MEDICAL LIBRARY

Temporomandibular Joint (TMJ) Problems

What is the temporomandibular joint (TMJ)?
The temporomandibular joint is the ‘jaw joint’. This joint allows your lower jaw to move and it is found in front of your ear where the bones of your skull and lower jaw meet. These bones are connected by ligaments and muscles and are protected by a covering called a capsule. Inside the joint, a cartilage disc sits between the bones. It moves forwards and backwards as your mouth opens and closes.

What problems can I have with my TMJ?
Problems with the jaw joint are very common. In most people these problems do not last more than a few months and often get better by themselves. Sometimes, the problems are only in the muscles which move your jaw. In other cases, the cartilage and ligaments may be affected. The most common problems that people notice are: noises in the joint (clicking, cracking, crunching, grating or popping sounds); pain inside or around the ear, jaws or neck; headaches (often at the temples); and difficulty opening the mouth or even locking of the jaw.

Should I be worried about my TMJ problems?
Jaw joint problems are usually not serious. Although jaw joint problems can cause you pain, they often respond to simple treatments.

Why have I got TMJ problems?
Many jaw joint problems are related to overuse of the muscles around the jaw, particularly the muscles that close your teeth. Overuse of these muscles can cause them to tighten up. It often happens because of habits like grinding or clenching your teeth. Poor neck posture often leads to problems by straining jaw muscles that attach to the neck.

What can I do to help ease my jaw pain?
The most important thing is to try not to overuse the muscles around the jaw. This allows them to recover and may also reduce stress on the cartilage disc. Try to eat soft food that does not require much chewing and avoid chewing gum. Identify and stop bad habits like clenching, grinding, and nail-biting even though these habits may be subconscious. Rest the joint as much as possible and avoid opening your mouth very wide when you are eating or yawning. You can try supporting your chin with a finger if you feel the urge to yawn. It may be helpful to use relaxation therapy to control tension and stress.

What can Physiotherapy do?
Your physiotherapist may give you jaw exercises which work to restore jaw joint mobility and strengthen muscles of chewing. Physiotherapy techniques such as manual therapy and upper neck mobilization are often helpful. You may also benefit from using therapeutic machines like laser therapy or ultrasound.

What happens if these methods don’t improve the problem?
For those people that grind their teeth at night, a custom night guard can be manufactured by a qualified dentist. This is worn in the mouth at night to prevent harmful grinding. For a very few people we may suggest surgery. This is extremely rare and patient should try all the other possible treatments first.

Whiplash

What is Whiplash?
Whiplash is the term used to describe a neck injury caused by a sudden movement of the head forwards, backwards or sideways. The sudden, vigorous movement of the head can injure the ligaments and tendons in the neck and can lead to pain, stiffness and a temporary loss of movement in the neck. Headaches, muscle spasms and pain in the shoulders or arms are other possible symptoms.

What causes whiplash?
Whiplash is common after motor vehicle accidents involving a collision or as a result of a violent blow to the head (for example, during contact sports such as hockey and rugby).

What are the symptoms of whiplash?
The symptoms of whiplash can take a while to develop after an accident and there is no set time-frame for onset of pain. Inflammation and bruising in the neck muscles may not be obvious at the time of the accident, but pain and stiffness is often strongest on the day after the injury. The pain may then continue to get worse during the following days. Sometimes it can take a number of months for the symptoms of whiplash to disappear completely. If you have had a whiplash injury and suffer from dizziness while turning your head, weakness in both arms or legs (non-pain related) or persistent and very severe pain, you should consult a doctor.

What treatments help whiplash symptoms?
There are a number of treatments that can ease the symptoms of whiplash. These include physiotherapy, osteopathy and massage therapy.
Doctors often prescribe various medications such as muscle relaxants, pain killers and anti-inflammatories to help control the symptoms associated with this condition.

Good posture
Maintaining a good upright posture by keeping your back straight while you’re sitting, standing and walking is important to prevent the pain and stiffness in your neck from getting worse. Supporting your head with a firm pillow will help you to maintain a good neck position while you’re sleeping.

Physiotherapy
If you have whiplash, it is important to try to move your neck as normally as tolerated. If the pain in the neck is severe, you may need to rest the neck for a day or so until the pain eases. The use of a soft collar is not recommended as this may cause the neck to stiffen up. If pain persists you may require assessment and treatment from a physiotherapist. This may include exercise, joint mobilisation, muscle stretching and use of therapeutic devices to encourage a prompt recovery.

