Upper/Lower and Level 3 Upper/Lower exams.  You would get a pass or fail grade on the exam.  That would be your feedback, pass or fail.  Then if you chose to go on further with you education you would have to write you Intermediate exam, which comprised of a written and a case study.  Again, your feedback would be only ‘pass or fail’.  I know a number of really good physiotherapists that tried the exam and failed the case study portion 2-3 times!!  That was because they did not know what they were doing wrong.  There was no feedback.  After a few years, the orthopaedic division decided to add a case study done in class.  The younger physiotherapists seemed interested listening to my tale of times past.  

The physiotherapists in the class working on each other's ankle joint.
Friday night working away

I was up and presenting.  My goal this weekend was teach the inferior tibiofibular joint and the talocrural joint.  We started with simply reviewing the anatomy of the area.  Going over the bones and muscles and ligaments in the areas that we were going to getting our hands into.  Did you know that the ankle joint is made up of three bones, the tibia, fibula and talus?  We will talk about that in my next blog post.  

Then we did the surface anatomy.  The surface anatomy is where you put your anatomy knowledge to practical use.  It is one thing to look at anatomy in a book and a totally different thing to find and move all the bones, muscles and ligaments on your partner’s foot/ankle.  We always go through everything twice.  Why you ask?  So one partner is the model, the other is the therapist and the second time around we switch.  

After a quick break, we dove right into the biomechanics of the ankle joint.  How the bones move, or at least how we think (and feel) they move. The inferior tibiofibular joint is a syndesmosis joint, that means there is no joint fluid there and it is held together with fibrous components.  While the talocrural joint does have the synovial fluid in the joint to lubricate and glide easily.  

We chatted about how the different joints were classified and how they move, their osteokinematics (how the bones move without caring about the joint surfaces) and their arthrokinematics (how the joints glide without caring what the bones are doing).  

Physiotherapists assessing their partners ankle range of motion and strength.
The physiotherapists assessing each other.

Once that was mastered we went into actually assessing the ankle joint.  Looking at how clients move, which is the specialty of Physiotherapy.  Squats, standing on one leg, single leg squats…  All of these movements can tells us something about how the client is moving.  But of course, it should relate to why we are seeing the client in the first place.  We ended off the night with going over some different treatment techniques for the ankle.  Everybody seemed to be in a good spot when we ended Friday evening.

Saturday morning, Christine was up and did a lecture on manipulation.  A manipulation is defined as a high velocity low amplitude thrust.  Chiropractors call these adjustments.  This technique can be used all over the body to loosen up stiff joints.  When most people think of ‘adjustment’ they think of their spine.  We were going to teach these physiotherapists how to do that to the ankle joint but we needed to cover the theory behind it first.  

I was back on the podium, so to speak.  We covered three ankle manipulations; distraction, posterior thrust and a loose body manipulation.  The loose body manipulation is used when something gets into the joint, sometimes a bone fragment from a fracture.  I think I have only used it once in my 13, close to 14, year career.  

Onwards and upwards onto ankle pathology.  We discussed ankle sprains, Achilles tendinopathy, osteochondritis dessicans, shins splints and high ankle sprains.  Lots of knowledge being poured into the minds of the learners.  Then it was time for the morning coffee break.  Whoa!

The physiotherapists are sitting in their desks and listening to Christine lecture on the foot.
Learning the foot from Christine.

Christine took the reins and started on the rest of the foot.  We started off talking about the functional foot and different assessment techniques for the students to start to try to use on their clients.  A few of them asked where does this fit into their assessment of the foot.  These techniques were about trying to watch the foot move through motion and how the motions occur and if compensations occur.

Then we started into the other joints of the foot.  There are a lot of different bones in the foot, as I previously mentioned.  I thought Christine did a great job of breaking it down.  It is difficult as there are so many different joints and different directions the joints could glide for different movements.  I think I was quizzed at every pair of students that I stopped in to chat with.  “Which way does the posterior subtalar joint glide for supination”?  I think that was their favorite question.  🙂  That is considered the hind foot/heel.

