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Calcific tendonitis: why is it soooo painful.

Calcific tendonitis: why is it soooo painful.

Calcific tendinitis of the shoulder, typically characterized by calcium deposits on the rotator cuff, is an extremely painful condition that can severely impair movement and life quality. A new study appearing in today’s issue of the Journal of Bone and Joint Surgery, found a significant increase in blood vessel and pain receptor growth among patients with this condition.

“We found a 3-to-8-fold increase in the number of small blood vessels, nerves and inflammatory cytokines (proteins that direct cell growth) in patients with calcific tendinitis in one of four rotator cuff tendons, as compared to patients with a torn yet normal tendon,” said George A.C. Murrell, MD, an Australian orthopaedic surgeon and lead author of the study. “This might explain the chronic inflammation and severe pain that patients with calcific tendinitis often experience.”

In the study, 30 patients received an ultrasound during arthroscopic surgery to identify and remove samples of calcium within the shoulder tendon. Each patient had calcific tendinitis, but no prior surgeries or fractures in the affected shoulder, and no history of rheumatoid arthritis or osteoarthritis. They were compared to similar patients with tears in normal rotator cuff muscles, without calcification or rheumatoid arthritis, and patients with healthy rotator cuff muscles.

Overall, the results showed significantly elevated blood vessel growth (neovascularization) and nerve growth (neoinnervation) in the calcific tendinitis lesions. In addition, the calcific tendinitis group had more frequent pain during sleep and more extreme pain in general. The findings are similar to, but much more pronounced than, those found in studies looking at patients with frozen shoulder and other tendon disorders and diseases.

“To our knowledge, few works have investigated the presence and/or role of immune cells and their molecular messengers in calcific tendinitis,” said Dr. Murrell. “The results could lead to new ways to manage the pain associated with this condition.”

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Back Spasms

Back Spasms

The first time I ever suffered a genuine “back spasm” was a day I will never forget. I was in a car park, sitting in the car, and I bent down sideways to pick up my wallet from the floor on the passenger side (trunk in flexion and rotation). Whilst I was in this position I sneezed and felt this almighty thump in my back like someone had shot me with a bazooka. I was stuck in that position for a good 5 minutes. Sweet relief only came with a cocktail of pain killers – Valium, Tramadol and Voltaren.

We often see clients who present to the clinic with acute onset of back pain associated with a degree of protective muscle spasm. Genuine back spasms are an example of common low back disorders, along with the more frequent lumbar spine disc injuries, facet joint sprains and rib joint sprains. A muscle spasm can be defined as an acute onset of uncontrolled and involuntary muscle contraction. Most of us may be familiar with the sensation of muscle cramps such as the calves and hamstrings that usually accompany fatigue in the affected muscles. These types of cramps (a form of spasm) are usually caused by fatigue related dehydration and/or electrolyte imbalance. These can be quite debilitating and painful and usually resolve with aggressive stretching and rehydration and are short term.

Back muscle spasms are rarely this type of phenomenon. Back spasms are more often caused by a sudden ill directed movement that causes a muscle to spasm. For example, if someone is bent over and sneezes, they may cause a sudden spasm in a thoracic muscle that “locks” the back up. Or the person may attempt to lift a heavy weight (gym or occupation) and they may feel a muscle spasm. Golfers often complain of acute back spasms following big tee shots with driving woods, due to the sudden forceful muscle contraction involved in rotating the spine.

Often the spasm is a warning sign that something under the surface is waiting to become problematic. For example, if someone sprains a facet joint or tweaks a disc, often the muscles in the back area will spasm as a protective mechanism. The common muscles to spasm are the quadrutus lumborum (QL) and the thoracic paraspinals. Red flag symptoms such as bladder and bowel problems or neurological sensations down the leg such as numbness, pins and needles and weakness are usually indications something much more sinister is happening at the spine level. The spasm is purely a warning sign. In these instances, a thorough workup is needed involving doctors, radiology and the like.

If the spasm is a true and genuine spasm caused by the uncontrolled contraction of the muscle, then there are number of things the therapist can do to relieve the spasm. Primarily, if the spasm is debilitating they may need referral to a doctor to obtain some muscle relaxants and/or anti-inflammatory medication. These can be quite effective in dulling the spasm very quickly. The more therapist orientated interventions are directed at relieving the spasm via gentle soft tissue massage to “work out” the spasm. This is particularly useful on muscles such as the QL in the case of low back spasm or the paraspinals and QL in the case of rib joint sprains.

The Side Lie Stretch can help alleviate the spasm. A safe stretch for the QL is the side lie stretch. Lie on the affected side and bend the knees and hips up. Prop up on the elbow and slowly let the body sink in towards the floor to create lateral flexion of the trunk. This can be held for 5-10 minutes and is quite safe to do even in the case of an acute and painful spasm.

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10 tips for Better Back Health

10 tips for Better Back Health

About 70 per cent of the general population will suffer from lower back pain at some time in their lives. Unfortunately for some, lower back pain is something that lingers and has to be managed on a day-to-day basis. But simple lifestyle changes can make a massive difference.

