Call 07 3102 3337

Call 07 3102 3337

reception@praxisphysio.com.au

Call 07 3102 3337
Book Online
FACT OR FICTION FRIDAY || All rotator cuffs tears need surgery.

FACT OR FICTION FRIDAY || All rotator cuffs tears need surgery.

by | Dec 28, 2019 | Pain, Shoulder, Surgery

Answer: FICTION. The devil is in the detail!

The rotator cuff is a group of 4 muscles that aid in providing stability through range for the shoulder joint, particularly overhead. There are multiple risk factors for RC tears, but most are down to overactivity of the shoulder joint decreased conditioning of the shoulder complex, which comes with age. In fact, cuff tears are common in individuals over the age of 40 with linear increase in incidence as we get older.

Pain with movement and function is one of the biggest symptoms of a rotator cuff tear. However, it is important to know that a sizeable portion of RC tears are actually asymptomatic and don’t cause the person any pain or discomfort! A study by Minagawa and Yamamoto in 2013 found that in a screening of 664 village residents, 147 subjects had RC tears on a medical imaging screening. Surprisingly 65% of them had no symptoms at all and didn’t have any shoulder complaints.

Mid Potion Achilles Tendinopathy Location

The two main ways of treating a cuff tear is either through conservative management with your physiotherapist or down the surgical route, which is also then followed by physiotherapy rehabilitation.

SO, back to the original question: “Do I need surgery?”. As always – it is a case by case decision!! There is no definitive evidence for supporting one over the other generally speaking!

However, it is vitally important to note that each option comes with their own pros and cons. Furthermore, it is important to remember that just as every person is different, each case of rotator cuff tear is different. Young vs old, acute vs degenerative RC tear, current and desired future function, pain levels, radiographic findings, previous history of shoulder trauma and the patient’s wishes are only some of the questions that aid in the decision process.

The best way to decide would be to contact us to asses you and discuss both options and what your goals of rehab are so that a tailored plan can be developed WITH you. To read more about RC tears, read our blog here

To get your shoulder back on track, book online or give us a call on (07) 3102 3337.

Team Praxis

PREVENT | PREPARE | PERFORM

Stingers AKA Neural traction injuries

Stingers AKA Neural traction injuries

by | Dec 17, 2019 | Nerve Pain, Pain, Shoulder, Sports Injury

SUMMARY:

  • Stingers are essentially a tractioning of the neural system
  • This can cause pain, movement and sensation changes
  • Chronic traction to the nervous system can have a cumulative effect on nerve function
  • The more damage to the nerve, the more serious the outcome
  • We shouldn’t be as dismissive of “stingers”, particularly if they are recurrent
  • Physiotherapy has a role to play

STINGERS:

Stingers have been the catch cry of many contact sports over the years. Often dismissed as ‘just a stinger’, trauma to the nervous system should probably be taken a little more seriously, as we delve into detail today.

Stingers are most commonly experienced in contact sports whereby the shoulder of a players is forcefully depressed, as experienced with a tackle in NRL or union. A large range of motion over a short period of time can result in a ‘traction’ of the Brachial Plexus (a network of nerves formed from exiting branches of the spinal cord in the neck that transverse to the shoulder and arm). Thus network of nerves sends signals from your spinal cord to your shoulder, arm and hand and thereby providing feeling and movement to these regions.

BACKGROUND:

To understand a stinger injury, a clear understanding of nerves and nerve related injuries is required. A nerve is an enclosed, cable-like bundle of nerve fibres called axons, in the peripheral nervous system. A nerve provides a common pathway for the electrochemical nerve impulses that provide a number of functions, including getting our muscles to move!

Seddon and Sunderland present a five-grade classification scale for nerve related injuries[1-4]. Figure 1 illustrates the physiological changes that occur through each grade of injury. Essentially it outlines the greater amount of disruption to the anatomy of the nerve.