Cervical Headaches

What is a cervical headache?

Cervical headaches typically occur because of injury to the joints, muscles or nerves at the top of the neck. The headache pain experienced with this condition is an example of referred pain, which is felt in a different area than where the actual problem is. The nerves that supply the upper neck also go to the skin over parts of the head, jaw, back of the eyes and ears. As a result, pain arising from structures of the upper neck may refer pain to any of these regions which causes a headache. Although cervical headaches can occur at any age, it is commonly seen in patients between the ages of 20 and 60.

Causes of cervical headache

Cervical headaches typically occur because of activities that place excessive stress on the upper joints of the neck. This may be a traumatic event such as a whiplash injury or a strain while lifting heavy objects. More commonly, it is caused by prolonged poor postures or repetitive activities. This can include lifting, carrying, computer work or jobs with the arms in held out in front of the body.

Signs and symptoms of cervical headache

Patients with this condition usually experience a gradual onset of neck pain and headache during the provocative activity. It is also common for patients to experience pain and stiffness after these activities have finished, particularly upon waking the next morning.

Cervical headache usually present as a constant dull ache, normally situated at the back of the head, although sometimes behind the eyes or temple region. Less commonly it is on top of the head, forehead or ear region. Pain is often felt on one side, but occasionally both sides of the head and face may be affected.

Patients with this condition often experience neck pain, stiffness and difficulty turning their neck associated with their head symptoms. Occasionally patients may experience other symptoms, including: light-headedness, tingling, dizziness, nausea, tinnitus, or decreased concentration.

Factors that lead to cervical headache

There are several factors which can predispose patients to developing cervical headache. These need to be assessed and corrected where possible with direction from a physiotherapist. Some of these factors include:

• poor posture
• neck and upper back stiffness
• muscle imbalances, weakness and tightness
• previous neck trauma (e.g. whiplash)
• inappropriate desk setup
• inappropriate pillow or sleeping postures
• a sedentary lifestyle
• stress
• dehydration

Treatment for cervical headache

Physiotherapy treatment can be very helpful for patients suffering with this condition. Treatment may include stretching to release tight muscles or joints and exercises to improve posture, flexibility and strength. Therapeutic machines like laser and interferential current can also help release muscles and reduce nerve pain. Physiotherapist can also give good advice for improving work ergonomics, posture and sleeping positions. Massage therapy is also useful to release tight neck and upper back muscles that contribute to this problem.

SHOULDERS

Frozen Shoulder

Frozen shoulder, also known as adhesive capsulitis, is a condition where the shoulder becomes very stiff and painful. Over time, the shoulder becomes very hard to move.

There is a loss of motion and significant pain with many types of daily activities. The shoulder joint is surrounded by a membrane or capsule that becomes painful and then shrinks, which prevents movement of the shoulder.

What are the symptoms?
Your shoulder will typically lose its ability to move freely in most directions. The pain and loss of motion is often most noticeable when trying to raise your arm above shoulder level or reaching up behind your back. Daily activities like getting dressed, fixing your hair, reaching for an object and lifting can be difficult and painful. The symptoms typically go through three phases. During the freezing phase your shoulder is very painful and gets tighter and tighter. Then, during the frozen phase the shoulder tends to have less pain but stays extremely tight despite exercise and therapy. At some point you hit the thawing phase where the pain decreases and the shoulder movement gradually returns.

The natural history of a frozen shoulder is that it will get better. Unfortunately, the time course is variable and this condition can last from 6 months to a year, or even longer.

Why does it hurt?
When you try to move your shoulder, you stretch the tight capsule which causes pain. This pain is not a sign of damage; in fact one of the treatments for frozen shoulder is to move the shoulder while you are under anesthesia.

Why do I have it?
We don’t know. There have been many theories but no clear answers. It may be related to hormonal changes as it occurs more commonly in women age 45-55. It could potentially be related to the immune system and it is more common and severe in patients with diabetes.

What is the treatment?
A frozen shoulder is typically treated with physical therapy, a home stretching program and anti-inflammatory medication. Using heat before stretching does help loosen things up so you may want to try a hot shower or a moist heat pack. At the end of the day or after a therapy session, you may want to use an ice pack for 15 minutes. This will calm the tissue and inflammation down and help with the pain.