1. Keep moving:

If you tend to sit in one position for more than 20 to 30 minutes, change your position and move. Doing little things such as rolling your shoulders, rotating your head, stretching your arms up and standing for a brief period gets the blood pumping in and out of your muscles, and flushes unwanted toxins out.

2. Stop slouching:

Sitting in a slumped position puts stress on your ligaments, muscles and joints. Visualise a string attached to the crown of your head, which is pulling you straight up. Then pinch your shoulder blades back, and tuck your chin in slightly.

3. Streching:

Lying on your back and rolling your legs from side to side, the cat stretch and the cobra pose all loosen up your middle back.

4. Sitting on a Ball:

This is a great way of getting you to think about your sitting posture and engaging your core muscles. It will help reduce the strain on your middle and lower back and is good for office workers.

5. Use a lumbar roll:

Many chairs come with lumbar support, but nothing beats a rolled-up towel in the small of your back, or you can buy a lumbar roll for back support

6. Check your ergonomics:

Get your workstation checked. Look at your chair height and back support, computer screen height, keyboard and mouse position, and your distance from your desk.

7. Bend with your knees:

Carelessness with bending and lifting is the most common way of injuring your back. Be particularly cautious in the morning – your back is most vulnerable at this time

8. Start exercising:

Non-specific exercise is often a great way of keeping your back healthy. Daily walking is a great start.

9. Pilates:

Pilates is a great way of improving your posture and getting the correct muscles to perform the correct functions.

10. Get a second opinion:

There are too many old wives’ tales concerning back pain. If you are unsure about anything, our qualified physiotherapists can set the record straight.

Retrieved from: http://www.bodyandsoul.com.au/health/health+advice/10+tips+for+better+ba…

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Sports Therapy 101: Muscle Injury

Sports Therapy 101: Muscle Injury

Anyone working in sporting environments would be very familiar with acute muscle injuries.

So how prevalent are they?

It’s been reported that a male elite-level soccer team with a squad of 25 players can expect about 15 muscle injuries each season¹. This equates to an average absence time of 223 days, 148 missed training sessions and 37 missed matches!¹

Despite how often people present with muscle injuries, how confident are you are diagnosing and classifying these injuries?

To be honest, I’ve had trouble over the years confidently grading a muscle injury, especially early in my career when I hadn’t seen many examples.

This widespread difficulty in the clinical setting was perhaps the impetus for a collaborative review of muscle injury classification, via a survey and analysis of 30 sports medicine practitioners thoughts in 2012.

What followed was an open-access publication² in the British Journal of Sports Medicine, which might be the most comprehensive guide for more accurately classifying muscle injuries.

The following is a summary of some of the concepts.

The healing time frames and principles of management more based on my experience.

 

Source: A great website!
http://physiodevelopment.com/classification-muscle-injuries-in-sport/

Classification of Acute Muscle Injuries in Sport

Broadly, a muscle injury can be classified as indirect or direct.

Indirect refers to an internal disruption to a muscle, without any external force/trauma involved.

Direct refers to any trauma (blunt or sharp) that impacts the muscle externally.

Indirect Muscle Injuries

Indirect muscle injuries can be sub-classified as a:
•functional muscle disorder, or
•structural muscle injury.

Functional Muscle Disorder

These can be further classified into the following:
•Type 1: Overexertion-related muscle disorder •Type 1A: Fatigue-induced muscle disorder
•Type 1B: Delayed-onset muscle soreness (DOMS)

•Type 2: Neuromuscular muscle disorder •Type 2A: Spine-related neuromuscular muscle disorder
•Type 2B: Muscle-related neuromuscular muscle disorder

Overexertion-related Muscle Disorder

Type 1A: Fatigue-induced muscle disorder:
•Increase in muscle tone (tightness or firmness) due to overexertion
•Diffuse, tolerable pain, involving up to the whole length of a muscle
•Imaging: clear

Healing Time Frame (approximate)

Less than 7 days.

Management
•Emphasis is on recovery (massage, ice baths, stretching)
•Prevention: •Warming up prior to exercise
•Maintaining good muscle length (stretching)
•Eccentric exercise and conditioning

Type 1B: Delayed-onset muscle soreness (DOMS):

•Generalised pain after unaccustomed eccentric exercise
•Swelling/oedema
•Pain at rest, as well as on isometric contraction
•Imaging: negative, except for oedema

Healing Time Frame (approximate)

Less than 7 days.

Management
•Emphasis is on recovery (massage, ice baths, stretching)
•Prevention: •Warming up prior to exercise
•Maintaining good muscle length (stretching)
•Eccentric exercise and conditioning

Neuromuscular Muscle Disorder

Type 2A: Spine-related neuromuscular muscle disorder
•General ache, with increase in muscle firmness.
•Occasional sensitivity of overlying skin
•No pain at rest
•Imaging: clear, possible oedema

Healing Time Frame (approximate)

Less than 7 days.

