Subacromial Bursitis

Subacromial bursitis is a condition characterized by tissue damage and inflammation of the subacromial bursa (a small fluid filled sac located beneath the bony prominence at the top / outer aspect of the shoulder) causing pain in the shoulder

Beneath the acromion lies a bursa known as the subacromial bursa . A bursa is a small sac filled with lubricating fluid and is designed to reduce friction between adjacent soft tissue or bony layers. The subacromial bursa reduces friction between the bony prominence of the acromion (above the bursa) and the tendon of the supraspinatus muscle (which attaches to the upper aspect of the humeral head) below the bursa.

During certain activities, such as arm elevation, rotating the shoulder, lifting, pushing or pulling or lying on the shoulder, friction and compressive forces are placed on the subacromial bursa. Pressure may also be placed on the subacromial bursa following a direct impact or fall onto the point of the shoulder, elbow or outstretched hand. When these forces are excessive due to too much repetition or high force, irritation and inflammation of the bursa may occur. When this occurs, the condition is known as subacromial bursitis.

WHAT ARE THE CAUSES?

Repetitive or prolonged overhead activities

Repetitive or prolonged arm elevation activities

Repetitive or prolonged use of the arm in front of the body

Activities involving rotation of the shoulder

Lifting (especially overhead)

Excessive pushing or pulling activities (placing strain on the bursa via the supraspinatus tendon)

Putting weight through the affected arm

Lying on the affected side

Signs and symptoms of subacromial bursitis

Patients with this condition typically experience pain at the top, front, back or outer aspect of the shoulder. Pain may also radiate into the upper arm as far as the elbow. In less severe cases, patients may only experience an ache or stiffness in the shoulder that increases with rest following activities placing strain on the bursa. These activities typically include arm elevation activities, use of the arm in front of the body or overhead, shoulder rotating activities, lifting, pushing or pulling, placing weight through the arm or lying on the affected side. The pain associated with this condition may also warm up with activity in the initial stages of injury.

As the condition progresses, patients may experience symptoms that increase during activity or sport, affecting performance. Patients with subacromial bursitis may also experience pain on firmly touching the top / outer aspect of the shoulder. A painful arc of arm elevation and / or a feeling of shoulder weakness may also be present particularly when attempting to lift or elevate the arm overhead.

Prognosis of subacromial bursitis

Most patients with this condition heal well with appropriate physiotherapy and return to normal function in a number of weeks. Occasionally, rehabilitation can take significantly longer and may take many months in those who have had their condition for a long period of time, or, in those with other associated injuries such as rotator cuff pathology. Early physiotherapy treatment is vital to hasten recovery in all patients with subacromial bursitis.

Physiotherapy for subacromial bursitis

Physiotherapy treatment is vital to hasten the healing process, ensure an optimal outcome and reduce the likelihood of recurrence in all patients with this condition. Treatment may comprise:

• soft tissue massage
• dry needling
• electrotherapy (e.g. ultrasound, TENS etc)
• stretches
• joint mobilization (of the shoulder, neck and upper back)
• joint manipulation
• heat or cold treatment
• the use of a sling
• progressive exercises to improve strength, flexibility, posture and scapula stability
• correction of abnormal biomechanics or technique
• education
• postural taping
• the use of a postural support
• anti-inflammatory advice
• activity modification advice
• a gradual return to activity programme

• External Rotation by use of Dumbell:
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• External rotations strengthen your infraspinatus and teres minor muscles. You can feel the infraspinatus if you touch the posterior, lower surface of your shoulder blade. The teres minor muscle lies on the outermost, lower border of your shoulder blade. Both muscles attach to the lateral, uppermost end of your arm bone.

This exercise is performed by holding a light dumbbell in the hand that's on the same side as your injured shoulder, then lying on the opposite side of your body. Bend your elbow to 90 degrees, draping your forearm across your abdomen; keep your injured upper arm and elbow tucked against your ribs. To work your external rotators, raise the dumbbell, rotating your arm outward as much as possible; repeat for three sets of 15 repetitions.

Lying Dumbbell Internal Rotation

This exercise engages the subscapularis muscle, which lies on the anterior surface, or underside of the scapula, and attaches to the anterior, upper end of your arm bone. First, lie flat on your back, holding a light dumbbell in the hand that's on the same side as your injured shoulder. Bend your elbow to 90 degrees, tucking your upper arm against your rib cage with your forearm rotated out to the side as much as possible. To work your internal rotator, pull the dumbbell toward you and across your abdomen; repeat for three sets of 15 repetitions.