The more damage to the nerve, the more serious the outcome. Table 1 outlines the three different grades of stinger injuries.[4, 5] The most common stinger is a grade 1 injury, which represents a neurapraxia, or nerve stretch injury, without axonal disruption.[4] In an acute setting, this can result in motor and sensory loss/changes, which usually resolve within minutes.[1, 4] Grade 2 and 3 involve a higher degree of nerve injury, usually involving a crush, transection or compression mechanism.[1]

Chronic traction to the nervous system can have a cumulative effect on nerve function. This is termed “chronic stinger syndrome” and represents a distinct entity from acute stingers that may reflect long- standing structural changes of the subaxial spinal canal and chronic irritation/degeneration of the exiting nerve root complex.[4, 6]. This sounds complex but essentially means

Mid Potion Achilles Tendinopathy Location

A Clinical Example from Zac

“During a Gridiron match, a player was injured whilst making a tackle. I reviewed the player on field and he was unable to utilise his right upper limb (full paralysis) from shoulder down to his hand. The player was removed from the field immediately to be further assessed and monitored. A complete neurovascular assessment was performed, assessing motor function/strength, sensation, reflexes, and vascular status, as well was the cervical spine. Motor and sensation changes were the only deficits noted and were reviewed frequently. After roughly five minutes, the player demonstrated full upper limb motor strength and sensation, with nil lingering symptoms. In collaboration with the patient, it was decided he would return to match play immediately. The patient was monitored throughout the game and reported no further symptoms.”

Figure 2 shows a proposed decision tree when managing stinger injuries.[4] This clinical example outline above fits the Grade 1 Mild category as he was able to return to competition with nil lingering symptoms. Despite the lack of symptoms during the game, it is recommended the patient be reviewed again both after the game and weekly for two weeks to ensure a full resolution of symptoms.[4, 7]

The role for neural mobilisation?

Current non-surgical management involves rest, pain control and resistance training[4]. Though not explored within the literature, neural mobilization may have an important role in patients with persistent symptoms, such as Grade 1 moderate to severe, and more recurrent neuropraxias. Though not assessed in this specific population, there is evidence for neural tissue management being superior to minimal intervention for pain relief and reduction of disability in nerve related chronic musculoskeletal pain.[8] It is biologically plausible that recurrent neuropraxias may respond in a similar way, utilising neural mobilisation (tensioning or sliding) and mobilisation of surrounding structures.

Management of persistent Grade 1 injuries may differ slightly, specifically if the suspected mechanism of injury was through traction rather than compression. The nerve structures may have a heightened sensitivity to tensioning based techniques due to the similar mechanism of injury and may respond better acutely to sliding techniques which limit the strain on the nerve and focus on excursion. Tensioning techniques may be important in the sub-acute phase by loading the patient’s nervous system (i.e. increased strain) in preparation for return to function (i.e. tackling with acute traction on the brachial plexus).

In summary, perhaps we shouldn’t be as dismissive of “stingers”, particularly if they are recurrent for you! If you have any questions or would like to see one of our physios regarding your injury, feel free to contact us on (07) 3102 3337 or book online on our website

Till next time, Praxis what you Preach

Team Praxis

Prevent | Prepare | Perform

REFERENCES:

Menorca, R.M.G., T.S. Fussell, and J.C. Elfar, Nerve physiology: mechanisms of injury and recovery. Hand clinics, 2013. 29(3): p. 317-330.

Tsao B, B.N., Bethoux F, Murray B, Trauma of the Nervous System, Peripheral Nerve Trauma. 6th ed. In: Daroff: Bradley’s Neurology in Clinical Practice. 2012.

Sunderland, S., A classification of peripheral nerve injuries producing loss of function. Brain, 1951. 74(4): p. 491-516.

Ahearn, B.M., H.M. Starr, and J.G. Seiler, Traumatic Brachial Plexopathy in Athletes: Current Concepts for Diagnosis and Management of Stingers. J Am Acad Orthop Surg, 2019.

Feinberg, J.H., Burners and stingers. Phys Med Rehabil Clin N Am, 2000. 11(4): p. 771-84.

Presciutti, S.M., et al., Mean subaxial space available for the cord index as a novel method of measuring cervical spine geometry to predict the chronic stinger syndrome in American football players. J Neurosurg Spine, 2009. 11(3): p. 264-71.

Aldridge, J.W., et al., Nerve entrapment in athletes. Clin Sports Med, 2001. 20(1): p. 95-122.

Su, Y. and E.C. Lim, Does Evidence Support the Use of Neural Tissue Management to Reduce Pain and Disability in Nerve-related Chronic Musculoskeletal Pain?: A Systematic Review With Meta-Analysis. Clin J Pain, 2016. 32(11): p. 991-1004.

Shoulder Pain

Shoulder Pain

by | Dec 6, 2019 | Gym and Strength, Pain, Shoulder, Sports Injury

Do you have a ‘good’ and ‘bad’ shoulder? Have you been putting up with that grumbly shoulder for weeks, months or even years? Shoulder pain can but a real dampener on your activity levels – but it doesn’t need to!

