ARTICLES
The following are a series of articles written for various publications.
BACK PAIN
March 2008
According to the Australian Bureau of Statistics, last year 6.4% of the work force
or 690000 people were injured at work. Previous research has shown us that
25% of all injuries occur in just one area, the back.
One of the major causes of back injury is poor lifting technique. Of course not all
back problems arise from a sudden event or trauma. In fact one of the most
difficult problems is that a significant number of injuries result from the effects
of cumulative stress on the back. This is where small amounts of trauma over a
period of time gradually build up to become a significant problem.
One theory suggests that repeated small or even unnoticed lifting injuries can
give rise to micro-trauma and local inflammation in the ligaments and muscles of
the low back. This in turn can interrupt the delicate feedback mechanisms that
control small muscle contraction in the spine which in turn leave the area less
coordinated and more vulnerable to further injury. Often what are felt as minor
aches and pains are ignored until the problems progress and become more
severe.
So what can we do about it? Well if you lift heavy objects at work here are some
simple rules that might help.
 Keep your back straight, bend your knees and keep weight close to your
body when lifting.
 Avoid twisting or reaching when carrying weight, instead move your feet
carefully and turn your whole body.
 Reduce the size of load wherever possible (lots of small loads are better
than one big one).
 If at all possible use appropriate lifting gear or get some help.
Of course if you do suffer a back injury it’s probably better to tackle it sooner
rather than later. Don’t wait for it to become a severe problem before you see
your health professional. Treatment of the injured area followed up with
rehabilitation including muscle strengthening, flexibility work and work on the
stabilising mechanisms in the spine may well help to reduce the risk of further
injury.
Peter E Leach
HAMSTRING ARTICLE
14/04/08
One of the most common sports injuries at this time of year is the hamstring
injury. The hamstrings are the muscles at the back of the thigh. Patients often
say to me that in the lead up to an injury that no matter how much they stretched
their hamstrings, they always seemed tight. This is easily explained if you
understand some of the bio-mechanics involved.
Interestingly it’s the muscles at the front of the thigh, the quadriceps, which often
cause the trouble.
Tight quadriceps muscles pull on their attachments at the front of the pelvis
causing it to move forwards and downwards. This is called anterior pelvic tilt.
This has the effect of stretching the attachment of the hamstrings at the back of
the pelvis, giving rise to the feeling of tightness (or tautness).
Paradoxically excessive stretching of the hamstrings in this situation can actually
make the problem worse. If the muscles at the back of the thigh are stretched
and the quadriceps muscles are allowed to tighten further, the anterior pelvic tilt
can worsen and more tension is felt in the hamstrings.
Of course it’s never quite as simple as that. There are many other factors
involved. Poor muscle tone in the lower abdomen, tight hip flexor muscles, poor
arch mechanics in the feet and spinal problems can all contribute to increased
anterior pelvic tilt.
And then there is the way the hamstrings work. As a runner strides out the
hamstrings contract eccentrically, which means they progressively release as the
quadriceps at the front contract powerfully, and thus rein in and control
movement at the knee. If the hamstrings are already at full stretch when you are
standing still, they will be under a huge amount of increased stress during
running and therefore are more likely to be injured.
With this in mind here are a few tips to help prevent injuries to the hamstrings.
Stretch your quadriceps and hip flexor muscles as least as much as your
hamstrings.
Always warm up before and warm down after exercise.
Work on your core stability to maintain strength and balance in your torso and
pelvis.
And if you still have problems, see your health professional.
Peter E Leach
UNDERSTANDING DISC INJURIES (PART ONE)
Nov 2009
People with disc injuries are often surprised to find out an osteopath can help. In
fact disc injuries are one of the most common problems we see.
Discs themselves don’t heal very well, but that doesn’t mean a person can’t
recover from a disc injury. What you have to look at is the role the disc plays in
your overall function and help it to work as well as it can to play its part.
Discs are made up of rings of tough fibrous tissue that resist stretching forces
and a central jelly-like nucleus that absorbs water to help resist compression
forces. There are various types and degrees of disc injury but in many cases
when a disc becomes overloaded the outer fibers can be stretched or torn and
the nucleus can start to push outwards at this weak spot creating a bulge.
Much of the disc structure has no nerve supply so often a disc bulge in itself isn’t
painful but local inflammation and swelling can affect the surrounding tissues
and that can cause either local pain or even referred pain in the leg.