When you are in the active stages (freezing and frozen) of the disease, you should do frequent gentle stretches—typically for a few minutes every hour. It is not likely that you will see much improvement in motion during these early phases but the stretches will help prevent further tightening and pain. Continuing these stretches through the thawing phase is important and it will be then that you finally see improvement in your motion.

ELBOWS

Tennis or Golfer’s Elbow

Most people have heard of Tennis elbow (lateral epicondylitis) which is a common cause of pain on the outer side of the elbow. Golfer’s elbow (medial epicondylitis) is less common, but can be just as painful. It affects the inner side of the elbow. On either side of the elbow you have tendons that attach to the bones you can feel sticking out there. These tendons attach to the muscles controlling wrist, hand and finger movements. When they become inflamed, we call it an ‘epicondylitis’.

What causes epicondylitis?
Usually repetitive strain and overloading of these tendons is to blame. Weakness and imbalance in the forearm muscle groups make overloading more likely. When chronic strain is applied to these tendons, microscopic tearing and inflammation occurs which eventually leads to chronic changes in the tendon involved.

Who gets epicondylitis?
The majority of people who suffer from epicondylitis don’t play tennis or golf. Typically we see this condition with people whose jobs involve computer work, repetitive heavy lifting, continuous gripping or exposure to constant vibration. This can affect people working in a variety of jobs such as office workers, carpenters, electricians or painters. Any sport that requires repetitive arm movements such as baseball or weightlifting can also make one prone to getting this problem. It is most common around the ages of 30 to 50 years old, but it can affect people of any age depending on the activity they are involved in.

What are the symptoms?
This condition causes pain or burning around the inner or outer aspects of the elbow. The pain can also radiate down into the forearm. Weakness while gripping objects in the hand is very common. Often epicondylitis causes problems when shaking hands, lifting objects and opening doors. It seems that the most frustrating part for most people is trying to pick up their cup of coffee in the morning.

How is it diagnosed?
In most cases, a physical examination by your doctor or physical therapist can accurately diagnose epicondylitis. If there is any doubt, a diagnostic ultrasound test is adequate to visualize these tendons. It would be unusual to require an MRI test to make a proper diagnosis.

What is the best treatment?
Usually the early stages of epicondylitis can be improved by resting the inflamed elbow or modifying activities so it doesn’t get as irritated. A special forearm brace can also help to take pressure off of the problematic tendons. If basic rest does not work, there are several options for treatment.

Massage therapy will help to reduce tension in tight arm muscles. Physical therapy offers specific exercises, stretches and therapeutic modalities that can help stimulate the healing process.

Physicians can offer medication to reduce inflammation and even injections in more severe cases. Even if medication helps control elbow pain, it is a good idea to have some therapy to learn which exercise can work to strengthen the muscle and tendon. Without this step the inflammation is likely to return later if aggravating activities are continued. Only the most resistant cases of epicondylitis would be considered for surgical intervention.

If left for too long, epicondylitis can become stubbornly resistant to treatment. It is always better to take care of it early and not wait until it becomes a chronic problem.

WRIST & HANDS

Scaphoid Fracture

The scaphoid bone is a small bone at the base of the thumb. It is common in individuals following a FOOSH (fall on outstretched hand). Individuals usually complain of pain at the base of the thumb which is tender to touch. Following surgery or immobilization from a cast, physiotherapy can assist in improving mobility and strength of the thumb and wrist as well as addressing pain management.

Colles Fracture

Colles fracture is a fracture to the distal radius of the wrist. This is usually caused by a FOOSH (fall on out-stretched hand). Physiotherapy intervention is effective in re-gaining mobility of the wrist joint, improving strength and function of the wrist.

Carpal Tunnel Syndrome

Carpal Tunnel Syndrome is a common condition involving the compression of the median nerve in the wrist. Individuals may experience pins/needles tingling affecting the thumb, index finger, middle finger and half the ring finger. This may be aggravated by typing, sleeping and excessive movements of the wrist. Physiotherapy can help with carpal tunnel syndrome by providing education on hand braces and proper ergonomics, relieving pain with therapeutic modalities and exercises to improve tendon and nerve mobility in the tunnel.

