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Meralgia paresthetica

Meralgia paresthetica occurs when the lateral femoral cutaneous nerve — which supplies sensation to the surface of your outer thigh — becomes compressed, or pinched. The lateral femoral cutaneous nerve is purely a sensory nerve and doesn’t affect your ability to use your leg muscles. In most people, this nerve passes through the groin to the upper thigh without trouble. But in meralgia paresthetica, the lateral femoral cutaneous nerve becomes trapped — often under the inguinal ligament, which runs along your groin from your abdomen to your upper thigh.

Common causes of this compression include any condition that increases pressure on the groin, including:

Tight clothing, such as belts, corsets and tight pants

Obesity or weight gain

Wearing a heavy tool belt

Pregnancy

Scar tissue near the inguinal ligament due to injury or past surgery

Nerve injury, which can be due to diabetes or seat belt injury after a motor vehicle accident, for example, also can Risk factors

The following might increase your risk of meralgia paresthetica:

Extra weight. Being overweight or obese can increase the pressure on your lateral femoral cutaneous nerve.

Pregnancy. A growing belly puts added pressure on your groin, through which the lateral femoral cutaneous nerve passes.

Diabetes. Diabetes-related nerve injury can lead to meralgia paresthetica.

Age. People between the ages of 30 and 60 are at a higher risk.

 Exercises

Hip Exercises. Reducing hip tightness is one way to alleviate the symptoms of meralgia paresthetica by improving flexibility and building strength. Bridging consists of lying flat on the floor and lifting your bottom up while tightening your gluteal muscles. Hip extensions involve lying on your belly and lifting your leg up while tightening the gluteals. Standing hip abduction requires standing upright while slowly lifting each leg to one side, keeping the knee straight. Such exercises should not cause any thigh pain.

Quadriceps Stretches. The quadriceps muscles are located next to the sensory nerve involved in meralgia paresthetica. Stretching these muscles can improve flexibility and strength in the upper thigh. A traditional quad stretch involves pulling the heel of your foot back toward your buttocks while standing, stretching the length of the upper thigh. Again, stretching should cease if pain occurs.

Lunges strengthen both the hips and quadriceps muscles to help prevent thigh pain. These start by standing upright and stepping forward with one foot, lowering the body until the opposite knee touches the ground at a right angle. The exercise then can either be reversed or proceed forward by stepping with the opposite leg.

More advanced outer thigh exercises can incorporate resistance bands to improve flexibility and strength. A resistance band is looped around the ankle and tied at the other end to a solid, immovable object. A variety of exercises can then be accomplished, including extending the hip backward, outward and forward. These should only be conducted when outer thigh pain is completely gone.

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Medial Collateral Ligament (MCL) Sprain

The medial collateral ligament is a flat ligament on the inside (medial) of the knee that connects the tibia (lower leg bone) to the femur (thigh bone). The medial collateral ligament is very important in providing stability to the knee joint.

The most common cause of medial collateral ligament sprain is a blow or sudden impact to the outside (lateral) of the knee joint. This causes the outside of the knee to collapse inward toward the midline of the body and the inside of the knee (where the medial collateral ligament is located) to widen and open up. This opening up stretches the ligament, which results in the injury. The most common symptom of a MCL injury is pain around the inside of the knee joint. Also common is bruising, swelling and tenderness.

Prevention

Warm Up properly A good warm up is essential in getting the body ready for any activity. A well- structured warm up will prepare your heart, lungs, muscles, joints and your mind for strenuous activity.

Avoid activities that cause pain This is self-explanatory, but try to be aware of activities that cause pain or discomfort, and either avoid them or modify them.

Rest and Recovery Rest is very important in helping the soft tissues of the body recover from strenuous activity. Be sure to allow adequate recovery time between workouts or training sessions.

Balancing Exercises Any activity that challenges your ability to balance, and keep your balance, will help what is called, proprioception: - your body's ability to know where its limbs are at any given time.

Stretching. To prevent MCL injury, it is important that the muscles around the knee be in top condition. Be sure to work on the flexibility of all the muscle groups in the leg.

Strapping. Strapping, or taping can provide an added level of support and stability to weak or injured knees.

Strengthening exercises:

Short-arc extensions are done sitting up or lying down. Use a rolled-up towel to support your thigh while you keep your leg and foot in the air for 5 seconds. Lower your foot as you bend your knee slowly. Repeat 10 times for each leg, twice a day.

Straight-leg raises are done lying down.Lift your whole lower limb at the hip with the knee extended, and keep it up in the air for 5 seconds. Then lower slowly. Repeat 10 times for each leg, twice a day.

Quadriceps isometric exercises are done sitting up,with your legs extended in front of you. Tighten your quadriceps muscles by pushing the knees down onto the floor. Hold for 5 seconds. Repeat 10 times each leg, twice a day.

Stationary bicycling on low tension setting improves your exercise tolerance without stressing your knee. Adjust your seat high enough so that your leg is straight on the down stroke. Start with 15 minutes a day and work up to 30 minutes a day.

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Iliotibial Band (ITB) Syndrome

The iliotibial band is a thick tendon-like portion of another muscle called the tensor fasciae latae. This band passes down the outside of the thigh and inserts just below the knee. The main problem occurs when the tensor fasciae latae muscle and iliotibial band become tight. This causes the tendon to pull the knee joint out of alignment and rub against the outside of the knee, which results in inflammation and pain.

Causes

The two main causes are “overload” and “biomechanical errors.”

Overload on the ITB can be caused by a number of things. They include:

Exercising on uneven ground;

Beginning an exercise program after a long lay-off period;

Increasing exercise intensity or duration too quickly;

Exercising in worn out or ill-fitting shoes; and

Excessive uphill or downhill running.

Biomechanical errors include:

Tight, stiff muscles in the leg;

Muscle imbalances;

Foot structure problems such as flat feet; and

Gait, or running style problems such as pronation.

Exercises

Pull foot up to back of buttocks. Cross the uninjured leg over the injured leg and push down, hold for 30 seconds.

Cross injured leg behind and lean towards the uninjured side. This stretch is best performed with arms over the head, creating a “bow” from ankle to hand on the injured side (unlike how it is depicted).

Cross injured leg over the uninjured side and pull the leg as close to your chest as possible.