There is a young female physiotherapist assessing the right ankle of a male colleague.
Now which movement goes with supination?

Then the midfoot.  The navicular.  The cuboid.  The cuneiforms.  How they all join together and work in harmony.  What are the joint shapes + which ligaments hold them together + how do they move = mind blown!  Yuppers, everybody left the second day with their brains full (if not overflowing) with new knowledge.  People sometimes ask if these Level 2 courses are worth it.  I always say yes, they are expensive but you gain so much knowledge.  Not only theoretical knowledge but real practical knowledge that when you get back to the clinic on Monday,  you can start to use your new found smarts.  

Sunday morning started off with Christine again.  She did a quick review and then onto the forefoot.  The metatarsals and the phalanges.  Did you know that you have phalanges in your hands and feet?  They are the bones that make up your toes and fingers.  

We chatted about how the metatarsals and phalanges move.  Looking at the AROM (active range of motion), testing the PROM (passive range of motion) and the different joint glides.  We then got into stability testing of this area of the foot.  It seemed like another brain full of material given to the students before the morning coffee break.  

A physiotherapist working on the right subtalar joint, medial side. The physiotherapist is applying a lateral glide to the subtalar joint.
Working on the subtalar joint.

After we got back to the classroom, we spoke about foot pathologies.  Metatarsalgia, pain on the bottom ball of the foot area, Morton’s neuroma and the BIG one, plantar fasciitis!  If you want to learn more about plantar fasciitis, you can read my previous blog post.  

Getting into treatment of the different areas of the foot.  How to mobilize the different joints and we even did a couple more manipulations, metatarsal phalangeal traction and a flick technique for the medial subtalar joint.  For the most part, the class really did well on these manipulations.  

This weekend was coming fast to a close after lunch on Sunday.  We  discussed exercises for some different foot pathologies and ways to strengthen the feet.  In my opinion, it is really rare for strengthening to make a client worse off.  Getting muscles working, firing, strengthening are all really good things.  

We ended off the afternoon with a short case study review to try and integrate a lot of what was learned this past weekend.  

I will be heading back to Vancouver in a few weeks time to help out with the knee.  Stay tuned…

If you have any comments or questions, please leave one below and we will get back to you. 🙂

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When to use Hot or Cold on your injuries?

One of the most frequent questions I get as a physiotherapist.  “Should I use heat or cold for my injury?”  I will let you in on my thought process when answering this question, because it really is individual for each person.  However, there are some basics rules.  But first, I am going to talk pain.  

Types of Pain

  1. Mechanical pain
  2. Inflammatory pain
  3. Neurological pain or irritation of the nervous system. 

Mechanical pain is the type of pain that is sharp and easy to localize.  It occurs when something mechanical happens to the tissue, i.e. stub your toe.  It is an immediate sharp, piercing pain that makes you catch your breath and try  not let profanities leak out of your mouth.  Another type of mechanical pain is a pinch.  When this type of pain occurs my client usually starts their sentence with something like this, “ Every time I…”.  There can be many examples, for the shoulder, the sentence could finish with “… lift my arm overhead, I get the pain” or for low back “…try to stand up straight after sitting for awhile, I get that shot of pain in my back”.  

If the client does not do the movement, then they do not get the pain.  That is how mechanical pain works.  Mechanical pain can occur in the body when something gets pinched, say a capsule around a joint (they help to keep the fluid in the joint to lubricate it) or a muscle spasm (many people describe this as a shot of pain and think that they have pinched a nerve).  

Inflammatory pain is a different type of pain.  This type of pain is more difficult to pinpoint exactly what causes this pain.  Inflammatory pain usually comes on 2-8 hours after you did “the something” to cause the pain.  Let’s go back to the stubbed toe example, 3-4 hours after you stub your toe, you finally get a chance to sit down and take your shoe off.  Your toe is just throbbing with pain.  It seems to throb/ache with every heartbeat.  That is inflammatory pain, a dull, ache, throbbing type of pain.  It is difficult to locate where the pain is actually coming from, other than the general area (i.e. the entire toe).  Another time that inflammatory pain shows up is first thing in the morning.  You did something and you thought you were going to be sore that night but were not.  You wake up the next morning and can hardly move because of the dull, aching sensation.  That is inflammatory pain.  

