Em Stuart Injuries Clinic

Graduate Sports Therapist Bsc Hons

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Cauda Equina Syndrome

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Cauda Equina syndrome is a spinal condition that its worth being aware about. Its uncommon, thankfully, but life changingly serious hence why I thought I’d write about it. Anyone who walks into the clinic with lower back pain gets this lecture.

When the spinal cord gets to the lumbar spine (L1) it starts to splay out like a horse’s tail, the Latin for which is Cauda Equina.

What is it?

Its compression of the lumbar nerves at the base of the spine which provide sensation to your legs, bladder, bowels and the area of skin around them.  Common causes are disc herniation and slippage of the vertebral body but there are other less common causes.

What are the symptoms?

The symptoms are not clear cut, but they can include lower back or leg pain coupled with;

Pins & needles or numbness in the saddle and seat (genitalia) area.

Bilateral sciatic pain (neural pain in both legs).

Changes in bladder and bowel frequency. If someone goes to the bathroom once or twice a night and that’s normal for them, then fine, but if that suddenly turns into four times a night, or day, then that’s a change for them.

Changes in bladder and bowel sensation. Not being able to feel when you go to the loo or not being able to ‘push’ or initiate a stream of urine. Loss of desire to void your bowels or urinary retention without pain.

Not being aware you need the bathroom until its almost too late or incontinence.

A symptom that’s missed is a complete absence of period pain during menstruation.

For ladies, not being able to feel anything during intercourse, for gentlemen, not being able to achieve erection – loss of sexual function.  

What happens if the symptoms are not addressed?

The damage can be irreversible to the bladder, bowel (incontinence) or sexual function. Complete loss of sensation to the genitalia or lower limbs or loss of function on the lower limbs.

If you have these symptoms, forget the GP, go straight to A&E, have an uncomfortable conversation, it could make all the difference. If it’s a positive case it will be identified usually by MRI and the nerve decompressed.

I’ve sent a few people to A&E and THANKFULLY, most cases have been ruled out so just because you have these symptoms does not mean its cauda equina, but DO have it checked out.

Hip Flexors…Part 19 of the Grumbly muscle blog

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Hip Flexors…Part 19 of the Grumbly muscle blog

What are hip flexors?

Hip flexors are a group of muscles which flex (bend) the hip, the opposite to Gluteus maximus (glute max), which extends the hip.

They also tilt the pelvis anteriorly.

You have Psoas major & minor muscles and iliacus…together they are the ‘iliopsoas’.

Anatomy

Psoas major – starts by attaching to the transverse processes of each of the lumbar vertebrae (L1-L5) and then attaches onto the inner femur (the lesser trochanter).

Psoas Minor – (not everyone has one) Starts at the first lumbar vertebrae (L1) and attaches onto the top of the pubis.

Iliacaus – starts out in the iliac fossa (the inside of the pelvis) and attach, along with Psoas major, onto the inner femur (lesser trochanter).

Rectus femoris (a quad muscle), and a couple of adductor muscles, Pectineus and Sartorius, and even tensor fascia latae (TFL) help to flex the hip as well.

 

Why do they get grumbly?

These muscles can become tight, weak, inhibited and short. People who sit down a lot for their jobs can have shortened and tight hip flexors and this can tilt the pelvis anteriorly, increasing the lordotic curve of the lumbar spine and impacting on lower back pain.

Tight and short hip flexors are implicated in lower cross syndrome; Tight hip flexors and erector spinae, with corresponding weak core/abdominals and weak gluteal muscles (see picture).

What can we do about it?

We can stretch out our hip flexors daily (see picture) and most importantly we can strengthen their opposing muscle, dear old glute max, and our core/abdominal strength.

For my clients, I often release their hip flexors which is effective if not a little painful.

Erector Spinae Muscles…part 18 of the Grumbly Muscle blog…

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Erector Spinae Muscles…part 18 of the Grumbly Muscle blog…

What are ‘Erector Spinae’?

Well, they do what they say on the tin – they keep the spine erect. They’re a group of muscles, 3 in fact; Spinalis, Longissimus and Iliocostalis. Longissimus is, unsurprisingly, the longest of this group.

What do they do?

They are the spinal stabilizers. They work with another spinal muscle called multifidus.

They are mostly deep muscles that sit underneath rhomboids and trapezius when they head towards the shoulders but they’re quite palpable near the lumbar spine. They help us extend the back (along with assistance from the QL’s – quadratus lumborum). They control thoracic flexion, side flexion and rotation of the spine.