We at Praxis, pride ourselves on taking the time to listen, assess and accurately diagnose your shoulder pains. Some of the more common complaints we hear are:

  • Sharp, dull, deep, aching pains around the shoulder
  • ‘Popping’ or ‘crackling’ sounds or feelings in the shoulder joint
  • Pain in the mornings after lying on that side
  • A feeling of the arm ‘separating’, ‘popping out’, ‘slipping’ or feeling unstable
  • Losing power when doing overhead tasks such as swimming, throwing or gym work
  • Pains, pins and needles and numbness down the arms or pain up into the neck
  • The shoulder feeling stiff and sometimes even “frozen”

So whether your symptoms are as a result of wear and tear or an acute trauma from sport, general life or occupation, we are here to help. The shoulder needs to be strong AND mobile so if yours isn’t, then contact us today on (07) 3102 3337 or book in online We are located at 4 convenient locations around Brisbane. Teneriffe, Woolloongabba, Bowen Hills and Carseldine.

Team Praxis,

PREVENT | PREPARE | PERFORM

ROTATOR CUFF TEARS || Do I Need Surgery?

ROTATOR CUFF TEARS || Do I Need Surgery?

by | Sep 14, 2019 | Pain, Shoulder, Surgery

That age old question in which the answers seems to be becoming increasingly more difficult to answer. We have looked over the research and tried to simply things for those who are unsure about what to do with their shoulder.

SUMMARY:

  • A rotator cuff (RC) tear is a common cause of pain and disability among adults.
  • There are multiple risk factors for RC tears, but most are down to overactivity of the shoulder joint decreased conditioning of the shoulder complex, which comes with age.
  • Most common in individuals over the age of 40 with linear increase in incidence as we get older.
  • A well-constructed strength program and active lifestyle is pivotal for preventing RC tears.
  • Diagnosis of a RC tear is done through first a physical examination, which is then followed by a positive finding on medical imaging.
  • To two main ways of treating a RC tear is either through conservative management with your physiotherapist or down the surgical route, which is also then followed by physiotherapy rehabilitation.
  • There is evidence for both choices and the decision between the two is down to many factors and the well-trained and experienced physiotherapists at Praxis Physiotherapy can greatly assist you in making the decision!

ANATOMY

The rotator cuff (RC) muscles are a group of four muscles that act as rotators and stabilisers of the shoulder. These are supraspinatus, infraspinatus, subscapularis and teres minor. Supraspinatus is the most frequently torn of this group.

These muscles work to help raise and rotate your arm for everyday activities such as putting on a t-shirt, combing your hair or putting away dishes on a high shelf. In sport the cuff works as a dynamic stabilisers of the shoulder to help cope with the forces associated with overhead activities such as swimming, tennis serving, throwing or weight lifting. Simply put, the cuff aids in keeping the ball (head) of your upper-arm bone (humerus) in your shoulder socket with movement.

CAUSES, SYMPTOMS & RISK FACTORS

The cause of RC tears is multifactorial. Degeneration (which comes with age), impingement and overload, may all contribute in varying degrees to the development of rotator cuff tears.

Mid Potion Achilles Tendinopathy Location

This disease is primarily of middle aged and older patients with observational data reveals a nearly linear increase in the frequency of rotator cuff tears with age. Pain with movement and function is one of the biggest symptoms of a rotator cuff tear. However, it is important to know that a sizeable portion of rotator cuff tears are actually asymptomatic and don’t cause the person any pain or discomfort! A study by Minagawa and Yamamoto in 2013 found that in a screening of 664 village residents, 147 subjects had RC tears on a medical imaging screening. Surprisingly 65% of them had no symptoms at all and didn’t have any shoulder complaints.

Why is this important? Well if you end up going to a GP and he/she send you for a scan and finds a torn RC, most will assume that it is the cause of them pain, but as seen in the study this is definitely not always the case. Before it can be decided whether the RC tear is the causes of the pain there are numerous structures in and around the shoulder that have to be examined and “crossed off the list” of possible causes of the pain. This can only be done by a physical examination of the shoulder which can be done by an experienced physiotherapist.

TREATMENT: CONSERVATIVE OR SURGICAL

The decision of treatment for rotator cuff tears is dependent on many factors. The current literature on the topic states three main modalities of treatment for a symptomatic RC tear; these being:

  • Use of a corticosteroid injection
  • Physiotherapy intervention
  • Surgical management

The use of corticosteroid injections is commonly recommended by GP’s for treatment of pain in RC tears. They may provide pain reduction in some patients but is important that you talk to your GP about both the pro’s and con’s of these injections as the current evidence does support that these injections do in fact have a detrimental effect on tendon health and strength.