Lateral Raises

Performing lateral raises with a very light dumbbell enables you to focus more on the supraspinatus muscle, instead of the deltoid muscle. You may do this exercise standing up or sitting down. Begin by holding the dumbbell with the hand that's on the same side as the injured shoulder. Align your entire arm along the side of your body; keep a slight bend in your elbow. Raise the dumbbell out to your side until your arm is parallel to the floor, holding the contraction for 3 seconds; repeat for three sets of 15 reps.

Exercises for Frozen Shoulder

Frozen shoulder syndrome   (also known as adhesive capsulitis) is marked by pain, discomfort and limitation of movement across shoulder joint with “waxing waning” symptoms over time. It has been observed that the risk of developing adhesive capsulitis increases in certain medical or vascular conditions that limit the mobility of upper limb. 

It is concluded that the progressive joint discomfort starts with a painful stage in which minimal movement of upper limb or shoulder joint evokes strong pain and discomfort. This is followed by a stiff stage which the pain experienced is minimal but the joint is stiff with impaired range of motion. 

Causes of Frozen shoulder:

Frozen shoulder syndrome is the inflammation of shoulder joint capsule that encase and embrace all the tendons, ligaments, muscles, bones of the ball and socket joint. Typically, any ongoing inflammatory process limits physical activity due to shoulder pain and discomfort. In the absence of any intervention, the connective tissue components begin to thicken as a result of ongoing inflammatory process leading to prolonged stiffness and limited range of motion. This stage is known as froze shoulder position.

Advanced age: 45 years of age or above. Most common in females.

History of recent limb injury or immobility: tearing of rotator cuff tendons, any vascular, orthopedic surgery involving upper limb or impaired limb motion due to stroke

Diabetes : Diabetes is one of the strongest risk factors that are associated with the pathogenesis of secondary frozen shoulder syndrome.

Certain metabolic or endocrinological disorders: like hyper or hypothyroidism, untreated or poorly managed circulatory conditions and tuberculosis also increases the risk of developing frozen shoulder syndrome significantly. 

Best Exercises For Treating Frozen Shoulder Syndrome

Shoulder exercises are generally recommended by healthcare providers to regain mobility and range of motion. Physical therapy maneuvers and exercises are especially effective in stiffness stage and recovery stage.  Some of the best exercises for frozen shoulder syndrome suggested by healthcare providers are discuss below:

Shoulder Abduction

Physical therapist suggests active-passive exercises to restore joint range of motion. A variety of pulley exercises are devised for such patients like shoulder abduction .

Attach a pulley to a door (as high and as secure as possible). Use a chair or stool with your back facing the door and grasp the two ends of the pulley with your both hands.Now extend your injured arm using pulley handle as fulcrum to the side of your body while using the non-injured arm as your overhead support.Now pull down the non-injured arm to the side of your body while extending and lifting the injured arm overhead.Repeat the exercise for 10 minutes twice a  day

Shoulder External Rotation

The basic principle of all shoulder exercises in adhesive capsulitis or frozen shoulder syndrome is to improve the range of motion by allowing passive movements with minimal discomfort. Moreover, since the weight of upper body is supported by the pulleys, the movements are less stressful for the body that helps in directing all the force towards the joint components.  

For this exercise, secure the pulley around the door knob and extend your elbows while keeping your forearms parallel to the ground level.With gentle traction on injured arm, stretch your non-injured arm and rotate the pulley strings between two arms alternately. The benefit of this exercise is loosening of ligaments that control rotatory motion of shoulder joint.

Shoulder Flexion

It is very important to perform all the shoulder stretching exercises with your elbows fully extended. This exercise involves securing a pulley on top of a door or with a hook on wall.

Once pulley is secure, stand straight with your back supported by the wall. Now using pulley handle, lift your normal arm in the air in full-extended motion, while your injured arm is stretched by the side of your body (shoulder joint is flexed in this position). Hold the position for a few seconds and extend your injured arm overhead while your normal arm is stretched by the side of your body. Repeat the exercise for a few minutes every day at periodic intervals.

This exercise helps in decreasing stiffness by promoting joint activity in vertical motion. 

Shoulder exercises to improve frozen shoulder

Arm Circles

Arm circle is a common fitness exercise that is often advised to athletes to improve their overall range of motion. Instructions are simple and benefits are immense and almost immediate. It helps to break down adhesions.