Anatomy;

You have a set each side of the spine. They originate from the thoracolumbar aponeurosis (a large diamond shaped fascia at the base of the spine) and run to the top of the spin (see picture). The thoracolumbar aponeurosis also feeds into Glute Max and the Lats (latissimus Dorsi).

Why do they get grumbly?

These muscles do and will refer pain, especially in the lower part of the back. They can spasm, painfully, when they’re not happy. When multifidus isn’t ‘firing on all cylinders’ these take the brunt of the load but can’t ‘shoulder it’ alone. Compression of the vertebra increases and special nerve fibres which only transmit pain (nociceptors) start telling you ALL about it… et voila! – lower back pain…

What can we do about it?

Multifidus can be activated by activating the core muscles so a physical therapist like myself can advise what to do to achieve that. Deep tissue massage and soft tissue release work well and provide temporary relief. Dry needling of the erector spinae can relieve pain quite well and for longer periods than just massage and soft tissue alone. At home, heat either from a bath or hot water bottle can relax tight and overworked muscles and gentle stretching and lumbar mobility exercises.

The common extensor tendon…part 17 of the grumbly muscle blog…

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The common extensor tendon…part 17 of the grumbly muscle blog…

What does a common extensor tendon do?

It is the tendon implicated in Tennis Elbow (lateral epicondylitis) and becomes our forearm extensor muscles (then ones on the top of your forearm) which help us extend your fingers and hands at the wrist (bend back towards you).

It becomes three superficial muscles;

  • Extensor Digitorum (extends the wrist and fingers)
  • Extensor Carpi Ulnaris (adducts the wrist and little finger)
  • Extensor Carpi Radialis Brevis (extends and abducts the wrist, extends the middle finger, and helps flex the elbow)

Anatomy

This tendon starts on the outside of the elbow (called the lateral epicondyle) before forming into the above muscles attaching at the wrist.

Why does it get grumbly?

Tendons exist on a continuum, and they can suffer from overuse. As we age, tendons don’t regenerate as fast, so we can experience degeneration of the tendon.  Most commonly those age 35 – 55, both sexes are affected and is usually felt in the dominant arm.

Some people lack range of movement in the shoulders (usually external rotation) and the forearm muscles can overcompensate to make up for this.

Office workers, drivers, trades people and athletes that predominantly use their arms in sport (not just tennis players) can experience this, so too can manual workers, especially involving tools weighing greater than 1kg, repetitive actions and heavy lifting.

What can we do about it?

Firstly, strengthen the shoulder complex and improve range of movement though rehab, but in the meantime, soft tissue release of the muscles and dry needling of both the muscles and the tendon work very well to alleviate the pain.  If you can get them to stay on, dry cupping is also quite effective.

Dry Needling

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Dry Needling

The differences between dry needling and acupuncture are many, so I’ll start with the similarities, it’s a much shorter list:

Both treatments use the same acupuncture needles…that’s pretty much it.

Is dry needling the westernised version of acupuncture?

Surprisingly no, it’s not.

It was used by physicians as early as the 1920’s. In the 1940’s (Travell and Simons) authored the ‘trigger point manual’ and dry needling became more widespread in the late 1970’s. It initially began as ‘wet needling’ where substances such as saline, steroids and pain killers were injected into muscular trigger points but later on it was discovered that it was the needling, rather than any substance, that was effective in treating musculoskeletal pain.

It is a minimally invasive treatment, but one that carries with it a low risk. I first had dry needling for my tennis elbow (lateral epicondylitis) last year and I was surprised at its effectiveness.

What can it do?

Muscles: Reduce musculoskeletal pain by targeting the trigger points (knots)  in the muscle; these are small palpable hypersensitive area within the bands of the muscle. It aids the removal of (noxious) substances that aggravate the local peripheral nerves and can increase local pain thresholds. Trigger points in muscles account for a high proportion of musculoskeletal pain, some studies have found up to 85%.

Tendons: By creating small holes in the tendon (fenestrations) the degeneration of that tendon is disrupted, and a healing response is promoted (fibroblast proliferation) which leads to improved collogen formation and healing of the tendon.

Fascia: Facia runs under our skin, around, and inside our muscles and stretches from our toes to the tops of our heads. It’s not just muscles which transmit force through the body, the fascia takes about 40% of the load. The thoracolumbar fascia, which is found in the lower lumbar area (see picture, it looks like a white diamond) has three times as many nociceptors (nerves that solely relay pain to the dorsal horn in the spine) as muscles in the back. Dry needling has a substantial effect on myofascial pain modulation.

What happens when the needles go in?