In the early stages of a disc injury conservative or manual treatment is often
recommended. The injured disc is often swollen making it more mobile and
vulnerable to further injury. The local muscles often go into spasm to splint the
region and then as they fatigue lactic acid is built up producing muscular pain.
The more the muscles fatigue the less able they are to splint the area and the
more vulnerable it becomes to further injury.
During the first stages of the injury the goals are often to reduce the local
inflammation and muscle spasm and to prevent further injury. Reducing muscle
tension can be done in a number of ways, including heat packs, but in my clinic
we tend to use gentle osteopathic soft tissue work to manually relieve the
muscles and gently stretch out the joints of the spine at the same time, which can
also reduce some local irritation to the nerves.
When people have a lot of low back pain we often see them moving in very
awkward ways to avoid hurting the injured area. This can often lead to stiffness
and soreness in other parts of the spine and as these areas start to hurt people
become less able to cope. Increasing the mobility in these areas with gentle
manual techniques can allow much better compensation for the patient, which in
turn can help improve comfort and speed up recovery.
To reduce the inflammation and swelling in the disc the application of cold packs
can be very useful. Fooling the body into closing the capillaries in the region
stops inflammation build up into the tissues and allows the body’s own
lymphatic system to drain the swelling more effectively. This is particularly
useful for people who can’t take anti-inflammatory medication for any reason.
Finally I will often apply strapping to the affected area. This is not, as some
people think, to provide support. In fact the strapping provides an early warning
system that stops people moving the injured area too far and causing more
damage.
Once over the acute phase, rehabilitation can begin to address some of the
underlying issues. This is usually tailored to your specific needs and varies from
person to person. The most important things here are to find out what other
mechanical problems in the body contributed to the disc being overloaded in the
first place and what other factors are preventing the disc injury recovering as
quickly as it can.
Always bear in mind that not all disc injuries are the same even though they may
give similar symptoms. If you think you have a disc injury seek out professional
advice and get the help you need to get back on track.
UNDERSTANDING DISC INJURIES (PART TWO)
April 2010
I have talked before (in my last piece) about managing acute disc injuries and
discussed how osteopathic soft tissue work can relieve much of the muscular
soreness, how using ice can help the local inflammation and that strapping over
the affected area can provide an ‘early warning system’ that helps prevent
further injury, allowing the problem to settle down.
But what if you keep getting back problems? What happens when managing the
short-term (acute) aspect of the injury isn’t enough? This is where you have to
look a little bit deeper than the disc injury itself.
The main thing to remember is that a disc in the spine doesn’t work on its own.
It is actually part of a complex system of muscles, ligaments, bones, nerves and
other discs that all have to play their part in the correct sequence for everything
to work properly.
So the first step in managing a long-term (chronic) or re-occurring (recurrent)
disc problem is to assess the structures immediately around the disc as well as in
the rest of the body, to see how well the parts of the system are integrating.
Problems with these other areas can contribute to either causing a disc problem
or preventing a disc problem from getting better. Osteopaths call these
problems contributing factors. Examples of these factors might be; stiffness in
the segments of the spine next to the disc causing the disc to become overloaded
with more movement than normal, or weak abdominal muscles that don’t
provide the necessary support through the trunk leaving the discs vulnerable.
Contributing factors might also include posture at work, driving position, lifting
habits and also stress to name a few.
The really important thing for any practitioner is to build up a unique picture of
what’s happening for that individual patient and to document and treat all the
factors that are either pre-disposing or maintaining that persons disc injury. In
fact once you have looked at all the contributing factors, you can often see that
the disc injury itself was the last in a whole series of events and problems that
may have happened. Only by addressing all of these factors can you hope to start
resolving the long-term underlying problem.
Remember, the factors that contribute to your injury are going to be unique to
you, which means your treatment plan should be too. For more advice see your
health professional.
LIVING WITH A DISC INJURY
April 2010
Using various treatment approaches practitioners can help patients to manage
both the short and long term effects of a disc injury. But what are the practical
things patients can do to help themselves live with a disc injury more
successfully?
In general day-to-day activity ‘moderation in all things’ is quite a useful phrase to
remember. I also tend to think about the effect of load over time. In other words
a small load that occurs for a long time (either continuously or repetitively) can
have a similar effect to a large load occurring over a short period of time. For
example you might expect to injure your back if you tried to lift a tree that
weighed four tonnes, but what about moving four tonnes of firewood in a couple
of hours?