De Quervain’s

De Quervain’s results from inflammation and strain to, abductor pollicis longus, and extensor pollicis brevis, two tendons of the thumb. This condition is common in individuals performing repetitive activities of the wrist especially new mothers who are frequently lifting their children or persons unaccustomed to particular exercise or activity involving the thumb/wrist. Individuals may experience sharp pain over their thumb. Physiotherapy can assist by reducing pain, education on proper lifting techniques and braces, and strengthening of the wrist musculature.

LOW BACK

Sciatica

The sciatic nerve is the longest and thickest nerve in your body. It starts in the lower part of your back and it branches down all the way to the tips of your toes. This nerve carries useful information from the legs to the brain, including pain signals, joint position, touch and sensation. It also sends signals from the brain to the legs, allowing muscle contraction and movement.

It’s no wonder that when something goes wrong with the sciatic nerve, it makes people miserable. The term ‘sciatica’ describes the pinching or irritation of this nerve that leads to leg weakness, pain, numbness and/or tingling down the back of the leg. Sometimes these symptoms occur together and sometimes sciatica can result in just one of these troubling problems. Depending on how much the nerve is being compressed, these issues can be experienced continuously from buttock to foot, or sometimes only in specific areas such as the calves and foot.

There are several things that can cause sciatica. The most common of these include:

1. Degenerative Disc Disease (DDD)
2. Lumbar Disc Herniation (also known as bulging discs or slipped discs)
3. Spondylolisthesis (also known as anteriolisthesis)
4. Piriformis Syndrome

When should you get help for sciatic pain?

Pain from sciatica can be quite severe, so most people will see a doctor for help. Simple x-ray testing can help to determine if there is a bony cause of the pain, such as Degenerative Disc Disease or Spondylolisthesis. An MRI is often needed to see disc herniation. If you are experiencing an inability to control bowel or bladder function with your sciatic pain, there may be severe pinching of the spinal cord and immediate medical attention is required. In the majority of cases, there is no emergency and your doctor can send you for conservative treatment such as physiotherapy. Please click on the appropriate links above to get more details about the conditions that cause sciatica and their possible treatments.

Degenerative Disc Disease (DDD)

Degenerative Disc Disease is an extremely common problem, especially in the low back. As the name suggests, this occurs when there is a deterioration of the discs that separate the vertebral bones in our spine. This process is usually age-related and occurs over an extended period of time. Several factors such as heavy physical work, certain sports activities and obesity can increase the likelihood of developing DDD later on in life.

Why do we have discs in our spine?

Everyone has ‘spacers’ in between each spinal vertebrae bone called discs. In the past these discs were seen as simple rubbery cushions that act as shock absorbers, while also allowing movement. Today, we have found that the truth may be a bit more complicated.

Discs are commonly compared to jelly donuts – Firm on the outside, but jelly on the inside. The ‘firm outside’ consists of many overlapping ligament-like layers. The gel inside is called the nucleus. This nucleus is quite dense and the hydraulic forces created by pressure on the gel actually provide support to the spine during loading and compression. Therefore, instead of being simple shock absorbers, discs provide structural support to the back while allowing mobility. This amazing anatomical feature gives us both flexibility and support in different situations.

What causes Disc Degeneration?

If you look at an x-ray of somebody with DDD, it appears that the disc is thinner and has lost height, however this is not the complete picture. It turns out that we cannot only look at the disc, but what is on either side of the disc as well. An ‘end plate’ is what we call the area where the disc attaches to the vertebrae. Just like the discs, end plates are very important structures. When the disc is compressed, the end plate must be strong enough to resist breaking, but also provide some flexibility as well. You could compare it to the surface of a drum; Firm, but with a little bit of give.

The process of disc degeneration often begins with this end plate. Small bone fractures in this plate can lead to inflammation and degeneration of the disc’s nucleus. When this happens, the back loses some of its ability to withstand compressive loading.

What causes these small fractures? Repetitive forward bending of the back over time, especially when combined with lifting, has been shown to cause the stress that produces these fractures. This eventually leads to a break down of the end plate, loss of nucleus gel and decreased disc height. There is no way to restore the disc once it is lost and you have developed Degenerative Disc Disease.

What effect does DDD have on the rest of the spine?

The pain that is experienced with DDD can be explained by looking at what happens to the rest of the spine after you lose disc height.