Neurological pain will bring on a totally different type of pain.  We will not talk about this type of pain in this blog post.

How to Determine the type of pain.

This chart is about inflammatory vs mechanical pain.
This is a chart from one of my lectures to physiotherapists about the differences of inflammatory vs mechanical pain.

In my mind, you should treat the different types of pain differently.  

Let’s look at timing after an injury.  When you get injured, enough to cause some either muscle or ligament tearing, the body goes to repair the damage.  Step 1 = inflammation.  Why inflammation?  The body part gets red, hot, swollen, painful.  Do you want to move the part of your body that meets the above?  The answer should be no.  That ‘no’ answer gives the body part some rest.  Generally, the inflammatory process lasts about 24-72 hours.   The really cool thing is that the body does not recognize the inflammatory process to start healing.  However, the body recognizes ‘the end’ of the inflammatory process as the time to start rebuilding the body.  

When to use cold on pain?

During the initial 24-72 hours, I recommend the use of cold to reduce pain and swelling.  Cold packs, ice packs, resting your icy, cold beer containers or other cold items can be rested on the body part you just injured.

A man is holding an ice pack with his right hand on the lateral aspect of his right knee
Using a cold pack can help with pain and controlling inflammation
from: www.everydayhealth.com

You might remember a couple of years ago, in 2014 or 2015, I believe, there was a reporter that called into question the act of using ice or cryotherapy.  They found that there was limited evidence.  So they suggested not using ice as the evidence was limited.  What a dumb thing to do!  I have even had other, less experienced physiotherapists ask me about using ice/cold and then asking what evidence do I have for suggesting that someone put ice on the hot, red, swollen ankle.  I usually say simply because it works!  

There are some people that cannot stand the immediate cold.  I, personally, find the initial drop in temperature to be excruciatingly painful.  So I will take my cold pack off whatever I hurt, for 10 seconds, until the sensation is only down to a low scream, then put it back on.  I will repeat this process about 2-3 times, if needed.  By that time, it is still really cold but it is much more tolerable.  

So what do I recommend?  Simple.  Take a tea towel, get it wet, then wring it out so it is just damp.  Then put a cold pack or some ice cubes or snow in the middle of the towel.  Fold the towel in thirds, left side of the towel goes to the right side of the cold pack, then the right side of the towel goes to the left side of the cold pack.  Fold up the ends to the middle.  Turn over the towel and put it on your sore spot.  How long? 10 minutes every waking hour, if possible.   After 10 minutes put the tea towel and ice/cold pack/snow in the freezer.  After an hour, take the towel out of the freezer, wet the towel again and put it on your ‘owie’.  And repeat.  I find this technique takes the inflammation down each time you do it.

warning icon

WARNING!  It is dangerous to put ice/cold on your skin for a long time!!  After about 10-15 minutes of an ice pack on the body part, the body says “whoa, if this part of the body stays this cold, it is going to get frostbite”.  Then the body actually increases blood flow to the area to stop from getting frostbite.  Increasing the blood flow = more swelling.  That is why I say 10 minutes every waking hour, if possible.  

When to use heat on pain?

When do I recommend heat?  Basically all the other times that are not mentioned in the ‘when to use cold’ section above.

There is a man, you can only see his left shoulder. He is holding a hot water bottle on the back of his left shoulder with his right hand
Hot pack can help increase circulation to the injured area.
from: www.sportsinjuryclinic.net

Why heat?  Heat increases blood flow to the area that is sore.  Interesting fact is that the increased blood flow is only to the outer 0.5 – 1.0 cm deep.  That is why when you remove your hot pack, you see a pink area of skin, the same shape as your hot pack.  Heating with a hot pack heats from the outside inwards.  While activity/exercise heat the body from the inside outwards.  One of my profs at the U of A, Sandy Rennie, said something like this to our class.  “A five minute walk will heat the body up more than 15 minutes on a hot pack”.  