In addressing whether a surgical or conservative route should be taken, there is currently very limited literature and evidence to support one modality over the other. A study by Lambers and van Raay in 2015 looked at comparing the effectiveness of surgical versus conservative management of 56 patients with rotator cuff repairs. They followed up over a year and the results showed no significant difference in pain and disability in favour of either modality.

However, a study by Moosymayer and colleagues collected data from 103 patients with RC tears, with half having surgical repairs and half being treated conservatively with physiotherapy. They were followed up over 10 years at 6 months, 1, 2, 5 and 10 year marks. The first three follow up saw no difference in results between both modalities. However at the 5 and 10 year follow ups they found preferable outcomes for surgical repair over conservative treatment, with a small proportion of the conservative management patients opting for surgical treatment at the 5 and 10 year marks due to decreased satisfaction in results from conservative management.

The big answer for the whether conservative management or surgical management is best for a rotator cuff tear………….

As always – it is a case by case decision!! There is no definitive evidence for supporting one over the other generally speaking! However, it is vitally important to note that each option comes with their own pros and cons. Furthermore, it is important to remember that just as every person is different, each case of rotator cuff tear is different. Young vs old, acute vs degenerative RC tear, current and desired future function, pain levels, radiographic findings, previous history of shoulder trauma and the patient’s wishes are only some of the questions that aid in the decision process. The best way to decide would be to contact your physiotherapist and have chat about both options and what the goals of rehab are so that a tailored plan can be developed WITH you.

We here at Praxis Physiotherapy pride ourselves on providing the best possible treatment and advice on all things musculoskeletal and are more than happy to assist, and advise you on your decision regarding rotator cuff tears. We also work closely with a number of excellent orthopedic surgeons specialising in shoulders in Brisbane to ensure you get the best possible advice and intervention if you require it. So stop waiting and suffering, give us a ring and book an appointment on (07) 3102 3337 or simply book online

Till Next Time, Praxis What You Preach

The Praxis Team

PREVENT | PREPARE | PERFORM

Throwing Injuries

Throwing Injuries

by | Mar 16, 2019 | Return to Sport, Shoulder, Sports Injury, Team Praxis

THROWING

This week in professional development session, our physio team delved into throwing techniques and links to injury. Proper throwing mechanics are important to understand as they may enable an athlete to achieve maximum performance with minimum chance of injury (Fleisig et al 2012).

Throwing, tennis serving, cricket fast bowling and golf swings are all excellent examples are how the summation of the bodies forces can result in massive outputs of power. Although force to a ball or other projectile is applied directly by the hand, a ‘kinetic chain’ of the entire body is used.

Mid Potion Achilles Tendinopathy Location

One essential and shared property of these activities is they utilise the kinetic chain to generate and transfer energy from the larger body parts to the smaller, more injury-prone upper extremities. These activities are all also notorious for high rates of injury. The kinetic chain principle asserts that in a coordinated human motion, energy and momentum are transferred through sequential body segments, achieving maximum magnitude in the terminal segment.

This kinetic chain in throwing includes the following sequence of motions: stride, pelvis rotation, upper torso rotation, elbow extension, shoulder internal rotation and wrist flexion (Fleisig et al 2012).

According to Agresta and colleagues (2019), Risk factors for shoulder pain are:

  • Workload (spikes or high volume)
  • Age (younger athletes are more prone to injury)
  • Throwing technique (e.g lack of follow through, elbow varus and shoulder external rotation torque)
  • Reduction in shoulder range of motion (particularly shoulder internal rotation in preseason)
  • Reduced preseason strength (supraspinatus and prone external rotation strength)
  • Reduction in thoracic rotation
  • Previous injury

Whilst we love a nerdy discussion on intrinsic vs extrinsic risk factors and specific rehab options as much as the next person, sometimes you just need to get outside in the sun and FEEL the task you are poring over!!

The key phases of throwing are loosely depicted in the below photos by our Praxis Principal and former 1st Grade Cricketer, Stephen (adapted from Escamilla et al 2007):

Click on the photo to slow the sequence

One of the final key questions from the day was: Who out of our physiotherapists has a “custard arm” and who has a “bullet”?? So if you or someone you know is in a throwing sport, have a chat to us today on (07) 3102 3337 or book online to ensure you have an injury free season ahead!

Until next time, Praxis what you preach

Team Praxis

Prevent. Prepare. Perform