Apart from a small prick, it’s quite painless, but what I’m trying to elicit is something called a ‘twitch response’ and leads a decrease in local chemicals and a ‘reflex relaxation’ in the muscle. The local muscle fibres become depolarised. This decreases electrical activity in the muscle which is a good thing. Muscles can be afflicted with ‘spontaneous electrical activity’ which dry needling studies have demonstrated they can supress.

Blood flow is increased, which is good news for the trigger point which has been a but starved of decent blood supply and therefore oxygenation. By increasing the blood flow, substances that open up and relax blood vessels (vasodilators) are released relaxing the surrounding tissue

Science has not yet confirmed the underlying method by which dry needling provides pain relief but there are sound theories.  Researchers widely believe that dry needling activates something called the Endogenous Opioid System (also known as descending inhibition). Yes, the body CAN produce its own opioids such as enkephalin and β-endorphin pain and stress reducing chemicals) which modulate pain signals going up (from the spinal cord to the brain) and it can modulate the response to those signals on the way back down as well, hence the descending bit. Acupuncture literature also strongly suggests this to be involved.

Other theories include an increased tolerance to pain thresholds and increases in neurotransmitters such as noradrenaline and serotonin. There is also the possibility of a placebo effect. Science cannot rule this out entirely. Whatever the reason for its success, science can at least agree its complex.

Possible side effects

  • Fainting is a possible side effect so, just as a precaution, you’re always lying down.
  • Soreness afterwards and perhaps even delayed onset muscle soreness (DOMS).
  • Its possible that a little bleeding happens on the surface or below the skin, so you may notice a subsequent small bruise.
  • Fatigue and dizziness.
  • Pneumothorax – a puncture of the pleura, the sac around the lungs. Caution is used when dry needling in the area around the thorax.

Multiple studies and systematic reviews have concluded that it is an effective treatment compared to no treatment at all, is good in conjunction with other therapies and carries a low risk.

Dry needling isn’t a magical cure-all, it won’t make a weak muscle suddenly strong again, but in combination with physical therapy and rehabilitation it can be a very useful adjunct.

Vitamin D

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Vitamin D

This is the time of year when sunlight is in very short supply. As I sit at my desk with my bright light therapy lamp shining in my face, I asked myself what’s the difference between getting vitamin D3 via sunlight as opposed to getting it via diet and supplementation…(yeah, this is going to be another ‘bee in my bonnet’ blog).

When our skin is exposed to sunlight, it produces endorphins, promotes feelings of wellbeing, and was used in the early 1900’s to treat Tuberculosis. UVB radiation is converted, via a complex chemical reaction, into Vitamin D3. The epidermis (the outer layer of the skin) absorbs this radiation and makes vitamin D3 in the cells of the skin. This process takes about 8 hours before its ready to leave the skin and travel into the body. 20-30 minutes of sunlight exposure daily is enough.

Vitamin D3 is essential for skeletal health, muscle function and the immune system…ever noticed how we’re more susceptible to illness in the winter? It’s not just the change in temperature.

Deficiency of this vitamin contributes to a range of health issues not limited to bone pathologies, autoimmune disorders, chronic illness, type II diabetes, cardiovascular disease, and depression and increased symptoms of SAD.  There is a high prevalence of vitamin D3 deficiency in the UK.

Absorption can be affected by;

  • Altitude (higher altitude, increased UVB absorption = more vitamin D3)
  • Skin pigmentation (lighter skin pigmentation = increased absorption), as mankind emigrated further from the equator, scientists believe skin pigmentation lightened to allow for greater vitamin D absorption.
  • Sunscreen can inhibit UVB radiation absorption by up to 98%. Australia was so good at covering up with sunscreen that 40% of the population experienced vitamin D deficiency but had a positive impact on lower skin cancer rates.
  • Air pollution (also absorbs UVB radiation)
  • It’s also affected by glass and plastic (which, you guessed it, also absorbs UVB radiation)
  • Season & Latitude – in Boston (USA), during the months of November to February, little vitamin D3 can be produced in the skin, Boston is 42° N latitude. Higher latitudes such as Canada (52° N) and Norway 60° N can’t produce any significant Vitamin D3 for 6-months of the year. Were about 51-52° N latitude in Gloucester, UK
  • Time of day – Between 12-2pm are the best time to get sunlight for Vit D3 absorption
  • Age decreases the ability of the skin to produce vitamin D3.

So, is getting vitamin D3 through diet and supplementation the answer in the winter?

Ingested vitamin D3 takes a different pathway, literally and chemically. We don’t get a huge amount of vitamin D3 through diet and we likely cant get enough from diet alone. Foods containing vitamin D3 include egg (yolks), liver and fish liver oil, red meat, oily fish – such as salmon, sardines, mackerel, trout.  Foods with added vitamin D3 include fat spreads, some fortified cereals and plant-based milks.