People tend to relax easier with heat than with cold, (both heat and cold can reduce muscle spasm).    When people relax, then the muscle tension decreases and increased blood flow through the muscles.  Why is it important to have increased blood flow?  More blood to the area = more oxygen.  The body uses the oxygen for energy to heal itself.

How long?  Basically after about 15 minutes, there is minimal therapeutic effect of the heat. Other than continually stimulating the skin, giving you that sense of warmth.  The stimulation of the skin can also stop some minor throbbing as well.    

Summary of when to use heat or cold on an injury.

To recap my basic rules (remember you can always break the rules) are to use cold in the first 24-72 hours after an injury.  Put the ice pack on 10 minutes every waking hour.  

Other than that, use heat.  

I did not talk about alternating hot/cold for a reason.  There is some evidence out there that states it does not make swelling go away any faster.  

My old running coach, Cliff Matthews, once said to try alternating cold and heat.  Put the cold on for 10 minutes and let the body part warm back up to regular temperature, then put the cold back on for 10 minutes.  

What do you think about this advice?  Do you like to do something different?  Let me know by commenting below!

Total knee replacements

Total knee replacement is otherwise known as total knee arthroplasty, TKA.  It is one of the most popular surgeries done in Canada.  In 2010-2011 there were 50,733 acute care hospitalizations for TKA’s.  These surgeries are routine.  Let’s give you a little bit of insight into what happens with a total knee replacement, during and after surgery.  But first let’s go over a little bit of information about the knee.  

the picture of the knee shows the upper thigh bone, femur, as well as the lower leg bone, tibia. As well as the meniscus of the knee, medial and lateral, and the medial and lateral collateral ligaments
The knee joint
taken from: ACLSolutions

The knee is the middle joint in the leg.  It sits between the femur, the thigh bone, and the tibia, the shin bone. The far end on the femur has the femoral condyles, rounded ends, that sit on the tibial plateau.  If the bone sat directly on the other bone, there would be no need of a knee replacement.  However, this is not that case, the end of the femur sits on the meniscus in the knee.  The meniscus is cartilage.  Cartilage is one of the shock absorbers of the body.  When you run and walk, the impact of the foot on the ground travels up the tibia, to and through the knee joint, up the femur and into the pelvis.  The meniscus helps to absorb the shock.  In addition, the only cartilage is not on the tibia but the end of the femur that is in contact with the meniscus is covered in cartilage.  The cartilage is called hyaline cartilage.  It is very smooth and very slippery, in fact is more slippery than a freshly polished ice surface.  Normally, there is minimal friction between the knee meniscus and the cartilage at the end of the femur.  The knee joint has a capsule around it and it is filled with fluid.  This fluid is called synovial fluid and it does a couple of things.  It lubricates the joint and the cartilage, to keep it nice and smooth.  It provides nutrition to the cartilage, we think this can occur through compression and distraction.  An example of compression and distraction of the knee joint happens with simple walking.  When you take weight onto your foot, the femur pushes down on the meniscus, compression, and when your leg is swinging from back to front, the knee joint is distracted and allows fresh fluid to go between the femur and tibia.  There are some things that can change this relationship…

Injury can change things with your knee joint.  If you have a fracture, broken bone, that goes into the knee joint, that can impact the cartilage health.  For example, if you break your femur and the broken part of the bone actually goes into the knee joint, there will most likely be issues down the road for that knee.  Especially, if the cartilage rips.  Yikes!  The good news is that fractures this severe are not common.  However, tibial plateau fractures are more common.  They are a crack at the top of the tibia and go downwards into tibia bone.  I have seen these done on someone that has fallen on an extended knee and some soccer players twisting away.  