Lie down on a flat horizontal surface like a table on your right side. Place your left hand on your left shoulder and try to make small circles in the air. Start off by making small circles and gradually increase the size and circumference of the circle by using elbow joint as the center point of focus. After making at least 20 clockwise circles, make 20 counter- clockwise circles. Repeat the activity with right side.

The most wonderful benefit of this exercise is increased flow of blood across the joint capsule and tissues that increase the pace of healing.

Back Clasp

Black clasp is another exercise that primarily aims at improving the flexibility of shoulder muscles and joint ligaments. It ensures pain-free movements and to restore full range of motion.

Stand straight with your legs wide apart. Next step is to use your hands and clasp on your back. Stabilize your arm and slowly raise the arms over your head. Stop the arm movement at the point of maximum resistance and hold your position for 30 seconds.Start from the base-level again and you will see that slowly your range of motion has increased by the time you are done with the exercise (at least for 5 to 8 minutes thrice a day).

Wall Climbing 

Wall climbing is an exercise or recreational activity that allows your shoulders to work in synchronous motion with the rest of your upper limb components. Since it is also a recreational activity, you may be able to work up your joint apparatus for a longer period of time without conscious perception. Stand straight with your legs wide apart. Now use your fingers to crawl or climb the wall and as you move up, stop and hold the position at every 6 inch to feel the grip. Discontinue when you begin to feel pain.

Physiotherapy Tips to come out from back pain

Because of our modern lifestyle, Every year one in three of us will get some form of back pain with most back pain affecting the lower back. In the majority of cases you will be able to manage this yourself with over-the-counter painkillers, by keeping mobile and exercising the affected area.

It can last for anything from a few days or weeks, or continue for many months or in some cases even years, sometimes it won't. Back pain can influence your mood, your normal daily activities, your regular sleep patterns, your ability to carry out your work,  and your regular sitting positions.

If you are experiencing low back pain, you will likely have tension, soreness and/or stiffness in and around the affected area, sometimes you feel depressive. You may also feel some pain in the front or back of your upper legs, sometimes until back of the leg. For most people, this is ‘non-specific back pain’, meaning it’s not caused by another health problem such as damage to your spine or a more serious pathology. In some persons, some kind of depression also leads to this back pain.

Our 5 Top Tips

1. Stay Active

Once upon a time, Physicians or Physiotherapists were advised to take rest once you get back pain. But in fact, lot and lot studies show that if you are taking rest means you won't recover from back pain. A big risk factor for prolonging back pain is a reduction in your activity levels. This may be gradual or enforced due to work and lifestyle changes that you may have no control over. However, reducing your general activity levels equals a higher risk of your body’s tissues becoming less flexible, of oxygen not being able to flow freely to aid your body’s natural recovery and of muscles being used less often.

Keep active and moving when you have back pain, gentle exercise, as your pain allows, will help to prevent stiffness. We would suggest you start with non or low impact exercise such as swimming or the cross trainer, even increasing your walking tolerance can be a good starting point. But remember short duration to start with and build it up slowly especially if you have not done it for a while. It is normal to get a more aches and pains the day after, but these should settle by the next day. This gives you an easy way of monitoring how much you should do.

2. Take Medicine

You may wish to consider the use of pain killers in order to reduce your pain levels so that you are able to keep gently active. A safe first option for most people is to try regular paracetamol (provided you have taken before and are not aware of any reasons why you should not take them). If paracetamol proves insufficient you may wish to consider combining these with a low dose of non-steroidal anti-inflammatory (NASIDs) such as ibuprofen (NSAIDs have a number of potential side effects and possible interactions with other drugs you may be taking we would therefore recommend that you always discuss this first with your pharmacist, treating health professional or GP).

3. Good Postural Habits

In our new passionate world, we are using mostly computers in all kind of jobs.  So you need to maintain good sitting position while working. Always try to maintain good posture, especially whilst sitting at work, avoid slouching in your chair and hunching over your desk or computer screen. Always use a chair with a backrest and ensure that your feet are flat on the floor or on a footrest, and place your hip and knee in 90 degree position. Don’t forget to also change your sitting position regularly and get up, stretch and move around at least every 20 mins. If you feel that your back pain is work related then talk to your employer and/or your HR department. They will be able to make adaptations to your work environment to help you better manage your symptoms.

