conditions

Every time the upper arm is lifted overhead, a narrowing of the space between the humeral head and acromian occurs. This space, (the subacromial space) is where tendons of the rotator cuff are located, protected by the bursa. Performing sports, or everyday activities which require repetitive overhead movements, rotator cuff muscle imbalances, or irregularities in the acromian profile may all cause increased friction inside this space, which can lead to the formation of calcium deposits within the subacromial space. The tendon most frequently involved in these injuries is the supraspinatus tendon, due to its location. The end result of these kinds of injuries are feelings of weakness and pain, often most felt at night time. The lack of movement that results from these feelings of pain can in turn perpetuate the injury as the joint becomes more and more stiff through under-use. Pre-existing, but undiagnosed wear of the shoulder joint is also a concern here as it can further contribute to the pain experienced. Quick and correct diagnosis followed by an early start to rehabilitation is key here, as stopping the vicious cycle mentioned above ensures rehabilitation is faster and more effective. Adopting this approach negates the need for prolonged courses of anti-inflammatory drugs, as well as preventing secondary damage to the joint through the adoption of bad postures or movement patterns. In cases of large calcific deposits, or complete tears of the rotator cuff tendon, surgery may be required. However, rehabilitation is always necessary here to correct and prevent the underlying issues which may have led to the injury forming in the first place. 

Spondylolysis (spondy = spine, lysis = breaking) refers to an alteration in the morphology of the lumbar spine, involving an interruption in the continuity of the vertebral arch, more specifically the isthmus (pars interarticularis) between the superior articular process and the inferior articular process of the facet joint. This absence of the bone tissue then becomes filled with thick fibrous tissue. Whilst the causes of this condition are not fully understood, it is thought that some people may simply have a congenital weakness of the isthmus. Successive microtraumas, or a single sudden jolt may cause the bone to fracture at this point, resulting in subsequent back pain. If the isthmus is interrupted on both sides (as usually happens), the vertebral body tends to slide forward on the vertebra below, producing a spondylolisthesis (listhesis = sliding). This pathology is the main cause of back pain in adolescents and is frequently the culprit when younger athletes mention recurring back pain.

This most commonly affects the fifth lumbar vertebra (L5), which tends to slip on the body of the sacrum (S1) and also, although less commonly, the fourth lumbar vertebra (L4) sliding along the fifth (L5). This condition is typically benign, although it will progress over the years causing an instability in the lumbar spine. As such, it is important to control this situation as early as possible with proper clinical and diagnostic examinations. Medical history and clinical examinations may lead to a suspicion of this condition, but further, more specific investigation is required to reach a clear diagnosis. These tests include X-rays of the lumbar sacral spine to investigate the presence of any ‘sliding’ or fractures. However, these fractures can be difficult to see on X-rays, meaning more specialized CT scans are sometimes needed to rule out this possibility. MRI scans may provide evidence of a ‘stress response’ in the isthmus. In the most advanced cases, this sliding may result in stenosis (narrowing) of the spinal canal with subsequent nerve compression and irritative symptoms. It is important to remember that not all cases of spondylolisthesis are the result of a fracture isthmus, older adults may experience spondylolisthesis without any associated spondylolysis occurring as the result of advanced degeneration of the joint between the lumbar vertebra. 

Treatment here is almost always conservative, consisting of reinforcement exercises to reduce the sliding forward of the vertebral body, address the tilt of the pelvis, reduce lumbar lordosis and strengthen lumbar-pelvic control. In addition, physical and manual therapies can be used, depending on the severity of symptoms. Surgery should only be considered in cases of marked instability and a large ‘slip’, where fixation using surgical hardware may be necessary. Following surgery, many of the same issues will be present (poor lumbar-pelvic control) so a period of rehabilitation will still be required.

Lower back pain describes symptoms localized in the lumbar region and is due to many different causes. It is not our intention to bore you by listing all the potential causes and classification of back pain, rather to give you a general overview. This is a very common condition affecting around 85% of the population. Back pain is usually characterized by an aching pain slowly or suddenly riding up the spine, which may or may not spread to the buttocks and thighs, as well as limitations with movement as a result of this pain.

Acute back pain may occur after a sudden torsion or flexion-extension movement of the spine and can result in extreme sudden pain. Patients typically tell their doctors that they were trying to lift something heavy from a semi-fixed position and their back “got stuck” or that “something went”. In cases where normal activities continue to exacerbate pain, a period of rest may be need to be enforced. 

Chronic back pain is described as when symptoms persist for more than 3 months. Patients describe pain and feelings of stiffness in the morning that improve throughout the day, although they may experience difficulties maintain the same position. This kind of problem is particularly prevalent amongst those with sedentary occupations, including those which require long periods of sitting. During the clinical examination, it is important to identify the origin of back pain and whether or not there is any evidence of nerve root compression. Compressed nerve roots can cause sharp, burning pain and, depending on the site, a loss or altered sensation and weakness in the surrounding muscles. 

Sciatica refers to burning pain shooting down the posterior side of the thigh down to the foot, this is caused by compression or irritation of the sciatic nerve. 

Muscles governing movements of the spine are frequently contracted and sore in these cases (gluteus, quadrates lumborum, paraspinal etc.) which can cause nocturnal disturbances which affect the quality of sleep – an often overlooked and important factor in rehabilitation. 