Vitamin D3 supplementation is highly recommended year long.  Sunlight derived vitamin D3 lasts 2-3 times longer than oral vitamin D3, but in higher latitudes, that’s not an option 5-6 months of the year.

Thanks for reading.

Hot Stones Sports Massage

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Hot Stones Sports Massage

Origin

The origin of hot stones dates back 5000 years. Hindus practiced the use of hot stones in India.  China was known to use the 3000 years ago placing stones on the abdomen to assist with digestion.  Hawaiians wrapped heated lava rocks in leaves and applied them to relieve pain. Russia, America, Japan, Egypt and Europe have all used hot stones for healing purposes throughout history.

 

What does a hot stone sports massage do?

For starters, even when used in sports massage context, its relaxing and stress relieving. As I’ve written in previous posts, the heat produces endorphins, opens blood vessels increasing blood circulation, increases lymph flow (the lymphatic system is your bodies waste disposal system) allowing toxins and waste products to flush out, reducing DOMS (delayed onset muscle soreness) aches and pains.

 

Where do the stones go?

There is a large selection of stones of all different sizes. Small ones that slip between your toes are rather nice. If there’s an area of pain or swelling, we can put a stone (wrapped in a cloth) on that area to warm it prior to massage, so really nice for the glutes and sore shoulders.

Using the gorgeously warm stones to glide over the skin it provides a deeper and more even pressure.

They’re nice to place under the shoulders when laying a client on their back and placing a stone over the abdomen is relaxing and believed to aid digestion.

Who says a sports massage can’t be relaxing?

The psychology and physiology of heat…

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The psychology and physiology of heat…

As I stood under a really hot shower the other day, I let out a contented relaxed sigh at the heat and wondered why I did that, what does heat actually do to our muscles and its it on a physiological or psychological level?

So I decided to do a bit of research…and it went down a rabbit hole.

 

What does the application of heat do to our bodies?

Both stress and the cold causes us to hunch and contract our muscles, decreasing blood flow to them.

Heat increases blood flow, by allowing the blood vessels to expand, which can aid the ‘flushing out’ of waste products like lactic acid.

It relaxes the muscle fibres making them longer and increasing mobility. It accelerates tissue metabolism and healing by increasing oxygen uptake and can also reduce joint stiffness.

Endorphins are released when we feel the warm sun and heat on our skin and the same effect happens when we bathe in warm water.

 

How can heat reduce pain?

The application of heat can aid the management of chronic pain, but how?

It’s a bit complicated…Heat increases stimulation of sensory nerve fibres (thermo receptors) which are connected to blood vessels close to the surface of the skin, this signals a substance that to be released that relaxes blood vessels called bradykinin (a vasodilator) reduces the threshold at which the muscle fibres fire, and relaxes the muscle, decreasing the tone.

Heat also stimulates sensory receptors that directly inhibit pain receptors. If pain is deep, then heat can reduce pain by altering the way the spinal cord talks to the brain.  

Going even more technical; Heat and cold are purported to alter calcium and sodium exchange in neural cells which positively affects pain tolerance and thresholds.

 

The benefits of taking a hot bath

A hot bath increases skin temperature and superficial blood flow, which allows for improved removal of waste products and relaxing muscle. The pressure of the water is thought to help reduce pain by assisting the removal of swelling (oedema).

Winston Churchill, who suffered from depression, was known for doing a great deal of his writing in the bath.

Immersion in hot water activates the parasympathetic nervous system (the bodies brake pedal). Heat and hydraulic pressure increase the metabolism allowing lactic acid and other substances to be removed from the muscles easier and decreasing fatigue. The buoyancy aspect aids relaxation and be good for the body on a physiological and psychological level.

Immersion in hot water is instantly relaxing and been shown to decrease the sympathetic nervous system (the bodies accelerator pedal).

Deep muscle structure blood circulation also increases significantly when the body is immersed in warm water, which aids oxygen flow and leads to improved healing.

 

Having a bath with Epsom salts

I told you I went down a rabbit hole…

Epsom salts, named after the town of Epsom, isn’t actually a salt but magnesium and sulfate (sulfur).  Magnesium is used for over 120 physiological processes within the human body, including heart function, nerve and muscle regulation, joint proteins, brain tissue and also helps line the digestive tract.

Having a couple of cups of Epsom salts in your bath can help with muscle soreness, relax you and help reduce the effects of stress.

How? The warm water increases circulation, allows the blood vessels to open up enabling the magnesium to be absorbed into your body, aiding the removal of toxins. It’s good for recovery post exercise. It’s known to be beneficial for arthritis as the magnesium possesses anti-inflammatory properties.

