The MRI & Disc Bulges

MRIs are considered the gold standard on identifying structures within the body. However, sometimes, there can be different perspectives to the same fact.

Case in Point by Physiotherapist - Jack Allen

John, a 40-year-old Caucasian patient came to me for a pre-op evaluation. He was a healthy male who frequently exercised outside of his working hours.

John also had a passion for gardening and it was during squatting while planting when he noticed a pulling sensation on the outside of his right thigh. This remained a constant issue for the next three weeks until he sought medical advice from an orthopaedic surgeon.

An MRI was performed which revealed disc bulges at L4/L5 and L5/S1 (lower back).

As bulging discs are often an incidental finding on the MRI (especially in patients over the age of 40), the surgeon recommended John to see a physiotherapist first. If his condition does not improve, surgery would then be an option.

Physiotherapy Evaluation

The MRIs that John brought along in his initial appointment clearly showed presence of the disc bulges. As we continued to talk, John revealed that he did not have a history of back pain and currently did not experience any localised or radiating pain. John’s only symptom was the strong pulling sensation on the outside of his thigh whenever he squatted. To some people, this might appear as a minor problem but to John, it affected his passion.

During the physical examination, John was noted to have a good squatting form but subjectively could feel the pulling sensation. John also had a full range of movement in his lumbar spine although certain hip movements were limited secondary to tight lower limb musculature. We performed all the special tests to assess the integrity of his sciatic nerve which all turned out to be negative. On feeling the quality and movement of the different levels of his spine, nil pain or restrictions were noted.

So What Was Wrong?

However, what we did find was that John had pain on feeling his right IT Band (a strong, fibrous band that runs from the outside of the hip to the outside of the knee), TFL (a small muscle that connects the ITB to the pelvis) and his VL (the outside quadricep muscle). John was also found to have poor posterior chain strength (muscles along the back of the leg) in comparison to his lower limb anterior chain (muscles along the front of the leg).

I explained to John that I believed his squatting issue was unconnected to his spinal disc bulges. I demonstrated on an anatomy model how his overly tight musculature pulls on his ITB while squatting and how this produces the pulling sensation.

The Treatment

I treated John using a combination of manual therapy and exercise within the session. Deep tissue techniques and dry needling were used to loosen the tight structures and gluteal bridges were given to activate his posterior chain.

At the end of the session, we re-assessed and John found the pulling sensation to be halved. A home exercise program was devised and after two more sessions, John could squat freely and return to his passion.

What Do MRIs Say Then?

A famous study found that MRIs identified disc bulges in 30% of pain-free 20-year olds. This highlights that a person is never defined by his MRI!

In the above case in point, John's disc bulges (as seen in his MRI) could just represent normal wear & tear.

A combination of manual therapy and exercise was just as effective at solving his problem, which originated from his overly tight musculature.

This post was written by Jack Allen. The name, age and details of this patient were also changed for privacy reasons.

Good Pain VS Bad Pain

How do you tell if you are suffering from good or bad pain? How do you decide when you have reached your maximum effort and you need to take a break?

Many believe that pain is inevitable when it comes to getting stronger and fitter. After all, that is where the popular saying, “No pain, no gain” fits in.

Good pain — or discomfort — according to sport and exercise physician Dr Andrew Jowett, reflects positive change in the body, and is part of the body's adaption to an activity or physical load.

"What we know about muscle adaption to (physical) loads is that when you put it under load or under stress, you actually cause microscopic injury to the muscle," Dr Jowett says.

"That injury stimulates muscle healing and hopefully replication of muscle fibres and ultimately strengthening. So that's the good sort of pain we're after out of any workout — to prevent injuries or to improve our performance."

To increase one’s muscle strength, the muscle has to have some form of increase in load, creating the stress and “burn”. This burning sensation is also termed as the building of lactic acid in the body.

Lactic acid is one of the most common "pain" and discomfort people feel while they are involved in an exercise. There may be times where there is insufficient oxygen as your muscles work and use oxygen to generate more energy at a faster rate during exercise. Lactic acid tends to go away shortly after we stop the exercise or strenuous activity.