Shows 5 different types of meniscal tears, longitudinal, bucket handle, flap, transverse and torn horn
Different types of meniscal tears.
Taken from: Caring Medical

In addition, injury to the cartilage itself, a meniscal tear can cause issues down the road.  About the outer 25% of the cartilage in the knee has a blood supply to it.  So if you are lucky enough to tear the outer part of the cartilage and you see a surgeon before it tears more, you might be saved!  The surgeons will usually stitch up the meniscus with a tear on the outer edge and it will heal itself!  But what if the tear is on the inner 75% of the meniscus?  Well, that is not so good…  You will see a surgeon and they probably will do surgery on you and simply cut out that part of the meniscus.  Let it heal for a 3-4 weeks and you can get on with your life.   There was a large study done in 2015, that showed, there was no difference between groups that had meniscus surgery and that did not have surgery, only physiotherapy.  Sounds great in theory however, when your knee is in acute pain, meniscus is caught and not able to move as well as very sore, you really wish for surgery to get that piece of cartilage that is catching, removed.  The research was done very well but when it is acutely flared up, let’s get real, surgery can help a lot.  The only issue is finding a surgeon that can see and operate on you, ASAP.  

Figure 1, on the left, = xray of a normal knee, thick cartilage/ meniscus. Figure 2, on the right, shows an xray of a knee with arthritis, narrowning of the cartilage/meniscus
Figure 1 = xray of a normal knee, thick cartilage/ meniscus. Figure 2 shows an xray of a knee with arthritis, narrowning of the cartilage/meniscus
taken from: WebMD

Arthritis of the knee joint.  What is arthritis of the knee?  It is when there is degeneration of the cartilage of the knee joint.  This can be seen on x-ray… Well actually it cannot.  Please let me explain.  What you see on x-ray are the bones, not the soft tissue, ie cartilage or muscles.  When you look at a knee x-ray there should be a nice space between the femur and the tibia, that is where the cartilage is.  If the space is missing, ie it looks like the bones are touching, there is a lot of degeneration of the cartilage of the meniscus.  You can see the bones close together but you cannot see the cartilage itself in the knee joint.  

Knee arthritis is a major reason of people getting a TKA.  What causes arthritis in the knee?  Well anything mentioned in the paragraph above, well two paragraphs above, is a good place to start.  Basically any type of rip or tear of the meniscus, getting part of the meniscus removed or another traumatic injury to the knee, ie ACL tear, will start you down the road of having knee arthritis.  Building strong muscles around the knee and hip joint will also help to absorb shock and forces going through the knee joint and possibly slow down or stop the progression of the arthritis.  We know the stronger the muscles, around the knee and hip joints, are before going into surgery, the faster the recovery post surgery.  However, most people post surgery wonder why they did the exercises because the knee does not work really well, right after surgery.  I can honestly say that it does make a huge difference.  I have worked on the orthopaedic surgical floor of Kelowna General Hospital for a few years now.  But I am jumping too far ahead of myself.  

So what happens in a knee replacement?  It is not very pretty, let me tell you.  If you ever see a full TKA surgery, you know why the clients are sore after. I have not seen a total knee replacement surgery in a number of years, but I see the recipients of the surgeries quite often in Kelowna General Hospital.  I work part time on the Orthopaedic floor of Kelowna General Hospital.  Every week there are at least 30 total hip and knee surgeries, combined.  But I digress.  Below is an animated video of a total knee replacement.  

The basic procedure, and this can change surgeon to surgeon, is this, not talked about in any order.  The surgeon puts a guide on the tibia, the shin bone and cuts off the top of the tibia, the cartilage and part of the bone.  This is important because next he or she pound in the metal implant on top of the tibia in which the femur will move on.  The reason it is important to cut off some of the bone, is that the implant and bone will grow together making them one, much stronger together.  Then the surgeon turns their attention to the end of the femur.  They attach guides to the femur and cut off the end of the end of the bone.  They do it in five angled cuts.  The surgeon then pounds in the metal implant into the end of the femur.  After that, the surgeon, then may or may not resurface the back of the kneecap, the patella.   Sometimes, if the backside of the patella is really worn down, it will be cut off and an implant will be attached.  Or other times, the surgeon may simply smooth out the cartilage.  During a total knee replacement, the surgeon maybe able to change the angle of the knee very slightly, if the person was knock-kneed or bowlegged.  