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Calf Muscle Tear (Gastrocnemius Tear)

Calf (Gastrocnemius) muscle tears commonly occur in middle-aged recreational athletes while performing actions that require forceful contraction of the calf muscle (ex: basketball, hill running, tennis, etc.). Calf muscle tears have similar symptoms and occur by a similar mechanism to Achilles tendon ruptures. The difference is the location of the injury. Achilles tendon ruptures involve the actual Achilles tendon with pain located just above the back of the heel. Calf muscle tears occur higher up where the muscle belly attaches to the fascia (musculotendinous junction).

Treatment

Treatment of Gastrocnemius muscle tears is usually non-surgical, and dependent upon the individual’s symptoms. In most instances, initial treatment includes activity modification (limiting muscle-loading activities), wearing a boot (Cam Walker), and using crutches. As the muscle tear heals, exercises are utilized to regain full range of motion and muscular strength. Significant improvement can be expected within the first two weeks, but full recovery can take up to 6-8 weeks. It may take many more months to regain muscle mass in the calf. Occasionally, excessive scarring will form in the location of the tear. This can cause chronic pain in the area, or render it more likely for future tearing as the fibrotic scar tissue absorbs forces differently than regular healthy muscle tissue.

Acute Phase (first 24-72 hours)

R.I.C.E.  (R = Rest, I = Ice, C = Compression, E = Elevation)

Anti-inflammatory medicines.

Gentle foot and ankle range of motion (ROM) exercises can be carried out as long as the motion is relatively pain-free

Recovery Phase

Once pain free, the patient should progress from gentle plantar flexion (downward motion) exercises against resistance (use of resistance bands), to gradual introduction of stationary cycling, leg presses, and heel raises. Massage techniques can help to decrease swelling and prevent formation of scar tissue.

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Sciatica

Sciatica is classified as pain in the sciatic nerve. This pain may be sharp, dull or burning. It may be focused in one area or it may radiate the entire length of the nerve. It is often felt in the lower back and buttocks region, and often spreads down the back of the leg. The pain is usually only felt on one side. Coughing, sneezing, squatting or extended periods of sitting can cause an increase in pain. The muscles that are innervated by the sciatic nerve may also spasm or cramp, causing additional pain. The pain in the lower back and hamstrings can also lead to inflexibility in the back and hips. Pain and stiffness in the opposite side may also result over time.

Four common causes of sciatica:

Piriformis syndrome is one common cause and is the result of the piriformis muscle putting pressure on the nerve. This may be caused by misalignment of the pelvis and/or hip joint, which changes the position of the piriformis, placing pressure on the sciatic nerve. This misalignment is often caused by muscle imbalances.

Herniated discs in the spinal column can also put pressure on the nerve. A herniation, or protrusion, of the disc can result from a traumatic event or from years of pressure from muscle imbalances.

A third possibility is spinal stenosis, or a decrease in the space between the vertebrae. This reduced space compacts the nerve where it leaves the spinal column. The narrowing is often caused by compression on the spine due to muscle imbalances.

The fourth cause is spondylolisthesis, which is a condition where one vertebrae moves forward in relation to the one below, putting pressure on or more roots of the sciatic nerve. This may be traumatic, degenerative or congenital.

Symptoms:

Pain - This pain can vary from dull, aching pain, to sharp, burning pain anywhere along the nerve pathway.

Numbness - This can also occur anywhere along the nerve pathway. Pain may be experienced in one area with numbness below it.

Weakness - The muscles innervated by the sciatic nerve may become weak due to a decreased ability to send signals along the pathway.

Tingling or “Pins and Needles” - This may be felt in the lower legs and feet.

Cramping or Spasm - The muscles of the hamstrings or calves may spasm or

cramp as a result of incomplete signals being sent through the nerve pathway.

Exercises

While Lying on the Back

Examples of the dynamic lumbar stabilizing exercises done while on the back include:

Hook-lying march. While lying on the back on the floor, with knees bent and arms at sides, tighten the stomach muscles and slowly raise alternate legs 3 to 4 inches from the floor. Aim to ‘march’ for 30 seconds, for two to three repetitions, with 30-second breaks in between repetitions.

Hook-lying march combination. Same exercise as described above, but includes raising and lowering the opposite arm over the head.

Bridging. Start by lying on the back with the knees bent, then slowly raise the buttocks from the floor. Hold bridge for eight to 10 seconds, then slowly lower to starting position. As strength builds, aim to complete two sets of ten bridges.

These exercises should all be performed with a rigid trunk. The pelvic tilt, tightening the lower stomach muscles and buttocks to flatten the back, can be used to find the most comfortable position for the low back.

While Lying on the Stomach

This same pelvic position (tightening the lower stomach muscles to flatten the lower back) is maintained while performing stabilizing exercises from the prone position (lying flat on the stomach):

Raise one leg behind with the knee slightly bent and no arch in the back or neck

Hold for four to six seconds, then slowly lower to starting position. As strength builds, aim to complete two sets of ten leg raises.

Lying face down, with elbows straight and arms stretched above the head, raise one arm and the opposite leg 2 to 3 inches off the floor. Hold for four to six seconds, then slowly lower to starting position. As strength builds, aim to complete two sets of opposite side raises.

Stabilizing exercises

These can be done in the 4-point position (kneeling on hands and knees), raising the arms and legs only as high as can be controlled, maintaining a stable trunk and avoiding any twisting or sagging:

Raise one leg behind with the knee slightly bent and no arch in the back or neck

Hold for four to six seconds, then slowly lower to starting position. As strength builds, aim to complete two sets of ten leg raises.

For a slightly more advanced exercise, raise one leg with the knee slightly bent and no arch in the back or neck and also raise the opposite arm

Hold for four to six seconds, then slowly lower to starting position. As strength builds, aim to complete two sets of ten leg lifts.

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Patella Tendonitis - Jumper’s Knee

Patella tendonitis is the inflammation, degeneration or rupture of the patella ligament and the tissue that surround it, leading to pain and discomfort in the area just below the knee cap. Overuse is the major cause of patella tendonitis. Activities that involve a lot of jumping or rapid change of direction are particularly stressful to the patella ligament. Participants of basketball, volleyball, soccer, and other running related sports are particularly vulnerable to patella tendonitis. Patella tendonitis can also be caused by a sudden, unexpected injury like a fall. Landing heavily on your knees can damage the patella ligament, which can lead to patella tendonitis.