If you feel a ‘sharp’ or ‘shooting’ pain that is accompanied with numbness or pins and needles, this could be an indication of a bad pain. You should immediately stop your activity and seek the help and advice of a physiotherapist.

So how can you counter and reduce good pain? One effective recovery method is to get a sports massage after your training session. Deep tissue massage helps to flush lactic acid out of congested tissues. It is vitally important that all athletes get a regular massage as it gives extra maintenance to the whole body.

Sports massage also helps to improve performance and reduce the likelihood of injuries. After a good massage, you will feel lighter, more powerful and more flexible.

This post has been written by Goh Yun Jie.

Plantar Fasciitis & Heel Pain Treatment: Questions Answered

Plantar fasciitis refers to an inflammation in the plantar fascia, which causes pain under your heel. Typical treatments include rest, good footwear, heel pads, painkillers, and exercises. In today’s blog, we answer five of the most commonly asked questions about plantar fasciitis.

What causes heel pain?

There are 2 main causes of heel pain. Plantar fasciitis is the most common, when pain is coming from the base of the foot, underneath the side of the heel, and it accounts for 15% of all adult foot problems. The plantar fascia is a fibrous connective tissue, running from the base of the heel and connecting to the base joint of each toe. The plantar fascia acts as a dynamic shock absorber for the foot and the entire leg when walking and running, acting like a gentle spring.

Plantar fasciitis can be caused by a number of factors, including poor footwear, weight gain, overpronation, biomechanical abnormalities, and specific muscle weakness and tightness, as well as work and lifestyle factors. The condition itself is created by repetitive and excessive stress through the plantar fascia, which creates micro-tears that are unable to heal at a rate that is faster than the damage is occurring. This causes degeneration and inflammation of the plantar fascia, causing pain in the base of the heel. The plantar fascia is like a rubber band – it will stretch out and contract during walking. However, if it becomes overworked, it will eventually tear and lead to pain.

Heel spurs are a common complication with plantar fasciitis. In response to the constant pressure being placed through onto the heel, the body replies by laying down extra bone tissue, in order to strengthen the structure. Not all heel spurs are painful, but they do indicate an underlying response by the body to poor biomechanics and stress reactions through the heel area. Heel spurs are indicative of plantar fascia problems, but they’re not a cause of pain – in fact, shaving the heel spur doesn’t always resolve any pain at all.

Achilles tendinopathy is the most common cause of pain at the back of the heel. In a similar process, degeneration and injury of the Achilles tendon is caused by excessive and repetitive stress. The main causes are similar to plantar fasciitis, including poor biomechanics, overpronation, poor footwear, weak calf and foot muscles, weight gain and changes in exercise or work habits.

Heel Diagram

Who is likely to have heel pain?

People who spend a lot of time standing up or who put excessive exertion on their feet are likely to have foot pain – for example, nurses, teachers, lab/factory workers, NS men, pregnant women, and salespeople, as well as those with a family history of medical conditions. However, what we see in Singapore is a lot of people with hypermobility. Genetically speaking, those of Asian ethnic backgrounds are generally predisposed to hypermobility, which is probably the biggest contributor.

An easy analogy to make is to try walking on a mattress. Then, try walking on the ground. There’s a big difference in the amount of effort required and energy expended. If you apply that to your feet, you can see why it’s easier to walk in a pair of sports shoes as opposed to a pair of flip flops. Unfortunately, in Singapore, everyone wears flip flops – poor footwear is abundant here. For most of the world, a few months in flip flops isn’t going to hurt your feet. However, in Singapore, people wear flip flops all year round, so you can imagine how that will affect their feet long term.

Clinically speaking, people who we see in the clinic with heel pain may have one or more of the following:

Walking and running assessments often pick up factors not only in the foot, but also in the knee and hip, that can ultimately lead to excessive stress and load through the heel.

Is there any way to prevent heel pain?