This video is an animated version of a total knee replacement.

The knee is then stapled up, wrapped up and sent to the recovery room.  The operation itself takes about 90 minutes and the client typically stays in the recovery room, 2-3 hours. We see the clients up on the floor, 4W, three to four and half hours post operation.  

That is when the really work begins for the clients.  I  have heard many times, “If I knew it was going to be this painful after surgery, I would not have gone through with it”.  Clients that have a TKA done are typically very painful for the first couple of days and that is with strong pain killers in their system.  In fact, more painful than client that have a total hip replacement.  If you think about it, the body does not know what happened is good.  The body knows it was cut open, bone sawed up, metal pounded in, then stapled up. There is good reason to be sore!

Heel slides SOURCE: Original art, redrawn from 5D11293. Used in 4D12023, 5D11987, version in 9D12096
Heel slides SOURCE: Original art, redrawn from 5D11293. Used in 4D12023, 5D11987, version in 9D12096

After the client comes up to the acute surgical floor, is when the physiotherapist gets involved.  Typically the day of the surgery is counted as day zero.  As long as the client can feel their surgical leg and can wiggle their toes we can work with them.  If the client cannot feel their leg or wiggle their toes, I try to just pop in and say hi to them and go over the exercises and let them know what to expect.  There are three exercises in which we do with the client, a heel slide, quads setting and quads over a roll.  As well, I might get them up standing and possibly ambulate using a walker.  How many times has someone asked me to get them up and when they stand up they just about pass out?  Way too many times, it is very common.  For this reason, I am not eager to get people up standing day zero.  

A guy has a very small rolled up towel under his left knee. He is pushing the back of his left knee down into the towel and his left foot is staying on the floor.
Quad setting
Taken from: WebMD

Day one, is the day after their surgery.  Typically, people with TKA’s find that the surgical leg is much more painful on day one.  Many people are surprised about this.  Unfortunately, I have to tell them that is normal.  Day one, we go through all the exercises, as much as they can handle and go for a walk.  The client do not walk by themself, I am not that mean.  They use a 2 wheeled walker to help take the weight off their sore leg.  The client’s are normally very nervous to ambulate because of the pain that happens during the exercises.  However, walking is normally less painful and some people are quite surprised.  Most people after a TKA are WBAT.  WBAT = weight bearing as tolerated.  What that means is that the person can take as much weight on their new knee as they would like.  I always tell my clients that they can take as much weight on your new leg, it may hurt but you are not harming anything.  I find this to be a very important statement.  Simply because if you start walking and it hurts, people think that they are doing damage, which causes the pain.  Letting the client’s know that pain does not equal damage to the knee is very helpful.  Typically people are seen twice the first day after surgery.

The drawing shows a rolled up towel under the clients knee and the clients foot up in the air. The knee is straight.
Quads over a roll SOURCE: 8A11987, redrawn from 8A11293. Used in 4C12023, 85939_1.

Day two, is when the rehabilitation assistant, RA, comes to see the client.  The RA’s will do the exercises with the client, get them up walking and do the stairs with the client.  Some clients do not want to do stairs because they do not have stairs in their house or condo.  What I tell them is that we live in a world of stairs.  Their house may not have stairs but just wait until you have to step up on the curb or to church…  The vast majority of people go home on day two post op. 

It typically takes 6 – 12 weeks for the knee to heal completely.  However, it can take up to a year or more to strengthen and regain the muscle lost in the operation.

If you would like to comment or have suggestions about a total knee replacements, please leave a comment below.  

Mobilisation of the Myofasical System

This is a picture of the first page of the course manual for Mobilisation of the Myofascial System

This past weekend of November 11-13, 2016, I was in Vancouver taking a course called, you guessed it, Mobilisation of the Myofascial System, MMS.  The course was taught by a physiotherapist and massage therapist, Doreen Killans and Betsy Ann Baron, respectively.  Both work out of Montreal and are fascinated with fascia.  I have heard Doreen’s name before as she was an examiner and chief examiner for the Canadian Physiotherapy Association’s Orthopaedic Division.  I have been helping out and starting to teach in the Orthopaedic Division courses, as you have seen in a few of my previous blog posts.  