Prevention

Warm up properly. A good warm up is essential in getting the body ready for any activity. A well- structured warm up will prepare your heart, lungs, muscles, joints and your mind for strenuous activity. Avoid activities that cause pain. Try to be aware of activities that cause pain or discomfort, and either avoid them or modify them.

Rest and Recovery. Rest is very important in helping the soft tissues of the body recover from strenuous activity. Be sure to allow adequate recovery time between workouts or training sessions.

Footwear. A good pair of shoes will help to keep your knees stable, provide adequate cushioning, and support your knees and lower leg during the running or walking motion.    

Strapping. Strapping, or taping can provide an added level of support and stability to weak or injured knees.

Exercises

Balancing Exercises. Any activity that challenges your ability to balance, and keep your balance, will help what is called, proprioception: - your body’s ability to know where its limbs are at any given time.

Stretching. To prevent patella tendonitis, it is important that the muscles around the knee be in top condition. Be sure to work on the flexibility of all the muscle groups in the leg.

Strengthening:

Short-arc extensions are done sitting up or lying down. Use a rolled-up towel to support your thigh while you keep your leg and foot in the air for 5 seconds. Lower your foot as you bend your knee slowly. Repeat 10 times for each leg, twice a day.Straight-leg raises are done lying down. Lift your whole lower limb at the hip with the knee extended, and keep it up in the air for 5 seconds. Then lower slowly. Repeat 10 times for each leg, twice a day.

Quadriceps isometric exercises are done sitting up, with your legs extended in front of you. Tighten your quadriceps muscles by pushing the knees down onto the floor. Hold for 5 seconds. Repeat 10 times each leg, twice a day.

Stationary bicycling on low tension setting improves your exercise tolerance without stressing your knee. Adjust your seat high enough so that your leg is straight on the down stroke. Start with 15 minutes a day and work up to 30 minutes a day.

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Iliopsoas Tendonitis and Iliopsoas Syndrome

Iliopsoas Tendonitis and Iliopsoas Syndrome are conditions that affect the iliopsoas muscle located in the anterior region (or front) of the hip.Technically, they are two separate conditions, but it’s not uncommon to hear the term iliopsoas tendonitis or iliopsoas syndrome being used to describe the same thing. Iliopsoas tendonitis refers to inflammation of the iliopsoas muscle and can also affect the bursa located underneath the tendon of the iliopsoas muscle. Whereas iliopsoas syndrome refers to a stretch, tear or complete rupture of the iliopsoas muscle and / or tendon. The iliopsoas muscle is actually made up of two separate muscles located in the anterior (or front) of the hip area. Psoas are responsible for lifting the upper leg to the torso,or flexing the torso towards the thigh (as in a sit-up). Although the two muscles start at different points (the psoas originates from the spine, while the iliacus originates from the hip bone) they both end up at the same point; the upper portion of the thigh bone. It is at this point; the insertion, that most injury occurs.

Causes

Iliopsoas tendonitis is predominately caused by repetitive hip flexion or overuse of the hip area, resulting in inflammation. Iliopsoas syndrome, on the other hand, is caused by a sudden contraction of the iliopsoas muscle, which results in a rupture or tear of the muscle, usually at the point where the muscle and tendon connect.Athletes at risk include runners, jumpers and participants of sports that require a lot of kicking. Also at risk are those who participate in strength training and weight lifting exercises that require a lot of bending and squatting.

Symptoms

Pain and tenderness are common symptoms of both conditions; however the onset of pain associated with iliopsoas tendonitis is gradual and tends to build up over an extended period of time, whereas the pain associated with iliopsoas syndrome is sudden and very sharp.

Prevention

There are a number of preventative techniques that will help to prevent both iliopsoas tendonitis and iliopsoas syndrome, including modifying equipment or sitting positions, taking extended rests and even learning new routines for repetitive activities. However, there are four preventative measures that I feel are far more important and effective.

A thorough and correct warm up will help to prepare the muscles and tendons for any activity to come. Without a proper warm up the muscles and tendons will be tight and stiff. There will be limited blood flow to the hip area, which will result in a lack of oxygen and nutrients for the muscles. This is a sure-fire recipe for a muscle or tendon injury.

Rest and recovery are extremely important; especially for athletes or individuals whose lifestyle involves strenuous physical activity. Be sure to let your muscles rest and recover after heavy physical activity.

Strengthening and conditioning the muscles of the hips, buttocks and lower back will also help to prevent iliopsoas tendonitis and iliopsoas syndrome.

Flexible muscles and tendons are extremely important in the prevention of most strain or sprain injuries. When muscles and tendons are flexible and supple, they are able to move and perform without being over stretched. If however, your muscles and tendons are tight and stiff, it is quite easy for those muscles and tendons to be pushed beyond their natural range of movement. When this happens, strains, sprains, and pulled muscles occur.

Exercises

Stretching:

Iiliopsoas stretch: Kneel on one foot and the other knee. If needed, hold onto something for balance and then push your hips forward.

The “quad stretch” with your leg held backwards like a bow offers some stretch to the iliopsoas. Another more specific stretch would be lying on your bed, and allow your leg to dangle off the side of the bed from the hip on down. This is uncomfortable, but it does stretch the area. You can do 3 sets of 20 second stretches on each side. Alternatively you can move down towards the bottom of the bed and allow both legs to dangle off the bottom of the bed. To lessen some of the pain you are having you’ll also find that when you get up from a lying (supine) position you may want to roll over onto your side first or use your elbows and hands to assist in lifting yourself up. When you are almost completely recovered, gentle lunges can help you regain more flexibility and your ability to take a full stride without pain. Don’t do this if it causes pain - focus on the other stretches in that case.

Strengthening:

Planks 15 to 45 seconds

Bridges - 10-15

Single Legged Bridges - 8-12

Side Planks - 10 to 30 seconds each side

In running, avoid hills. Uphills will be somewhat painful when lifting the leg, and downhills may also aggravate the condition. Curtail your speedwork, and shorten your stride. Also, try a brief rest of a few weeks, while continuing your stretching and strengthening exercises.