Stacking firewood includes a number of component activities to be careful of.
Firstly bending puts a stretch through the back of the discs and this is usually the
location where injury occurs in the first place. The disc also compresses at the
front and the jelly-like nucleus is forced backwards placing further pressure on
the back from inside the disc. This is why bending from the knees is often
recommended.
Secondly stacking wood involves lifting weight. Weight has the effect of
compressing the spine, which causes the discs to bulge outwards between the
vertebrae. The jelly-like nucleus in the centre of the disc pushes into any weak
spots in the fibres of the disc, which can cause further tearing or damage. The
more weight lifted the more bulging.
The third component activity stacking wood often involves is twisting. When
twisting the outer fibres of the discs are stretched in a torsional fashion. If a
person is already loading the disc by lifting any weight or by bending forwards
then adding a twisting movement can be very damaging. Generally it is better to
turn your whole body rather than twist at the waist.
Other examples of activities that combine load in the spine are; Digging, which
has an element of repetitive bending often combined with twisting and lifting
load at the end of a lever; Sitting, particularly in a car, which combines sedentary
weight with bending forces.
So to sum up: Take care when lifting weight, bending forwards (which includes
sitting) or twisting. Be particularly careful of combining these forces together.
Limit bending to short periods and remember that repetitive bending
accumulates stress over the time you do it, so keep that short too. Sitting is
bending too, so limit that to shorter periods and if in a car break the journey up.
When lifting heavy things try to bend from the legs instead of the spine and keep
heavy objects close to the body, not at arms length. Store heavy objects where
you don’t have to bend to get them and leave the lighter stuff for the lower
shelves.
Avoid twisting when carrying things and instead move your feet to turn your
whole body.
As always if you have any doubts about managing your injury get more specific
advice from your health professional.
SHIN SPLINTS
Feb 2009
At this time of year I tend to see a lot of patients with ‘shin-splints’. This can be a
very painful and debilitating condition in the legs and is probably due to a
number of factors, not least of which, is often pre-season training sessions on
hard-baked summer ground.
To help prevent ‘shin-splints’ it is first important to understand what it is. The
clinical name for this condition is Medial Tibial Periostitis. This literally means
inflammation of the periostium (bone covering) on the inside aspect of the shinbone. Pain usually occurs on the inside part of the leg (not the front) and can
vary in intensity from a mild soreness to a burning/tearing sensation. It can stop
people running and cause significant disruption to training programmes and
activity in general.
Usually inflammation in this part of the leg occurs where the deep muscles of the
leg attach to the tibia (shin bone). If these muscles become overly tight they can
pull excessively at their attachment causing micro-tearing and inflammation.
These muscles can become tight for a variety of reasons, but quite significantly
because these muscles are important in supporting the arch of the foot, any
problems with the foot itself can be an issue. Overtraining, particularly on hard
surfaces, with a lack of stretching can be another issue. Another major cause is
related to poor footwear, either ill-fitting running shoes, or worse, running shoes
that have done too many kilometers and have lost their support.
Treatment is usually focused on reducing the local inflammation along the tibia,
reducing tension in the deep muscles of the leg and correcting any other
mechanical problems in the lower limb. Most people find rest in the early stages
the best relief but underlying issues usually need to be addressed if the problem
is not going to return.
Prevention is of course better than cure, and here are some tips to reduce the
risk of problems: Wear the correct footwear for the activity you are doing (make
sure they are not too old either); Make sure to stretch the calf muscles regularly;
Try to vary the surfaces that you run on, avoiding overly hard ground wherever
possible. But if these simple measures still don’t work and you are experiencing
problems, always remember to talk to your health professional for more
individual advice.
PREGNANCY ARTICLE
August 2008
Pregnancy can affect your posture in more ways than one.
Most of us are familiar with the idea that changes to body shape during
pregnancy can cause low back pain. As weight and size in the abdominal area
increases body weight is pulled forwards causing the curve in the low back
(lumbar lordosis) to increase. Because the small joints of the spine are at the
rearmost part of the back, they can be compressed by the increase in lordosis
and this can give rise to pain.
To keep the body upright and the eyes level, the body automatically compensates
by increasing the forward curve in the upper back (thoracic kyphosis). This in
turn pushes the shoulder girdle forward. At the same time breast development
occurs further adding to the pull forwards and downwards. These secondary
changes in posture can also have dramatic effects. Increased pressure in the
pectoral girdle causes increased pressure at the top of the arm, which reduces
drainage in the arm and can predispose to problems like carpal tunnel
syndrome. Other knock on effects can be problems with the neck and headaches.