One source of pain can be the facet joints that connect the upper vertebrae to the one below it. These small joints are more compressed when the spinal bones are closer together and can become arthritic. When these joints rub together it may also produce ‘osteophytes’, which are little bony spurs on the edge of the joint.

These spurs can build up around the openings (foramen) where the nerve roots leave the spinal cord. This may result in rubbing and irritation of the nerve. With DDD, the size of the foramen can also become smaller and pinch the nerve roots as they exit the spine.

Finally, as the disc loses its nucleus, the outer wall of the disc can sag and bulge. This may also pinch the nerve roots.

In addition to pain, DDD causes decreased mobility and stiffness through the segment of the spine that it affects. Although the effects of DDD can sound scary, it is important to realize that as we age it is very common to see mild to moderate degeneration in diagnostic tests results (like x-rays or MRIs). This level of degeneration often does not result in any symptoms at all. The problems mentioned above are most likely to occur when severe degeneration has been found.

What are the symptoms of DDD?

You can imagine that with the spinal changes mentioned above, there are a wide range of symptoms that can be produced by DDD. In cases that are mild, one might experience only stiffness or light aching from facet joint arthritis. In more severe cases when nerve roots are being pinched, symptoms might include sciatic pain, weakness or numbness in the legs and feet. Pain intensity can vary from a nagging ache to being completely debilitating, depending on how severe the degeneration is.

Pain can be experienced during various times throughout the day and night. Difficulties can be felt while turning in bed, sitting or standing for extended periods, and while bending, lifting or twisting the back.

How is DDD diagnosed?

A physical examination by your doctor or physiotherapist can be very helpful to determine if you have degeneration in your back. In cases that are not so clear, often a simple diagnostic x-ray test will be enough to see if the spaces between your vertebrae have decreased. In occasional cases, an MRI is required to provide a clearer picture of the disc and nerve root themselves.

How do you treat DDD?

Once you lose disc height, the disc cannot grow back. Conservative treatments such as physiotherapy, massage and osteopathy can help by decreasing muscle tension, restoring postural balance and improving core strength. Some therapists will use traction (also known as decompression) to open up the foramen spaces and decrease pressure on effected nerve roots. This conservative strategy can be effective in many cases where restoring strength and alignment are enough to reduce pressure on painful body tissues.

Doctors often prescribe medication to help reduce pain, inflammation and muscle tension that result from disc degeneration. Some physicians will inject medication right into the affected area for a more direct effect.

Finally, in the most severe cases where leg function is significantly compromised and conservative treatment has failed, surgery may be a final option. Often this includes fixating segments of the spine together and trimming away bone or tissues that are compressing the nerve roots. This is almost always considered the last option after all other treatments have failed.

Lumbar Disc Herniations (Bulging Discs)

We see several people in our office each year with painful Lumbar Disc Herniations. Many people have heard about bulging discs, but most know little about them until it affects themselves or a family member. Large herniations can cause an immense amount of pain that makes going about normal daily activities practically impossible. To understand what causes this disabling problem, it is important to know a little bit about the anatomy of the spine.

Why do we have discs in our spine?

Everyone has ‘spacers’ in between each spinal vertebrae bone called discs. In the past these discs were seen as simple rubbery cushions that act as shock absorbers, while also allowing movement. Today, we have found that the truth may be a bit more complicated.

Discs are commonly compared to jelly donuts – Firm on the outside, but jelly on the inside. The ‘firm outside’ consists of many overlapping ligament-like layers. The gel inside is called the nucleus. This nucleus is quite dense and the hydraulic forces created by pressure on the gel actually provide support to the spine during loading and compression. Therefore, instead of being simple shock absorbers, discs provide structural support to the back while allowing mobility. This amazing anatomical feature gives us both flexibility and support in different situations.

What causes these discs to bulge?

Discs herniate after the outside layer (known as the annulus) develops small tears and cracks in it. The annulus tends to tear in the back corners, which unfortunately is close to where nerve roots exit the spinal cord. This tearing usually occurs during forward bending of the low back, especially if twisting is also taking place. When the annulus tears in this way, the jelly nucleus can push out through the crack and apply pressure to the nerve as it exits the spine. Depending on the size of the bulge, it may cause extreme pain and even weakness or numbness in the leg that the nerve runs to.