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Ankle Sprain

An Ankle sprain is one of the most common musculoskeletal injuries. Patients typically describe an episode where they roll their ankle to the inside. Patients typically have significant pain and swelling, and usually limp. However, quite often they are able to bear weight, unlike an ankle fracture where weight bearing is extremely difficult. With the ankle swollen over the outside (lateral) aspect, there is often associated redness due to the increased blood flow to this area.

Classifications

Ankle sprains are typically classified as mild, moderate, and severe. It is often difficult to tell exactly which category the ankle sprain is.

A mild ankle sprain involves partial tearing of the anterior talofibular ligament. This ligament is torn and may be even stretched, but it is intact. These ankle sprains will take 4-7 days to achieve most of the recovery.

A moderate ankle sprain involves a significant tearing of the anterior talofibular ligament and some tearing of the calcaneofibular ligament. This type of ankle sprain often takes 7-12 days to mostly recover.

A severe ankle sprain involves disruption of all of the ligaments on the lateral aspect of the ankle, specifically the anterior talofibular ligament, the calcaneofibular, and the posterior talofibular ligament. This is a major injurythatmaytake4-6weeks,or even longer,to largely recover. Furthermore, in approximately 8-10% of patients suffering a severe ankle sprain, there will be associated injuries such as an osteochondral injury to the talar dome.  

Initial Treatment

R.I.C.E.  (R = Rest, I = Ice, C = Compression, E = Elevation)

Anti-inflammatory medicines.

Subacute Phase

Figure of Eight Exercises. Imagine that the tip of your big toe is a pen, then “draw” a figure of eight with your big toe. Move slowly and repeat this motion for 30-60 seconds. Take a break, and then repeat this exercise 5-10 times for a total of 5-10 minutes per day. Don’t be discouraged if your motion is limited compared to the opposite foot. It often takes time to get this motion back. Be sure not to do anything that creates excessive discomfort.

Resisted Eversion. A stretching band is attached to a fixed object such as a doorknob, and then wrapped around the outside of the foot (Figure 1). The foot is then moved in an outward direction against resistance. This motion is repeated 10-20 times. A total of 3-6 sets should be performed.

Proprioception Exercises. Perform a graduated program that works to improve proprioception until both the right and left sides have equal propriceptive ability (assuming one side is uninjured). Compare to your uninjured side (do exercises on both sides until each side is equal). Do exercises daily. Do exercises for 30 seconds and repeat for 5-10 repetitions. Gradually progress the complexity of the exercises:

Basic Exercise. Stand on one foot on a flat surface with your eyes open (30 seconds)

Higher difficulty. Stand on one foot on a flat surface with your eyes closed (30 seconds). Have something available to grab if you lose your balance.Even higher difficulty

Stand on one foot on a flat surface with your eyes closed and move your head from side to side (30 seconds). Have something available to grab if you lose your balance.Highest difficulty

Stand on one foot on a soft surface (ex. a pillow or bed) with your eyes closed, and move your head from side to side (30 seconds). Have something available to grab if you lose your balance.

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Osteitis Pubis

Osteitis Pubis is the inflammation of the pubic symphysis; the point where the left and right pubic bones meet at the front of the pelvic girdle. Individuals who are most at risk of Osteitis Pubis are those who participate in running events, especially distance runners. Weight lifters, ice skaters and dancers are also vulnerable to Osteitis Pubis, and people who have recently had prostate or bladder surgery.

Causes

Osteitis Pubis is predominantly caused by repetitive contraction of the muscles that attach to the pubic bone and the pubic symphysis, and while many things can be attributed to this, they can all be categorized into two main groups: Overload (or training errors); and Biomechanical Inefficiencies.

Overload (or training errors): Osteitis Pubis is commonly associated with sports that require a lot of running, change of direction or weight bearing activity. Other overload causes include:

Exercising on hard surfaces, like concrete;

Exercising on uneven ground;

Beginning an exercise program after a long lay-off period;

Increasing exercise intensity or duration too quickly; and

Exercising in worn out or ill-fitting shoes.

Biomechanical Inefficiencies: The major biomechanical inefficiencies contributing to Osteitis Pubis are faulty foot and body mechanics and gait disturbances. Other biomechanical causes include:

Poor running or walking mechanics;

Subluxation of the sacroiliac joints;

Tight, stiff muscles in the hips, groin and buttocks;

Muscular imbalances; and

Leg length differences.

Exercises

The following exercises are commonly prescribed to patients with osteitis pubis. You should discuss the suitability of these exercises with your osteopath prior to beginning them. Generally, they should be performed 3 times daily and only provided they do not cause or increase symptoms.

Transversus Abdominus Retraining. Begin this exercise in lying or standing. Slowly pull your belly button in “away from your belt line” and breathe normally. Your rib cage should remain relaxed and should not elevate during this process. You should be able to feel the muscle contracting if you press deeply 2cm in from the bony process at the front of your pelvis. Practise holding this muscle at one third of a maximal contraction for as long as possible during everyday activity (e.g. when walking etc.) provided it does not increase your symptoms. Repeat 3 times daily

Adductor Stretch. Begin this exercise by standing tall with your back straight and your feet approximately twice shoulder width apart. Gently lunge to one side, keeping the other knee straight, until you feel a stretch in the groin or as far as you can go without pain (figure 3). Ensure the stretch is pain-free. Hold for 15 seconds and repeat 4 times at a mild to moderate stretch provided there is no increase in symptoms.

Bridging. Begin this exercise lying on your back in the position demonstrated (figure 4). Slowly lift your bottom pushing through your feet, until your knee, hip and shoulder are in a straight line. Tighten your bottom muscles (gluteals) as you do this. Hold for 2 seconds and repeat 10 times provided the exercise is pain free.

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Sacroiliac Joint Sprain and Dysfunction

There are two Sacroiliac (SI) joints. They connect both sides of the sacrum to the iliac part of the pelvic bones, forming the ring of the pelvis. The sacrum is usually formed by five vertebrae fused together (though it can be four or six). The SI joints are big and very strong and are synovial (fluid filled) joints. They are held together by thick and strong ligaments. They are subjected to a small rocking movement in opposite directions to each other when walking. They are subjected to twisting forces when the spine twists. They are under compressive forces when standing or walking, and extreme forces when landing after a jump. The SI joints are ‘shock absorbers’, and transfer forces from the axial skeleton to the legs, and from the legs to the axial skeleton. In women, a large movement of the SI joints are needed to facilitate childbirth. No single muscle crosses the joints and moves the joints as a ‘prime mover’; instead, the joints are moved as a result of complex musculoskeletal movements such as walking.