After childbirth many new mums focus on improving strength in the abdominal
and pelvic areas. This is great for supporting the low back. But the upper back
shouldn’t be overlooked either. As well as the problems with posture in this area
many new mums also find themselves breast feeding as well as lifting and
carrying a baby throughout the day which compounds the tension in the upper
back and neck.
Despite the need to constantly focus on the baby, mums need to look after
themselves too! If you can find a few minutes in your hectic schedule here’s a
stretch that may be of help:
Stand in a doorway placing your right forearm upwards on the architrave. Make
sure your elbow is the same height as your shoulder or just above it. Then take a
half step back with your left leg turning the toes of your left foot outwards by
ninety degrees. Gently bend your right knee to lean through the door, feeling the
stretch in the front of your shoulder girdle (pectoral muscle). Hold gently for
thirty seconds then reverse these directions to stretch the other side.
Remember this should be a gentle stretch and never painful so if it hurts stop.
Of course if you get persistent problems don’t forget to seek advice from your
health professional.
WHIPLASH INJURY- IT’S NOT ALL IN THE NECK
Dec 2008
Whiplash can be a nasty experience, but for some people symptoms can last for
many months or even years.
Whiplash is a specific type of neck injury involving rapid acceleration of the body
followed immediately by rapid deceleration. Typically it is caused by a motor
vehicle accident and can occur when a stationary or slow-moving car is hit from
behind by a faster moving vehicle. The neck is first ‘snapped’ backwards by the
initial impact and then ‘whipped’ forwards as the torso is restrained by the
seatbelt.
Tissues at the front and back of the neck are both stretched and compressed.
This can cause injuries to the muscles, joints and ligaments throughout the whole
spine. Severe complications can include ligament rupture, bony fracture and
nerve damage leading to symptoms in the arms. Even without these severe
complications the muscle damage and joint injuries can cause prolonged pain.
Interestingly one of the most important areas in treating people with whiplash is
not the neck, but the upper back!
One of the complicating factors affecting recovery is the fact that the neck is
already one of the most mobile regions of the spine. After being over-stretched
in this way the surrounding muscles tend to spasm and splint the affected area.
Normally in this situation a person would naturally compensate by moving more
through the torso or upper back, however with whiplash injuries this area is
often already traumatised by impact from the seat belt. Difficulty compensating
for the neck injury in this way causes further fatigue and muscle pain.
Tackling problems in the upper back can therefore help enormously to reduce
further stress on the neck and improve the speed of recovery. This might include
work to relax the muscles throughout the spine and upper torso as well as the
neck itself. Improving joint mobility in the spine itself as well as the joints of the
rib cage is also important. And don’t forget any stretching or flexibility exercises
should incorporate the upper back as well.
For more information consult your health professional.
REFERRED PAIN IN THE KNEE
Aug 2009
When is a sore knee not a sore knee? When it’s a sore hip!
Many people with hip problems get some pain in the groin, but much of the time
when people have problems in the hip pain is actually felt in the knee! This is called
referred pain. One theory for this is that the brain gets confused about pain signals
from the hip and interprets the sensation as though it is coming from the knee.
There are other sites in the body that give referred pain as well. (e.g. the shoulder
hurting when there is a liver problem.)
Of course people with knee problems usually feel pain in the knee as well, which can
make it difficult to be sure what is actually happening. Many of the things that
aggravate knees and hips are the same too, like walking for example, making it even
harder to distinguish between the two.
So how does someone distinguish between the two? There are a few things you can
check for yourself. The first thing is to see if there is any local tenderness. The hip
is a very deep joint, which means you cant really feel it, but the knee can be easily
palpated for tender spots. Secondly if there is any inflammation the knee might be
red or swollen, and thirdly if there is any structural damage in the knee you may find
it locks or gets stuck in certain positions.
If you have knee pain but don’t have any obvious signs of any knee injury then it’s
possible your hip could be the cause. There are many types of hip problem that can
cause referred pain some of which include osteoarthritis (OA), which is wear and tear
of the joint and Perthes disease in children. Some types of hip problem can be very
serious if not detected early so if you find you are experiencing knee pain for no
apparent reason, a full clinical assessment by your health practitioner might be the
only way to really work out what is going on.