Magnesium deficiency in the body can cause mental fog and confusion, low mood, poor sleep, muscle weakness and twitching and even seizures.

So, I had a nice hot Epsom salts bath tonight. A much-needed bit of self-care for my tired muscles.

 

Rectus Femoris…Part 16 of the grumbly muscle blog…

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Rectus Femoris…Part 16 of the grumbly muscle blog…

So what’s a Rectus Femoris (Rec Fem)?

Its both a quad muscle and a hip flexor because it crosses both hip and knee joints.

As a quad muscle it extends the knee and, you guessed it, it helps flex the hip (with help from iliopsoas – a group of hip flexors) especially then the knee is already flexed.

It also helps when walking during the ‘toe off’ phase of gait and is particularly active while kicking a ball for example.

Rectus means ‘straight’ (it runs ‘straight’ down the thigh bone) and femoris meaning ‘femur’

Anatomy

It comes from the AIIS (anterior inferior iliac spine) on the hip and together with the other quad muscles forms the quadriceps tendon before the kneecap, which then inserts onto the tibial tuberosity on the tibia.

Why does it get grumbly and how does it happen?

As part of the hip flexor group, it does the opposite to Glute max and can potentially put both it and the hamstrings on a stretch by pulling on the front of the pelvis.

As a quad muscle, tightness in this muscle can lead to a reduction in knee flexion (bending of the knee) and a kneecap that sits higher up than it should.

The muscle can also become tight and develop very tender trigger points (area’s of heightened sensitivity).

We can strain the tendon, most often near the hip, in fact it can be torn off completely with a bit of the bone (called an avulsion) and we can also get tendinopathy caused by unaccustomed explosive sprinting or kicking.

What can we do about it?

Strengthening Glute max and hamstrings will help the pelvis stay in a neutral position.

Warming the muscle up dynamically prior to training, and regular stretching both your quads and hip flexors is helpful not just after exercise. Foam rolling is also a good way to perform self-myofascial release, and a good sports massage works well too.

Knots, trigger points and super tight muscles…Part 15 of the grumbly muscle blog…

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Knots, trigger points and super tight muscles…Part 15 of the grumbly muscle blog…

Why do muscles become painfully tight?

I’ve had a couple of clients recently that have come in with one singular muscle that feels, in tone, akin to hard wood under the skin. This is called hypertonic (hyper = excessive amount & tonic = tone/tension) or hypertonia, and this can be accompanied with or without painful spasms.

Normally when we contract a muscle we can see its excessive tone, but at rest this should not be the case.

This excessive resting tone is enough to restrict the normal range of a joint.

So how does this happen?

This is essentially a neural problem rather than a muscular problem…

Muscles have something called a ‘stretch reflex’ which is essentially protective in nature. We also have a ‘tendon reflex’ but more of that another time.

Nearly all muscles have ‘spindles’ in them which detect how much ‘stretch’ they are experiencing and report it directly to the central nervous system (CNS). If a muscle is reporting to the CNS that its under too much stretch this activates the ‘stretch-reflex’ to contract the muscle and stop further stretching, therefore reducing potential damage to the muscle. A good example of this is whiplash.

What causes it?

Overuse and fatigue of the muscle increases pull on the tendons (the white bit of the muscle that attaches to the bone), causing pain. The central nervous system then tells the muscle to contract, to protectively reduce motion (and therefore pain), but humans don’t like having to stop, so this then increases pain.

Muscle overstretching – Having a muscle in a stretched position for prolonged periods can trigger the stretch reflex and potentially cause spasms if that muscle is then stretched too far or too fast. For example, if we’re driving long distances or sat at a desk for long periods, gluteus maximus is in a stretched position and then in order for us to get up or out of the car, the muscle contracts, and we can experience tightness, pain and even spasm.

This is why trainers and coaches advocate dynamic stretching before exercise when the muscle is cold and static stretching post exercise when the muscles are warmer.

Muscle Guarding (splinting) means the muscle might shorten to protect other injured tissues such as ligaments – an example of this is the hamstrings protectively tightening following an ACL (anterior cruciate ligament) injury at the knee.

Muscles become stuck in a pain-spasm-pain cycle.

Prolonged contraction of the muscle (or being in a prolonged poor posture) reduces blood flow, so there is a build-up waste products and irritants which usually have an acidic pH further irritating the muscle.

Strategies to overcome this – Try and increase length of the muscle (stretch it, heat it and or massage it) and try to reduce fatigue of the muscle by strengthening it.

Other causes can be neurological in nature such as muscular dystrophy.