Exercises

If you are looking to do exercises for sacroiliac joint pain then your first focus should be to stabilize the pelvis including the sacrum in proper alignment. DO NOT do SI joint exercises in poor pelvic alignment, you will only stabilize the faulty alignment and cause more problems! See your osteopath first!

1) Learn neutral spine:Neutral Spine is the healthiest and most stable position for the spine and pelvis taking in to account the natural curvature of the spine.

Standing: Back up against a wall with your buttocks and shoulder blades leaning into the wall. Notice whether your lower back is against the wall or if there is an excessive arch there. The latter is more common.To achieve neutral keep the buttocks and shoulders against the wall and then draw the middle part of your back into the wall. You should feel the abdominal muscles engage and/or the ribs drawing in.

Lying: Lying on a mat with your knees bent and feet hip width apart, arms at your side. Begin by releasing your tailbone down creating an arc in the lower back, move up into the mid back and draw it down without flattening the spine. The shoulder blades are down and heavy and the back of the neck is long, do this by drawing your chin down towards your chest leaving the size of a fist space there.

Sitting: When sitting in a chair press your bottom right up against the back of the chair then stack the rest of the spine over it. Your collarbone is over your hip bones and your breastbone is right above the pubic bone. Navel drawn in gently.Proper posture is the best way to reduce tension from sitting at work all day, on computers, driving, etc.

2) Pelvic Stabilization Exercises for Sacroiliac Joint Pain:

Wall squats Position: Standing in neutral against the wall with your feet the length of your thighs away from the wall.Action: Bend your knees no lower than a 90 degree angle keeping your weight in the heels evenly for both feet. Kneecaps should line up with the second toe in each foot. Repeat for 8-12 repetitions. Do 2-3 sets every other day. Cues: Place hands on hip bones and make sure they stay level as you bend and lift, also keep the buttocks, shoulder blades, and mid part of the back against the wall throughout the exercise.

Pelvic clocks Position: Lying on the floor with neutral spine and knees bent.Action: Imagine your pelvis as a clock. 12 o'clock is at your navel, 6 is at your pubic or tailbone, 3 and 9 are the hip bones. Now imagine there is water in that clock or bowl and you are going to empty from 12 o'clock around clockwise and then counterclockwise feeling each number on the clock working. Cues: Keep the knees still you are just mobilizing the pelvis.

Diaphragmatic Breathing Position: Lying in neutral spine. Action: Without changing the position of your spine inhale deeply through the nose filling up or expanding into the ribs and upper back, then exhale through your mouth expelling the air again without changing the spine. On the exhale feel all the air leave your body feeling the muscles tighten around the waist as your abdomen flattens.

3) Strengthening Exercises for Sacroiliac Joint Pain: Once you have a stable and aligned pelvis you can begin mobilizing exercises to continue strengthening.

Leg Circles. Position: Lying on the floor with one leg extended along the mat and the other at a 90 degree angle to the floor and a neutral spine.Action: Keeping the pelvis still circle the thigh (leg) in the hip socket 6 times each direction. Switch legs. Cues: Focus on keeping the torso and leg on the mat very still as you freely circle the leg in the air.

Bridges. Position: Lying in neutral with knees bent arms at your side.Action: Inhale to prepare and exhale as you press into your heels lifting the pelvis up in neutral until weight is between shoulder blades not in the neck. Inhale hold then exhale to bring the tailbone and ribs down all at one time. Cues: Focus on the navel drawn in to lift the pubic bone up to the ceiling. Weight even in the feet. Rotation and side bending exercises can be added as you are symptom free in neutral spine.

4) Stretching Exercises for Sacroiliac Joint Dysfunction.

The main objective of exercises for sciatic pain from sacroiliac joint dysfunction is to restore the range of motion in this joint which can be limited if the joint is inflamed. Performing range of motion exercises directed at the SI joint can often restore normal movement and alleviate the irritation of the sciatic nerve. Three helpful exercises are:

Single knee to chest stretch. Pull one knee up to the chest at a time, gently pumping the knee three to four times at the top of the range of motion. Do 10 repetitions for each leg.

Press-up. From the prone position, press up on the hands while the pelvis remains in contact with the floor. Keep the lower back and buttocks relaxed for a gentle stretch. Hold the press- up position initially for five seconds, and gradually work up to 30 seconds per repetition. Aim to complete 10 repetitions.

Lumbar rotation—non-weight bearing. Starting by lying on the back with both knees bent, keep the feet flat on the floor while rocking the knees from side to side. The thighs should rub together and the knees will not move very far. The lower spine should remain fairly still. Rock the knees for 30 seconds.

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Hamstring Strain

The hamstring muscles are very susceptible to tears, strains and other common sporting injuries. Those athletes particularly vulnerable are competitors involved in sports which require a high degree of speed, power and agility. Sports such as Track & Field (especially the sprinting events), rugby, soccer, basketball and tennis have high rates.

How is the Hamstring Strained?

During sprinting the hamstring muscles work extremely hard to decelerate the tibia (shin bone) as it swings out. It is in this phase just before the foot strikes the ground that the hamstrings, become injured as the muscles are maximally activated and are approaching their maximum length. A pulled hamstring rarely manifests as a result of contact -if you have taken an impact to the back of the leg it should be treated as a contusion until found to be otherwise.

Exercises

Dynamic Stretching. This involves gentle swings of the leg forwards and backwards gradually getting higher and higher each time. Around 10 to 15 swings on each leg should be enough. The stretches can be done early in the morning (be careful not to force it) as this will set the length of muscle spindle for the rest of the day. Do not attempt this type of stretching in the early stages of rehabilitation, or if it is painful. It works by using the properties of muscle spindles. A muscle spindle is a sensor in a muscle that senses amount of stretch and speed of stretch. By gradually taking the leg higher and higher the muscle spindle allows it to go safely and lengthen the muscle. If the muscle is forced then a stretch reflex is initiated which causes a reflex contraction (shortening) of the muscle. This is called ballistic stretching and can damage muscles. Dynamic stretching is particularly important when returning back to full fitness, especially when speed work is involved. Muscles need to be able to move throughout their full range of motion at speed - not just when stationary.