In some people, the disc will herniate straight back towards the spinal cord instead of towards one of the corners. The resulting pressure can cause symptoms in both legs.

While disc herniations can occur at any age, it is more common among young adults because the gel in their discs is more fluid and has not become progressively firm with age.

What are the symptoms of a disc hernation?

When nerve roots are pinched, intense pain can be felt in one or both legs depending on where the disc herniation occurs. Most commonly, sciatic pain will run down the back of the leg and can reach as far as the foot. The annulus itself is well innervated and can be a source of strong localized low back pain. The pressure on the nerves can also cause muscle weakness or numbness in the legs.

Often with larger herniations that push out more to one side, a person will have a noticeable shift of their trunk away from the painful side.

Pain is aggravated with bending or sitting, as this tends to allow the disc to bulge even more.

In very rare cases, a disc herniation will lead to a lack of control of bowel or bladder function. This is very serious and immediate medical attention should be sought.

How do we diagnose a disc herniation?

The best way to see a disc herniation is with an MRI test. There are specific pain and movement patterns that a doctor or therapist can look for to help decide if a disc herniation may be present. Treatment can be started immediately based on these results. A surgeon, however, will usually want to have an MRI test done before they decide if an operation is going to be helpful.

Treatment options

The type of treatment one gets depends on a number of factors. Activity level, age and the type of herniation are all important.

Less serious bulges may only require conservative therapy treatment to see improvements. A physiotherapist will likely teach a program of home exercises and stretches. Treatment in a clinic can include lumbar traction (also known as decompression), hands-on stretching, massage or use of specific machines to help cope with pain and muscle spasm.

If chronic pain is an issue, some doctors choose to use medication or even local injections to help deal with pain and inflammation.

In the most serious cases, surgery may be necessary. A discectomy surgery removes disc material that is causing pressure on the nerve roots or spinal cord.

Spondylolisthesis (also called Anteriolisthesis)

This low back problem is not as commonly known to the general public as lumbar disc issues are, but is still relatively common. In many cases it can be seen as a contributing factor for people suffering with chronic low back pain.

What is it and where does it come from?

When you translate the Greek origins of this word literally, it comes out as a ‘spine sliding down a slippery path’. This provides a good mental image for what is actually happening (although maybe not so dramatic.) In spondylolisthesis, one vertebrae bone has slid forward on the vertebrae below it. There are varying degrees of slippage and the symptoms vary accordingly. A small degree of forward translation probably does not cause any pain at all. A large translation can cause compression of joints and narrowing of the spaces where nerve roots travel out of the spinal cord.

This slippage is often caused by repetitive backwards arching of the low back. With time small fractures occur in parts of the vertebra that allow movement of this bone. A simple x-ray will be enough to see this problem and determine the grade of severity. These grades are ordered from 1 (for less severe) to 5 (maximum severity). A ‘stable’ spondylolisthesis will not tend to slip any further while an ‘unstable’ one continues to move. The most common level to see this problem is at the lowest part of the lumbar spine (L4-L5 or L5-S1) because of the spine’s anatomy in this area.

What are the symptoms?

As mentioned earlier, lower grades of spondylolisthesis may not be associated with any pain or discomfort at all. However, if the vertebra has slipped enough, it is certain to cause some issues. Typically, pain is initially experienced when moving into end ranges of movement while bending forward or arching backwards. In either direction, the pressure on the vertebra causes it to shift a bit.

More severe spondylolisthesis means that excess pressure is forced onto the lumbar facet joints which may become arthritic and cause local low back pain. Nerve roots coming out of the spine can also be compressed. This may result in typical sciatica pain and weakness in one or both legs.

What is the treatment?

Therapy can be done to help relieve some of the unpleasant effects of this condition by decreasing muscle tension and pain. For long-term success, core strengthening to stabilize the low back area is necessary. Specific exercises that work to strengthen trunk muscles without using any bending movements are the best. A good therapist can design a personalized program that will work towards building a good core. Braces or belts that support the back may be a quick way to decrease symptoms for some. It is not advised to wear these devices for long periods however, as their long-term use can weaken the core muscles that are needed to support the spine.

Physicians may choose to medicate for pain and inflammation caused in this disorder. Medication can be injected directly into the problem areas as well.