4. Get Stronger

You can get advise from your physiotherapists , what kind of strengthening or stretching exercises for your back pain. There are many stretches and strengthening exercises you can do for your back pain. Ideally, these should be individual to your specific problem. If you have tried some generic exercises from the internet or the exercises you are doing are not working for you, then it is worth having an appointment with one of our specialists to get an individualized programme. Research into low back pain recognizes that improving your general well being, eating habits and cardiovascular fitness are all important elements to your recovery. But also, research and our own experience informs us that improving the strength of your abdominal and back muscles can be very effective at reducing your pain. Strengthening these muscles will get you more active and importantly prevent re occurrences of your back pain in the future. Mostly core strengthening exercises is more safe and accurate exercises for mostly all kinds of back pain.

5. Don’t Worry, Stay Positive

Most non-specific back pain will settle down, usually in around 4-6 weeks. Be realistic in terms of setting yourself achievable goals for your recovery to help build your confidence. Avoid trawling the Internet for comparative cases, you will not find the correct outcome and will more often than not end up making things worse. We hope that these points above will help you to better manage your back pain and get well on the road to recovery. You self psychological support is needed to get recover from your back pain soon. So be positive always, we can kick out back pain from your life with the help of your physiotherapists.

Calf Muscle Injuries

What is calf muscle? 

The gastrocnemius and soleus muscles taper and merge at the base of the calf muscle. Tough connective tissue at the bottom of the calf muscle merges with the Achilles tendon. The Achilles tendon inserts into the heel bone. Soleus  muscle is known us " Peripheral heart" because of its function of bumping back blood to the heart.

Calf injuries are one of the most prevalent muscle injuries in athletes involved in running-based sports, secondary only to hamstring injuries. 

We see calf injuries as a result of sports involving a lot of high-speed running like AFL, soccer and rugby, as well as sports involving high-volumes of running load like athletics and recreational running. 

Calf injuries often involve a 4-6 return-to-play rehabilitation period for a Grade 1 tear, and are often more likely to occur during critical periods, such as the pre-season or during finals when athletes are fatigued. 

Structure of the Calf

The calf complex consists of two main muscles: Gastrocnemius & Soleus, as well as several smaller accessory muscles.A recent study showed that 62% of all calf injuries are to the Soleus muscle. Other reports suggest this figure may be upwards of 70%. Which leads to the question – are we doing enough Soleus strengthening in our rehabilitation? And, is our rehabilitation specific to how the calf muscle functions during running?

Mechanism of A Calf Injury

As with any soft-tissue muscle injury, there can be an acute ‘incident’ whereby you feel a strain/immediate onset of pain.However, often with calf injuries (particularly soleus) there doesn’t always have to be not a specific onset of pain – often people will report their calf “pulled up tight” directly after running, or even the following day. Usually it looks like muscle cramp . Once we get acute injury, we have to take rest then rehabilitate as well, or else it leads to chronic calf injury.

Risk Factors Associated with Calf Injury

• Increasing player age & future calf strains. Hence, they often call it an ‘Old man’s injury.’
• There is also evidence to show that a previous calf injury within 8-weeks relates to increased risk of future strain.

How Does the Calf Work During Running?

Foot contact time with the ground:

• Walking = 0.6sec
• Running = 0.39 sec
• Sprinting = 0.18 – 0.2secs

What this means is: We have a long period in swing phase.We have an extremely short period of foot contact time (with the ground) for the calf muscles to actively transfer load & propel us forwards.

So technically – we end up with a very quick isometric (static) contraction of the calf complex, supported by the spring of the tendon & fascia. This is important to consider & build into someone’s rehabilitation, especially when preparing a client/athlete to return to running. So we have to rehabilitate as well to prevent further injury

Rehab Considerations

1. Physiotherapists need to think of the calf/foot/ankle as one ‘functional unit’. so we have to rehabilitate all of them
2. Introduce the concept of the lower limb as a ‘spring’, and creating ‘stiffness’ throughout the calf/foot/ankle unit during running. You can train Stiffness. 
3. Think about the person ‘bouncing’ along the ground like a kangaroo
4. Focus on the ability to hit the floor & produce as much force as you can in a short space of time – quick isometric contractions.
5. We likely need to include more soleus strengthening (seated calf raises + weight) into our rehabilitation, as well as both Gastroc & Soleus isometric holds.

Physiotherapy role in Bocking Pain Gate

Peoples are usually thinking, what is pain? and How does it transmit and control ? Me also had the same feeling once upon a time. This post will give a suitable answer for  all of your questions.