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ACL Injury

ACL injury, or Anterior Cruciate Ligament injury, is another common problem that affects the knee joint. The ACL is damaged in about 70% of all serious knee injuries, which makes it the most common injury affecting the knee joint.

Exercises

Heel slide: Sit on the floor with legs outstretched. Slowly bend the knee of you injured leg while sliding your heel/foot across the floor toward you. Slide back into the starting position and repeat 10 times.

Isometric Contraction of the Quadriceps: Sit on the floor with your injured leg straight and your other leg bent. Contract the quadriceps of the injured knee without moving the leg. (Press down against the floor). Hold for 10 seconds. Relax. Repeat 10 times.

Prone knee flexion: Lie on your stomach with your legs straight. Bend your knee and bring your heel toward your buttocks. Hold 5 seconds. Relax. Repeat 10 times.

Add the following exercises once knee swelling decreases and you can stand evenly on both legs without favouring the injured knee.

Passive knee extension: Sit in a chair and place your heel on another chair of equal height. Relax your leg and allow your knee to straighten. Rest in this position 1-2 minutes several times a day to stretch out the hamstrings.

Heel raise: While standing, place your hand on a chair/counter for balance. Raise up onto your toes and hold it for 5 seconds. Slowly lower your heel to the floor and repeat 10 times.

Half squat: Stand holding a sturdy table with both hands. With feet shoulder’s width apart, slowly bend your knees and squat, lowering your hips into a half squat. Hold 10 seconds and then slowly return to a standing position. Repeat 10 times.

Knee extension: Loop one end of Theraband around a table leg and the other around the ankle of your injured leg and face the table. Bend your knee about 45 degrees against the resistance of the tubing and return.

One Legged Standing: As tolerated, try to stand unassisted on the injured leg for 10 seconds. Work up to this exercise over several weeks.

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de Quervain’s Tenosynovitis

Tenosynovitis is inflammation of the sheath that surrounds a tendon as opposed to inflammation of the actual tendon itself. de Quervain’s Tenosynovitis is inflammation of the synovium (sheath) of the abductor pollicis longus and extensor pollicis longus muscles as they pass through the wrist, on the radial or thumb side. It occurs more frequently in racket sports such as tennis, squash or badminton as well as canoeing and ten pin bowling. It also occurs in golfers (left thumb of a right handed golfer and vice versa).

Symptoms

Tenderness and swelling on the thumb side of the wrist where the tendons pass.

Crepitus may be felt (a creaking of the tendon as it moves).

Finkelstein’s test may be positive (thumb is placed in the palm of the hand and wrist moved laterally towards the little finger to stretch the tendons - pain may be felt).

Treatment

Rest, splinting if necessary.

Using an extra thick pen may help as this reduces the stretch on the tendons when writing.

Ice or cold therapy to reduce pain and inflammation.

Osteopathy.

A cortisone injection may be given.

In rare cases surgery may be indicated.

Exercises

Wrist Exercises

To help rehabilitate your wrist, stretch the area. Rest your elbow on a level surface. A desk or table works well for this exercise. Elevate your forearm until it is vertical with your chosen surface, and then bend your wrist (palm toward the table) so that your hand and forearm make about 90-degree angle. With gentle pressure from your other hand, hold this position between 15 to 30 seconds, and then return your wrist to its original position. Keeping your arm in this same position, bend your wrist back in the other direction. With gentle pressure from your other hand, press down on your fingers to counter-stretch the wrist, holding this position between 15 to 30 seconds. Repeat these two stretching exercises until you’ve completed 3 sets of each.

With the next exercise, drop your forearm until it rests on the level surface with the outside of the hand touching the table (your thumb should be pointing toward the ceiling). Place a weighted object in the palm of this hand, making sure you can comfortably hold it. Canned goods work well for this exercise. Keeping your forearm on the table, lift the object up and then return your hand to its original position. Repeat this movement for 3 sets of 10 repetitions.

Maintaining your grip on the weighted object, roll your forearm so the palm of your hand now faces the level surface. This exercise is very similar to the previous one, because you’ll lift the can up off the table so that the back of your hand faces you and then lower it back down. Repeat this movement for 3 sets of 10 repetitions.

Still maintaining your hold on the object, roll your forearm so the back of your hand now rests on the level surface. Bend your wrist up off the table, lifting the object toward you, and then return it to its original position. Repeat this movement for 3 sets of 10 repetitions.

Thumb Exercises

Leave the back of your hand resting on the table, but set aside the weighted object. You no longer need it for the rest of the exercises. Keeping the back of your hand on the table, bring your thumb and little finger together and hold for 5 seconds. Repeat with your ring finger, middle finger and index finger, holding each for 5 seconds. Repeat these movements until you’ve completed 10 repetitions for each finger.

Leaving the back of your hand on the table, place a rubber ball in your palm. Squeeze the object, holding anywhere between 5 to 10 seconds, and then release. Much like the other exercises, repeat this movement for 3 sets of 10 repetitions.

Set the ball aside and wrap a rubber band around your fingers so that it cups the thumb and little finger of your affected hand. Stretch your fingers as wide as possible, holding for 5 seconds, and then release. Repeat this movement for 3 sets of 10 repetitions.

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Rotator Cuff Injury and Shoulder Tendonitis

The rotator cuff is a group of four muscles that helps to lift your arm up over your head and also rotate it toward and away from your body. Unfortunately, it is also a group of muscles that is frequently injured by tears, tendonitis, impingement, bursitis, and strains. The major muscle that is usually involved is called the supraspinatus muscle. The other rotator cuff muscle are: subscapularis, infraspinatus, and teres minor. Rotator cuff problems are usually broken up into the following categories listed below. If you’re not sure which one of these you have, start with rotator cuff tendonitis.

 Rotator cuff tendonitis

This is also known as impingement syndrome or shoulder bursitis. Usually this occurs in people 30-80 years of age, and usually the weakness in the shoulder is only mild to moderate. Rotator cuff tendonitis, also known as “bursitis” or “impingement syndrome” occurs when the rotator cuff gets irritated on the under surface of the acromion. The reason this begins in the first place is a source of some debate. Some people are born with a “hooked” acromion that will predispose them to this problem. Others have rotator cuff weakness that causes the humerus to ride up and pinch the cuff. This means that the bursa — a water-balloon type structure that acts as a cushion between the rotator cuff and acromion/humerus — gets inflamed.