This course was put on the PABC, Physiotherapy Association of British Columbia.  I am a proud member of this organization and they do great work hosting courses and promoting my profession.

The opening slide on the course, it is titled: Connecting With The Fascia Theory Notes
Opening slide of the course

Why would I take a course like this?  Simple.  I do not really know much about fascia.  When I was in physiotherapy school was discussed fascia minimally.   It was thought to simply be there and give the muscle it’s shape.  Also, it was thought that fascia did not have any nerve input and that it was simply there. I recently learned that those assumptions are just not true.

We now know that fascia is there and supports the muscle shape.  However, fascia is much more than simply the casing on the sausage.  Every part of the muscle is surrounded by fascia.  Muscle cells are surrounded by fascia which links them together to other muscle cells. This creates myofibrils which attach to other myofibrils via fascia.  These form muscle fibres which attach to other muscle fibres to form the muscles.  The outer layer of fascia covers the muscle and links to other fascia covering other muscles.  This leads to the different fascial chains/trains throughout the body.  

A burry picture of Doreen and Besty Ann teaching
Doreen, right, and Betsy Ann, left, teaching.

I also learned that fascia does have nerve innervation.  What does that mean?  It means that fascia can be a source of pain and restriction.  Fascia is innervated by nociceptors and mechanoreceptors.  Nociceptors are responsible for sending warning signals to the brain in which the brain can interpret the signal as painful or not.  Mechanoreceptors tell the body about movement and when something is touching the body/skin.  Fascinating.  

So what is fascia?  Here is the official definition:

A fascia is a sheath, a sheet or any number of other dissectible aggregations of connective tissue that forms beneath the skin to attach, enclose, and separate muscles and other internal organs.  

There are 4 basic types of cells that make up fascia, neural (I talked about that above), muscular (also see above), epithelial and connective tissue.  Epithelial cells attach the fascia to the skin.  The connective tissues play a role with the structure, defensive, trophic and the shape of the fascia.  

Fascia is composed cells and extracellular matrix.  What does extracellular matrix mean?  Extracellular matrix is the stuff outside the cell.  It is made up of ground substance, collagen, water and elastin.  

The class participants listening to Betsy Ann and following along on the television monitors
Listening to Betsy Ann describe some of her techniques

Ground substance, I never really understood what this was when I was in school, is a viscous transparent gel made up of proteins.  It is produced by the fibroblasts and mast cells.  It is the ‘fluid’ outside of cells that hold everything together and allows for the exchange of metabolites/substances.  The ground substance is thixotropic, yes, just like ketchup.  Any substance that is thixotropic means that when at rest the substance is difficult to get moving.  But once it is moving, the substance just moves along.  Think of getting the ketchup moving in a bottle.  Difficult to get moving but once it is moving it comes out easily and sometimes too fast.  Getting all over your fries and plate and table.

Collagen makes basically everything in the body.  There are 12 different types of collagen.  Skin, muscles, ligaments, tendons, lungs, membrane, transparent cornea of the eye and fascia are all made of collagen.  

Elastin is a substance that has the properties of being elastic.  Some ligaments in the body have more elastin in them so they ‘spring’ back into shape after being deformed.  Fascia quickly moves back into its original shape after it is stretched out.  

When fascia gets stuck it can have some crazy effects on the body and restrict movement.  Ever where are shirt and someone pull on one corner of the shirt and you feel the restriction on the other side of the shirt?  That is similar to what can happen with fascia.  It was interesting that sometimes during the course, I would be working on someone’s hip and they would feel it pulling in their opposite shoulder.  