In some serious cases, especially if there is an unstable spondylolisthesis, surgical intervention may be advised. If the vertebra has slipped too far and is pinching a nerve root too much, the top vertebra can be fused to the one below to hold it in place. This may lead to other back problems in the future and should only be considered for the worst cases.

Piriformis Syndrome

The piriformis is a muscle located deep to the gluteal muscles in the buttock area.

It is a smaller muscle that has the important job of making sure that the hip bone stays stable inside its socket during any leg movement. In most people, the large sciatic nerve runs underneath this muscle before emerging below it. However, in up to 16% of individuals (by some estimates) the nerve passes directly through the belly of this muscle.

There are several reasons that can lead to piriformis problems. Most commonly, this muscle can get overworked and tight when the gluteal muscles are weak. It tries to do the job of the larger gluteal muscle, but ultimately it cannot. Trauma to the back of the hip can also cause injury to this muscle.

This muscle itself can be a source of localized pain, but things can be worse for those people whose sciatic nerve runs directly through the piriformis. In these cases, sciatic nerve pain can develop and we call this Piriformis Syndrome.

Symptoms

Pain, tingling and numbness often starts in the buttocks area but can extend down the length of the sciatic nerve. This can be felt along the back or side of the leg and can reach the foot in the worst cases.

Activities that tend to aggravate this syndrome are prolonged sitting, climbing stairs, running or even applying firm pressure to the area. Women tend to be more likely to get this issue because of their wider pelvis, but men definitely can develop it too.

Treatment

In order to settle down the most acute pain, resting can be effective. Rest can help with pain, but does not address the long-term reasons that this problem developed in the first place.

Therapy can be done to address many of these issues. Massage therapy can help to reduce tense and sore muscles. Physiotherapists often work to stretch tight muscles and provide graduated gluteal strengthening programs. They may also use various ‘modalities’, which are machines that can help speed up this process. Postural retraining is important for those that have a centre of gravity that is shifted forward.

Physicians can offer medication and injections that help to directly reduce pain and swelling around the piriformis. Surgery is rarely considered.

HIPS

Trochanteric Bursitis

What is Trochanteric Bursitis?
Trochanteric bursitis is inflammation of the bursa which lies over the prominent bone located on the side of your hip. A bursa is a small, cushioning sac meant to reduce friction where tendons move over bony areas.

How does it occur?
The trochanteric bursa may become inflamed when a group of muscles or tendons repetitively rubs over the bursa and causes excess friction against the thigh bone. This injury can occur with running, walking, or bicycling, especially when the bicycle seat is too high.

What are the symptoms?
Pain is localized to the upper, outside area of your thigh or back of your hip. The pain is worse when you walk, cycle, or go up and down stairs. The bursa is close to the surface, so you will probably feel tenderness with pressure to this area. Often laying on either side at night or getting into a car will aggravate the pain as well.

How is it treated?
Initially, it may be necessary to modify or reduce the activity that is causing the pain in the first place. This will help decrease the rubbing that causes inflammation. Application of a cold pack to the area can also be soothing and lessen inflammation.

In many cases, there are also imbalances of the thigh and hip muscles that make it more likely for someone to suffer from this condition. A good physiotherapy assessment will identify these imbalances and a specific stretching and strengthening program can be introduced. Often massage can also be helpful to loosen tight muscles in this area.

Some cases may need to be addressed by custom orthotics to correct imbalances in the feet that lead to increased strain higher up in the leg.

Medication or injections will often be used by doctors to address painful inflammation in the bursa, but this may not address the primary source of the problem.

KNEES

Osgood-Schlatter Disease

Osgood-Schlatter Disease is characterized by activity-related pain and swelling under the patella (at the insertion of the patellar tendon to the tibial tubercle). It is more common in young boys (age 10-15) and occurs during a rapid growth spurt when the tibial tubercle is susceptible to stress. The cause is usually prolonged overuse. Physiotherapy management aims at reducing pain and swelling by application of therapeutic modalities including ice, stretching exercises to tight muscles, especially quadriceps group and education to avoid sports and excessive exercise involving deep squats and jumping.

Quadriceps Tendonitis

Quadriceps Tendonitis is the inflammation of the quadriceps tendon from overuse. Individuals will experience pain just above the kneecap and will be particularly painful with activities such as jumping, squatting or stairs. Physiotherapy can assist in improving strength of the quadriceps muscle, pain management through therapeutic modalities and exercises to improve knee stabilization.