Pain and Gate control theory of pain is an attempt to discuss about how pain sensation is transmitted. Pain is defined as the subjective sensation which accompany the activation of nociceptors and which signals the location and strength of actual or potential tissue damaging stimuli.

Various types of pain may range from mild irritation, through burning and prickling sensation to more intense stabbing and throbbing sensation and finally to agonizing and intractable pain which may be intolerable to many subjects.

Nociceptor afferent enters the spinal cord via dorsal root and makes synaptic connections with other neurons located in the dorsal horn of the spinal cord grey matter, which is the site of convergence of many inputs. The main reflexes involving nociceptor reflex are- Withdrawal reflex and Crossed extensor reflex.

Nociceptive efferent enter the spinal cord, terminate on the dorsal horn and make synaptic connections with-

• 1st- Inter neuron serving reflex.
• 2nd- second order neuron (T cell or transmission cell).

These second order neurons cross the mid line of the spinal cord to transmit the information to the higher center via lateral spinothalamic tract on the contra lateral side of the spinal cord. These ascending neurons reach ventrobasal nuclei of the thalamus where they terminate on the 3rd order neurons which convey the information to the cerebral cortex. Also the information is passed to higher centers via multisynaptic spinoreticular tract.

Modulation of pain transmission

At the level of spinal cord 

As noted before primary nociceptive afferent terminate at the 2nd order neuron or T cells. The excitability of this pathway can be altered by other inter neurons present in the dorsal horn. The cells of Substantia gelatinosa have an inhibitory influence on the transmission cell by Presynaptic Inhibition of the nociceptive afferent terminals at the point where they synapse with transmission cells.

Substantia Gelatinosa cells are inhibited when the nociceptive afferents are activated, this reduces the presynaptic inhibition and allows nociceptive information to be passed to higher center. Substantia Gelatinosa cells are stimulated by the activation of low threshold large diameter A beta mechanosensitive afferents. This leads to increase in presynaptic inhibition and prevents the transmission of nociceptive information to be passed to higher centers.

Pain modulation at Higher Centers: Gate control theory of pain

If the nociceptive information is allowed through the gate according to gate control theory of pain, then the traffic will continue up the lateral spinothalamic tract of the spinal cord through the thalamus and to the cerebral cortex. As the stimulus passes through brain stem, it may cause an interaction between Periaqueductal grey matter and the raphe nucleus in the mid brain.

These nuclei form part of the Descending pain suppression system and their neurons lead to the excitation of Substantia Gelatinosa cells and thus will cause inhibition of the pain transmission. The endogenous opioids the enkephelins, endorphins and dianorphins are involved in pain modulation at this level. They are thought to be associated to produce analgesia related only to prolonged pain rather than initial fast pain, produced when an injury first occurs. Therefore the inhibitory effect of higher centers influence the pain transmission mediated through C fibres.

So, according to Gate control theory of pain, Gate is open when Substantia Gelatinosa cells are inhibited as the cells allows nociceptive stimulation to be passed on higher center and the Gate is closed when SG cells are excited. Gate control theory of pain argues that human thoughts, beliefs and emotions affect the amount of pain felt from a given physical sensation. The basis of this theory is that both the psychological and physical factors guide the brain’s interpretation of painful sensations and subsequent response.

Modulation of pain by Physical Therapy

At the level of spinal cord: The large diameter mechanosensitive afferents can be stimulated by large number of modalities. They can be stimulated by direct simple mechanical stimulation of receptors in skin, muscles and joints. Techniques used include- massage, joint mobilisation, traction, compression, thermal stimulation, TENS, IFT, electrical stimulation of muscles.

At the level of Higher Centres: The Physio therapeutic agents which cause stimuli to flow along nociceptive fibres can stimulate the higher centers to inhibit to inhibit the pain transmission. Modalities used include- ice, friction, Ultrasonic therapy, UVR, low TENS, thermotherapy.

At the Periferal level:

i) Chemical released by the tissue injury may stimulate the nociceptive nerve ending. Degree of stimulation depends on the amount of chemical present. Therefore removal of these chemicals by the physio therapeutic agents affecting the circulation may help to reduce the level of nociceptive stimulation. Example- HEAT, ICE, CONTRAST BATH.

ii) Nociceptive fibres have a maximum frequency at which they can conduct. C fibres- 15 pulse/sec and A delta fibres- 40 pulse/sec. If higher frequency of stimulation is applied, a physiologic block to conduction might occur. Example- TENS and IFT.