What is the role in the body of having something like fascia?  One thing it does is that it gives the muscles the shapes

This is a picture of the first page of the course manual for Mobilisation of the Myofascial System
Course manual

in which they have.  For example, fascia makes a bicep muscle look like a bicep.  Without the fascia, all the muscles would look the same.  In addition, it can help to support our posture without the use of muscles.  The way we stand, sit is partly supported by the fascia.  One final thing, is that it can act as a shock absorber, spreading the force from an impact over a larger area.  This can help protect our bodies.  

There are many different fascial lines or trains in the body.  These have been dissected out of the body.  In fact some of the deep lines actually go through the tissues that surround the heart (pericardium)!  The names of the lines are: superficial back line, superficial front line, lateral line, spiral line and the deep front line.  

The lines tend to go from the top of the body to the bottom.  For example, the superficial back line ‘starts’ at the head; scalp fascia, occipital ridge, down the erector spinae muscles, to the lumbo-sacral fascia, sacrum, sacrotuberous ligament, hamstrings, gastrocnemius, Achilles tendon, plantar fascia and short toe flexors.  This complete line has been dissected out of a human body.  Very interesting stuff!!  (well at least to me…)

So what does fascia pain feel like?  The pain does not follow any myotomal or dermatomal patterns.   There is disturbed sleep with morning stiffness for a couple of hours.  The quality of pain is usually dull and aching being low grade to severe.  I found this not to be very specific.  What I found more specific was the pain has been chronic.  If there is only a joint that is fixated/stuck, then they get manipulated to get the moving.  If there is only a muscle strain/pull, treating the muscle and exercise will work wonders.  When fascia is involved, the joint will become stuck again for no apparent reason.  Or maybe a recurrent calf strain, that seems to happen a few times a year and never seems to go away.  Maybe certain poses in yoga always give a more global pull throughout the body.  Those are the types of things that seem to implicate a fascial restriction.  

One final little bit of theory that stood out to me is that about 75% of the body is water.  Most people know that.  But what you did not know is that ⅔ of the body water is contained in the fascia!  I have read/heard that we, as society, are in a constant state of dehydration.  That can play a huge role on the fascial system.  This video is called Strolling under the Skin.  It was done by a French plastic surgeon, Jean-Claude Guimberteau.  It highlights how much water is in the fascia.  I believe this fascia, in a living human.  Very cool.  

That was a good part of the theory of the course, which was mostly on the first half day but there were sprinklings throughout the course.  

Most of the 3 days were spend observing and then working on the different fascia testing/ treatment areas in the lower body.  We started with along the spine, top to bottom, and moved into the thoracolumbar fascia.  The techniques for the most part are quite painless.  However, when a tight fascial spot is found, I felt that the two points were connected, even though working on opposite sides of the low back.  

Areas covered on the course, were the  spine, low back, back of the leg, front of the leg, lateral side of the leg, bottom of the foot and the medial side of the leg.  

We also learned from Betsy Ann, no just a number of techniques but also Postural Somatic Awareness or PSA.  What the heck is PSA you ask?  PSA is about getting the client ‘in touch’ or put another way being aware with their body.  The therapist gets the client to standing a posture that is comfortable and familiar.  Then the therapist simple asks the client questions about what the client is sensing.  For example, where are your shoulders?  Another question might be, where is the weight on your right foot?  There are no right or wrong answers.   Then a treatment is given to the client and the questions are asked again, with the client in a standing posture.  It gets the client to start to think about their posture more and get better proprioception of their body.  We practiced this throughout the course before and after each technique.  It was interesting of how some of the course participants perception of themselves changed over this one weekend.

Overall it was a very good course and I learned a lot of new theory but more importantly many new techniques to work with fascia in different ways.  I am looking forward to taking the Level 2 for this course in 2017.  The level 2 course are all the techniques for the upper body.  That would include the head and the crazy fascia connections.  I could see that being very helpful to a number of my clients to help them with their recurring headaches that go away for a few weeks after a treatment and slowly start to return.  

If you have any questions about fascia or want to comment on this blog post, please do.  Call New Leaf Physiotherapy, 778-363-4888 for an appointment to have yourself and your fascia assessed.