Management
•Principles of muscle retraining •Maintain or improve muscle length
•Improve strength (especially eccentric)
•Address any deficit in motor control (functional lower limb)
•Progress with sports-specific retraining

•Addressing any symptoms of lumbar spine dysfunction •Inflammation or irritation around lumbar nerve roots
•Treating any low back movement dysfunction or motor control disorder

Type 2B: Muscle-related neuromuscular muscle disorder

•Cramp like description of pain
•Increase in muscle tone
•May result from dysfunctional neuromuscular control (e.g., reciprocal inhibition)
•Imaging: clear, possible oedema

Healing Time Frame (approximate)

Less than 7 days.

Management
•Principles of muscle retraining •Maintain or improve muscle length
•Improve strength (especially eccentric)
•Address any deficit in motor control (functional lower limb)
•Progress with sports-specific retraining

•Retrain any dysfunction in agonist/antagonist muscle function •Are there adjacent muscle groups that are inhibiting the affected muscle, or contributing to an increase in muscle tone?

Structural Muscle Injury

These can be further classified into the following:
•Type 3: Partial muscle tear •Type 3A: Minor partial muscle tear
•Type 3B: Moderate partial muscle tear

•Type 4: (Sub)total tear

Partial Muscle Tear

Type 3A: Minor partial muscle tear:

•Tearing of small muscle fascicle or bundle
•Sharp pain and sudden onset of injury
•Localised pain, with possible defect on palpation
•Stretching induces pain
•Very often musculotendinous junction
•Often minimal loss of muscle strength
•Imaging: Positive disruption on MRI, with intramuscular haematoma

Healing Time Frame (approximate)

14-21 days

Management
•Optimise environment for healing, based on the stage of tissue recovery
•Maintain or improve muscle length
•Improve muscle strength (especially eccentric)
•Address any deficit in motor control (from a functional perspective)
•Sports-specific retraining and improve overall conditioning

Type 3B: Moderate partial muscle tear

•Tearing of greater diameter than the muscle fascicle or bundle
•Sharp, localised pain at onset of injury
•Possible fall of athlete
•Well defined, localised pain
•Palpable defect in muscle
•Stretching induces pain
•Definite loss of muscle strength and function
•Imaging: Positive with significant fibre disruption, possible retraction, and intermuscular haematoma

Healing Time Frame (approximate)

4-6 weeks.

Management
•Optimise environment for healing, based on the stage of tissue recovery
•Maintain or improve muscle length
•Improve muscle strength (especially eccentric)
•Address any deficit in motor control (from a functional perspective)
•Sports-specific retraining and improve overall conditioning

Type 4: (Sub)total muscle tear / tendinous avulsion

•Tear involving complete diameter of muscle, or tendinous avulsion from bone
•Localised dull pain at onset
•Athlete often falls
•Considerable defect in muscle
•Muscle retraction
•Considerable loss of function
•Haematoma
•Imaging: Subtotal/complete discontinuity of muscle/tendon, intermuscular haematoma

Healing Time Frame (approximate)

A minimum of 12 weeks.

Management

For complete tears, a much slower and extended rehab process follows, guided by pain and changes in muscle tone. The same principles still apply:
•Optimise environment for healing, based on the stage of tissue recovery
•Maintain or improve muscle length
•Improve muscle strength (especially eccentric)
•Address any deficit in motor control (from a functional perspective)
•Sports-specific retraining and improve overall conditioning

Surgery is advocated for complete tendon avulsion, followed by postoperative rehabilitation.

Direct Muscle Injuries

The main type of direct muscle injury to note is a contusion. This is characterised by:
•Direct trauma to muscle by an external force
•Haematoma, causing loss of mobility and function
•Imaging: Diffuse oedema and haematoma at sight of trauma

Healing Time Frame

In the absence of any structural damage, an athlete can often continue playing. If there is any associated muscle fibre disruption, then healing will be based on the severity of the indirect muscle injury (see above).

Management

Again, if there is no structural damage, just localised swelling and oedema, the emphasis is on recovery. Acute management of swelling and haematoma.
Additional Notes
•Healing time frames and management will vary slightly depending on the muscle group involved.
•Risk factors for injury will play an important role, for example (but not limited to): •Age, previous history of muscle injuries, level of competition, physical conditioning, and fatigue³.

References
1.Ekstrand J, Hagglund M and Walden M 2011, ‘Epidemiology of muscle injuries in professional football (soccer)’, American Journal of Sports Medicine, vol. 39, pp. 1226–32.
2.Ueblacker P et al 2013, ‘Terminology and classification of muscle injuries in sport: The Munich consensus statement’, British Journal of Sports Medicine, vol.47, pp.342–350.
3.Bruckner P et al 2014, ‘Recurrent hamstring muscle injury: applying the limited evidence in the professional football setting with a seven-point programme’, British Journal of Sports Medicine, vol. 48, pp. 929-938.

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