Conservative (non operative) treatment is warranted in the vast majority of cases but as with cervical pain, it is of paramount importance to address contributing factors, such as poor posture. 

Therapeutic sessions are generally based on the use of manual therapies to aid in relaxing the muscular groups responsible for controlling movements of the spine and pelvis in addition to physical therapies designed to reduce pain. When possible, exercises are used to selectively improve tone in certain muscles and to correct imbalances of strength which are almost universally present in cases of persistent back pain. 

Patients must also become aware of how the ‘small factors’ mentioned earlier can affect the outcomes of therapy, and continue to pay attention to things like how they sit on the sofa, how much time they spend behind the wheel and perhaps most importantly, how much weight they have gained recently. It is important to focus on these seemingly trivial details in order to prevent the recurrence of symptoms. 

Caused by the posterior or posterior-lateral migration of the nucleus polposus due to a weakened fibrous ring
The intervertebral discs act as shock-absorbing cushions interposed between two consecutive vertebra. They consist of a central ‘nucleus polposus’, rich in water and held in place by an external fibrous cover. Movements of the spine change the position of the nucleus polposus inside the vertebral disc; an anterior flexion of the spine causes the nucleus polposus to move backward, while an extension of the spine will result in it moving forward. These physiological movements are prone to stress during the repetition of incorrect posture and during sudden, large impacts. In these cases, the nucleus polposus may protrude (bulge), pushing it to the side without treating the fibrous ring that retains the nucleus inside the intervertebral disc. These fibrous rings are supplied with rich supplies of nerves; therefore the pressure exerted by displaced nuclei can result in pain. In more advanced phases, where the fibrous ring has torn, the material contained inside the ring leaks out (slipped disc) pushing downwards or sideways. Slipped discs and bulging of the nuclei vary according to their location and direction in which they have migrated. This is important to establish as it will dictate both the urgency, and the type of treatment required. Clinical examination are used to determine whether or not there are signs of a compressed nerve. This may causing an aching, shooting type of pain as well as a loss of strength in the muscle supplied (myotome) and/or an alteration in cutaneous sensations in the area around the compressed nerve root (dermatome). These alterations may include hyperalgesia (an increase in sensation) or hypoalgesia (a decrease/ loss of sensation). Diagnostic tests require here include MRI or CT scans. It may also be necessary to undergo an eletromyography (EMG) or nerve conduction study (NCS), in order to evaluate any neurological deficits. These examinations can be quite invasive as they require the introduction of needles into muscles or nerves to test their functioning. 

Conservative (non operative) methods can treat the vast majority of cases of disc injuries, especially when there is minimal muscle weakness, since even the most severely affected discs tend to correct themselves in a few months. Surgical treatment is reserved for more severe cases where the disc has slipped into the intraforaminal area (the space in which the spinal cord travels), where the nucleus is dehydrated, when muscle and sensory limitation do not improve, cases where conservative treatment has been unsuccessful and in urgent cases where irreversible neurologic deficits are possible. 

Whiplash injury occurs after a sudden, violent hyperflexion/ hyperextension movement of the cervical and upper thoracic spine. Causes of these injuries vary from: sports injury, falls, accidents in the workplace, and most commonly car accidents. The pain experienced here can be extremely intense and is usually felt most in the cervical muscles, whose tension and rigidity can increase over time, limiting movements of the head. Vertigo and intense headaches often contribute to the pain experienced. In rare cases pain can radiate along the arm through to the fingers of the hand which may be associated with altered sensation and weakness. If these symptoms occur it may be a sign of a slipped cervical disc(s) and needs particular attention. In these cases the first diagnostic exam you undergo is a standard X-ray of the cervical spine in order to exclude fractures. 

A CT scan may be required if there is any suspicion of a fracture that the first X-ray may have missed. MRI scans may also be used where neuropathic pain is experienced.

Pain arising from the neck, or ‘cervicalgia’, has many different underlying causes. These include problems connected to poor posture, sedentary behaviour, the use of improper pillows, impact sports, a ‘slipped disc’, arthritis and, not least, traumatic events such as whiplash injury. Cervical pain can be localized to the neck or felt in other parks of the body. Cervicobrachialgia is the term used to describe sharp, shooting type pain that is perceived in the shoulder, arm, and hand, through the fingers. This is often caused by nerve root compression but the formation of a clear diagnosis is fundamental to plan a proper rehabilitation path. This will always require a thorough clinic examination and often a series of investigations. These may include a series of X-rays, which help evaluate the state of the vertebra and their alignment, a CT scan or an MRI to detect possible compression of the spinal cord or presence of the slipped discs causing compression of the nerve roots. 

Conservative (non operative) methods can treat the vast majority of cases of cervicalgia, especially when the underlying cause and contributing factors are appropriately addressed. During therapeutic sessions manual based therapies are used to help relax the muscles of the cervical spine and shoulder girdle that are commonly a source of tension. Specific exercises are utilized to help strengthen deeper, postural muscles of the neck and shoulder girdle that often become weaker from poor posture, pain or disuse. Stretching of overactive is also particularly effective. An important matter is identifying at the first examination poor postural habits that can make the rehabilitation path more complicated and neutralise positive results. The patient has to be conscious of the fact that, in part, the results patients obtain depend on small details of their lives such as the way they sit on the sofa, or the time they spend in front of a computer. This attention to detail may seem trivial, but these small factors often explain why symptoms persist for months or even years.