Iliotibial Band Friction Syndrome

Iliotibial Band Friction Syndrome is a condition resulting in excessive tightness of iliotibial band, causing pain from the hip down the outer side of the leg to the knee area. Usually the primary cause is hip/knee muscular imbalance that will be addressed by a physiotherapist through specific exercises and postural education (e.g. proper footwear, orthotics, etc.)

Knee Replacement

A procedure that involves replacing the knee joint with a prosthetic implant to improve function usually after degeneration secondary to osteoarthritis. Individuals with knee replacements are provided with a list of activity restrictions from their surgeon. Physiotherapy can assist in the post-surgical recovery through pain management with therapeutic modalities, strengthening of knee musculature, and stretching of appropriate muscles.

Jumper’s Knee

Patellar Tendinitis is an overuse injury causing inflammation in the patellar tendon. It is common in athletes particularly those involved in volleyball or basketball. Pain is often sharp and localized to the tendon below the patella (knee cap). Physiotherapy can assist in improving pain through therapeutic modalities and taping, stretching of tight structures (e.g. hamstrings, quadriceps, IT band) and strengthening of quadriceps, gluteus and hip muscles. Education is also provided on return to sport.

Patellofemoral Pain Syndrome – Runner’s Knee

Patellofemoral Pain Syndrome is the result of damage to the joint between the patella (knee cap) and femur (leg bone). This condition is more common in young females, and as the name suggests runners where stress is placed on the quadriceps muscle. Individuals describe pain under or around the patella, and indicate pain worsens with squatting, kneeling or with the use of stairs. Physiotherapy is effective in taping for proprioception and pain relief, strengthening of the quadriceps and hip muscles, and education on running pattern and appropriate footwear.

Ligament Tears

There are four main ligaments in the knee: anterior cruciate ligament (ACL), posterior cruciate ligament (PCL), medial collateral ligament (MCL), lateral collateral ligament (LCL). Any one of these ligaments may be partially or completely torn due to trauma (pivot, forceful hit to the knee). Physiotherapy is effective in reducing pain and improving strength in both partially torn ligaments and following surgical repair. To reduce pain therapeutic modalities such as ultrasound and laser can be used. A physiotherapist will provide an exercise program to improve control of the knee stabilizers and education to prevent re-injury.

Meniscal Tears

The meniscus is a cartilaginous structure providing cushioning between your femur and tibia. Tears in the meniscus (either lateral or medial) may result from trauma such as twisting of the knee, or from degeneration. Individuals with meniscal tears often have difficulties with weight bearing activities (e.g. running, walking), going up the stairs, and may experience locking or “giving away” of the knee. Physiotherapy treatment may consist of strengthening the quadriceps, stretching of the hamstrings, and improving proprioceptive control of the knee stabilizers.

ANKLES & FEET

Tibilais Posterior/Anterior Tendonitis

Tibialis Posterior or Tibialis Anterior Tendonitis is inflammation of the specific tendon due to overuse. This is a common injury in football players, dancers, speed skaters, and long distance runners. Individuals will experience pain and decrease strength in the particular tendon. Physiotherapy for tibialis posterior or anterior tendonitis will consist of: stretching, strengthening of affected muscle, education on bracing, taping and proper footwear, and therapeutic modalities to address pain.

Stress Fractures

Stress fractures are common in athletes involved in sports with running and jumping. Repetitive stress to the leg results in the loss of shock absorption. Individuals with stress fractures are irritated by activities such as running, walking, jumping or wearing improper footwear (e.g. footwear that lacks arch support). Individuals usually feel better with rest or ice. Physiotherapy can be effective in reducing pain through therapeutic modalities, correcting muscle imbalances through stretching and strengthening appropriate leg muscles and education regarding proper footwear, braces and return to sport.

Plantar Fasciitis

Plantar Fasciitis is inflammation of the plantar fascia, a thick tissue, along the sole of your foot. This condition results in significant pain with the first few steps in the morning and with prolonged walking. Plantar fasciitis may coincide with heel spurs. Individuals with plantar fasciitis can benefit from physiotherapy to help with pain management through the use of ultrasound, laser or shockwave therapy. Stretches to the plantar fascia and calf will be an important part of physiotherapy along with education regarding proper footwear.