Rotator cuff tears

These occur usually in people who have had tendonitis for a while and are starting to experience more weakness. It can also happen in someone who tries to lift something too heavy and feels a pop in the shoulder. A rotator cuff tear occurs when the tendonitis in the rotator cuff gets so bad that it wears a hole through the rotator cuff tendon. Since the tendon is what connects the rotator cuff muscle to your humerus bone, when the tendon is torn, you have weakness in the shoulder. Usually these tears occur in people who have had shoulder pain for some time (called a “chronic rotator cuff tear”). This is, by far, the most common type of rotator cuff tear. However, tears sometimes happen in people who do not have a history of shoulder problems. These people try to lift something that is too heavy and feel a pop in their shoulder, usually with immediate pain (this is called an “acute rotator cuff tear”). Usually the diagnosis is made with an examination by your osteopath. He or she can do special tests to determine how weak your rotator cuff muscles are. In addition, the doctor can check your motion to see if stiffness has developed. X-rays can show bone spurs in people with rotator cuff tears. Often these bone spurs helped to create the tear. Sometimes an MRI is ordered. This can show the osteopath with great detail the rotator cuff tendon and where it is torn. If your osteopath suspects a partial thickness tear (the tendon is not torn all the way through, just part of the way), an MR-arthrogram may be recommended (with consultant referral). This involves an injection into your shoulder before the regular MRI.

Instability impingement

Mainly occurs in younger patients, typically 15-30 years old. The rotator cuff is irritated because the shoulder is loose in the socket. This often happens in baseball pitchers, swimmers, and other throwing athletes. The pain of both of these types of bursitis is usually better with rest or even using some heat over the areas of pain. This is the most common type of bursitis.

Exercises

Phase 1 - Isometric exercises.

The subscapularis is the anterior stabilizer of the rotator cuff and responsible for internally rotating the shoulder. It is best strengthened by holding your arm in front of the body, with the arm flexed to 90 degrees, and rotating the hand to touch the belt. The exercise can be performed while lying on your back with the elbow close to your side and flexed ninety degrees. Lift the weight until it is pointing toward the ceiling and then lower it slowly. Add small amounts of weight as you progress, making sure you are in minimal pain at all times. If it gets too painful, stop and rest.

The supraspinatus is strengthened by holding out your arm straight in front of the body, with the thumbs pointed toward the floor. Slowly elevate the weight to above the head. Stop if pain is produced in any portion of this motion, as the rotator cuff is under maximal stress in this position. As you feel better, you can slowly introduce small amounts of weight to continue strengthening of the muscles.

The infraspinatus is strengthened by holding your arm (and later on, a weight) in the position of the ski pole just prior to planting the pole. By rotating the arm from the neutral straight ahead position, to the externally rotated (out to the side) position, the infraspinatus and teres minor are strengthened. Again, this exercise can also be performed while lying on your side with the elbow close to your hip, and flexed ninety degrees. Rotate the weight until it is pointing toward the ceiling. Shoulder exercises are best performed with relatively light weights and multiple repetitions. The logic behind stretching and strengthening the inflamed rotator cuff in order to speed healing and functional performance is as follows: the inflamed tissue is characterized by increased fluid between the cells, increased numbers of new blood vessels and inflammatory type cells. As a result of this inflammatory reaction, new collagen tissue is laid down in an effort by the body to heal the injured tissue. If the shoulder is immobilized during this time, the new collagen is laid down in a disorganized fashion, creating scar. The goal of gentle stretching, strengthening and anti-inflammatory medication, is to stimulate the cells to lay down collagen along the lines of stress, forming normal strong tendons. The combination of a good warm up, gentle stretching,  strengthening below the limits of pain, icing after working out and anti-inflammatory medication has been consistently shown to speed recovery time in the strongest possible fashion. After you are comfortable with these stretches and have minimal pain and good/fair range of motion in your shoulder, you can move onto resistance exercises. These usually start with what is known as tubing exercises. The ‘tubing’ is also known as a theraband, which is just a big rubber elastic band that you tie, at one end, to something and you hold the other end and pull the band thereby stretching it and providing resistance for your shoulder.

Phase 2 - Tubing exercises

External rotation: Stand resting the hand of your injured side against your stomach. With that hand grasp tubing that is connected to a doorknob or other object at waist level. Keeping your elbow in at your side, rotate your arm outward and away from your waist. Make sure you keep your elbow bent 90 degrees and your forearm parallel to the floor. Repeat 10 times. Build up to 3 sets of 10.

Internal rotation: Using tubing connected to a door knob or other object at waist level, keep your elbow in at your side and rotate your arm inward across your body. Make sure you keep your forearm parallel to the floor. Do 3 sets of 10.

Extension: Same principles as the other two. Keep the arm parallel. 3 sets of 10.  As you feel more confident and you find your strength increasing, you can add more resistance - either in terms of shortening the length of the theraband so you need more resistance to stretch it or by increasing hand held weights in small increments.

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Spinal Stenosis

Spinal stenosis occurs when the space around the spinal cord narrows – most commonly in the lumbar spine and less so in the cervical spine. As the space narrows and pressure is put on to the cord, the blood and nerve supply are pinched and everything lower down in the body from the level where the stenosis is taking place can be affected.

The narrowing can be due to osteoarthritic changes where your body starts developing new bone, particularly around the facet joints at the back of the spine, to try and support the spine. This bony growth can cause encroachment within the central spinal canal or the foramina on either side of the spine where the nerves exit to supply the arms or the legs. The ligaments can also thicken which may increase the encroachment. A much less common cause is when there is vertebral collapse.

Patients with spinal stenosis usually present with back or leg pain (of one or both legs) which is often worsened when the patient walks beyond a certain distance and eased with rest. The patient may describe a feeling of tiredness, cramping or numbness in the legs which relieves when the patient rests and draws their legs up to their chest and takes the pressure off the spinal cord or nerve roots.

Spinal stenosis is most common in the those over 50 with spinal osteoarthritis and degenerative changes, however it can occur as a result of other conditions including:

Paget’s disease

Ankylosing spondylitis

Hyperparathyroidism

Congenital reasons

For those with spinal stenosis, it is most important to be aware that, in the worst case, the pressure on the spinal cord or nerve roots can be a medical surgical emergency. This is when the cauda equina (the amalgamation of nerves at the base of the spine) is compressed. If left untreated, the patient may experience loss of bowel or bladder control and weakness or paralysis of both legs. It is therefore vital to ensure that spinal stenosis is diagnosed and treated as early as possible.

Osteopathy can be a very effective treatment for this often painful condition although it has to be appreciated that the clock cannot be turned back. As spinal stenosis is usually a chronic condition which has taken years to develop, it can take quite a bit of time to really reduce the symptoms. That said, osteopathy can often prevent a worsening of the spinal stenosis and vastly reduce the need for surgical intervention.

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Osgood-Schlatters Disease

Osgood-Schlatters Disease is a common cause of knee pain in late adolescent and early teenage boys. The condition is less prevalent in females, although being active in sports increases a young female’s chances. This condition was named for the two doctors who defined the condition, simultaneously, in 1908; Dr. Robert Osgood and Dr. Carl Schlatter.

Anatomy

The quadriceps tendon attaches to the patella (knee cap) and then continues down to the top of the tibia as the patellar tendon. When the quadriceps muscle flexes it shortens pulling upward on the tendon, which in turn causes the tendon to pull up on the tibia, causing the lower leg to extend. As with any attachment it is under considerable stress when forcibly extending the knee or supporting the bodyweight during dynamic activities. Repetitive forceful contractions of the quadriceps can cause tiny avulsion fractures at the tendon attachment on the tibia. The bone will attempt to repair itself by adding more calcium to the area to protect and strengthen the attachment. This causes the lump under the knee often associated with Osgood-Schlatters Disease. When an adolescent or young teen goes through a growth spurt the muscles often struggle to keep pace with the growing bones and therefore are often too short compared  with the accompanying bones. This places additional stress on the attachments and happens often with the femur and quadriceps muscle. The femur grows quickly and the quadriceps does not stretch so the muscle is tight until it has a chance to adapt to the new growth. This puts a chronic strain on the quadriceps and patellar tendon. This stress leads to those tiny fractures at the attachment site when the muscle is under stress. These lead to the calcium loading at the site and pain and inflammation result.

Signs and Symptoms

Knee pain without an apparent direct cause or pain in the knee during and after exercise may be a sign of Osgood-Schlatters Disease. Although the symptoms may be similar to other conditions, such as patellar tendonitis, in younger athletes this condition should be considered. Some of the common signs and symptoms of this disorder include:

Pain below the knee cap, worsens with exercise or when contracting the quadriceps.

Swelling and tenderness below the knee.

A bony prominence may be noted under the knee as the condition advances.

A “grinding” or stretching sensation may be noted at the tendons attachment site.

Exercises for Osgood Schlatters disease

The following exercises are commonly prescribed to patients with this condition. You should discuss the suitability of these exercises with your osteopath prior to beginning them. Generally, they should be performed 3 times daily and only provided they do not cause or increase symptoms.

Static Quadriceps Contraction. Begin this exercise by sitting with your leg straight in front of you (figure 2). Tighten the muscle at the front of your thigh (quadriceps) by pushing your knee down into a towel. Put your fingers on your inner quadriceps to feel the muscle tighten during contraction. Hold for 5 seconds and repeat 10 times as hard as possible pain free.

Quadriceps Stretch. Begin this exercise by holding a chair or table for balance. Take your heel towards your bottom, keeping your knees together and your back straight until you feel a gentle stretch in the front of your thigh or as far as you can go without pain. Hold for 15 seconds and repeat 4 times at a mild to moderate stretch pain-free.

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Groin Strain

Depending on the severity, a groin strain can range from a slight stretching, to a complete rupture of the muscles that attach the pubic (pelvis) bone to the thigh (femur) bone. A groin strain specifically affects the “Adductor” muscles. (Adductor; meaning, moves part closer to the midline, or middle of the body) These muscles are located on the inside of the thigh, and help to bring the legs together. The adductor muscles consist of “Adductor Brevis”, “Adductor Magnus” and “Adductor Longus,” all of which are displayed in the picture to the right. Adductor Longus has been cut to display the muscles underneath.  Of these three, it is Adductor Longus that is most susceptible to injury, and the most common place of injury on Adductor Longus is the point at which the muscle and tendon attach to the femur (thigh) bone. When a muscle is strained, the muscle is stretched too far. Less severe strains pull the muscle beyond their normal excursion. More severe strains tear the muscle fibres, and can even cause a complete tear of the muscle. Most commonly, groin strains are minor tears of some muscle fibres, but the bulk of the muscle tissue remains intact.

Symptoms

An acute groin pull can be quite painful, depending on the severity of the injury. Groin pulls are usually graded as follows:

Grade I Groin Strain: Mild discomfort, often no disability. Usually does not limit activity.

Grade II Groin Strain: Moderate discomfort, can limit ability to perform activities such as running and jumping. May have moderate swelling and bruising associated.

Grade III Groin Strain: Severe injury that can cause pain with walking. Often patients complain of muscle spasm, swelling, and significant.

Exercises

Athletes who sustain a groin strain will need osteopathy and incorporate a stretching program as part of their rehabilitation. Some simple stretches can help ease the symptoms of a groin strain. Furthermore, stretching can be a useful part of preventing groin injuries from occurring. As a general rule, the stretches should not hurt. There should be a gentle pulling sensation of the muscle, but this should not be painful.

The squatting adductor stretch:

Squat to the ground with your arms between your legs.

Allow your knees to move outwards.

Stretch your legs apart by pushing out with your elbows.

The butterfly stretch

This is done in a sitting position.

Sit with your feet together and knees bent. Grasp your feet with your hands.

Stretch your knees down towards the ground.

Do not bounce. Feel the stretch along your inner thigh.

The adductor stretch

This is done while standing.

Stretch one leg out to the side, keeping your other leg under your torso.

Bend the knee underneath your torso to stretch the muscles of the inner thigh of the opposite leg.

Your outstretched leg should have a straight knee, and you should feel the stretch on the inner thigh.

The cross-leg stretch

This is done while sitting.

While sitting in a chair, cross one leg over the other.

Press the knee of the crossed leg down towards the ground.

This stretch will emphasize the muscles of the inner thigh and front of the thigh.