By the time patients feel pain in their heel, the injury and the degeneration have well and truly set in. Typically, most acute pain in the feet will resolve itself within 48 hours. However, if the pain is persistent then it can lead to a chronic injury that can last for weeks, months, and, in some cases, years. The difference between pain in the feet and pain elsewhere in the body is that it’s very difficult to rest our feet and let them recover.

Unfortunately, pain will not go away by itself unless the causes are addressed. We always find that the earlier we treat the condition, the quicker it resolves.

Orthotics serve as the cornerstone for treating heel pain. They’re most successfully applied when combined with specific manual treatment (massage and mobilisation), specific muscle stretches and strengthening exercises, and a correction of any biomechanical issues through the whole leg. If insoles/orthotics are required, they will give your heel bone an extra level of support and cushioning that they’re currently lacking. You could liken them to the shock absorber found in cars. They provide extra stability and cushioning from the forces that impact on your feet. You can function without them, but you’ll find that your gait (or ride) won’t be as comfortable as when you are using them.

At PhysioActive, we’re also having success with the use of shockwave therapy. This has been useful in treating long-term chronic heel pain, helping to break down scar tissue adhesions and to promote a healing response at the site of injury. Prevention is always a fascinating topic. Footwear and strengthening/stretching are very important, because the anatomical structure of the foot and ankle is impossible to change. The way that our joints and ligaments allow movement is generally fixed. What we can do, however, is to improve the strength and fitness of the muscles around the foot to support and unload pressure from the plantar fascia. This includes small muscles underneath the arch, as well as the calf.

For runners, the placement of the foot upon landing is very important. Our running assessment will pick up whether patients are landing on their heel first, which can lead to tremendous pressure. Not managed properly, it can result in heel pain and worse, a stress fracture. With exercises and different physiotherapy techniques, we aim to have patients landing on the whole foot.

Flat Feet Test

What about people with flat feet?

‘Flat feet’ is a somewhat misleading term – it can be divided into ‘rigid’ or ‘flexible’. Rigid flat feet are caused when the bones of the foot have fused together, and it’s quite a rare condition. On the other hand, flexible flat fleet are much more common. This is where the joints of the foot move excessively and do not fully support the body’s weight when standing or walking. There are varying degrees of this condition and there are multiple factors which can contribute to it:

As mentioned earlier, however, having flat feet or pes planus may not lead to pain, as I’ve seen many adults who have ‘flat feet’ but are also asymptomatic. The height of the arch in the foot doesn’t cause pain, as it’s more important to look at how the size of the arch changes when putting weight on it. This is a better indicator, as people with seemingly ‘normal’ feet often wonder why they have pain, because they have an arch in their feet which disappears when weight is put on it.

When assessing flat feet, I like to consider all of the above factors, as well as the angle of the knees, the ankles, the big toes and the mid and rear foot, before deciding whether the person really has pes planus or not. Depending on the severity, a treatment plan will then be devised. By the age of five, the arch of the foot should have fully developed in the majority of children. If it continues developing into adulthood, it can contribute to injuries not only in the foot and ankle, but also the knees, hips and lower back.

Some exercises, combined with stretching footwear and orthoses (insoles), will help the feet and the arch of the foot to develop naturally, so it’s important for children to be assessed early (if they complain of any lower limb pain, have poor coordination or the alignment of their limbs appears abnormal). For adults, the treatment is the same, but it’s harder to correct flat feet as the foot has usually fully developed by the age of eighteen. Pain is always the biggest indicator, but it needs to be remembered that although the feet themselves may not hurt, problems with the ankles, knees, hips and lower back can be caused by flat feet. So if you’re unsure, get them assessed as it can prevent the need for costly surgery later in life.

What's the correct way to walk or stand to prevent heel pain?

The best way to walk to avoid heel pain is to walk from heel to toe, something we learn from our very first steps as a child. But as easy as it seems, not everyone will do this knowingly. The heel should typically move towards the centre, followed by the foot rolling forward until the toes push off and the foot leaves the ground. We do this without thinking, but for some, the way that the foot functions during walking is a little different. This can be due to medical conditions (e.g. diabetes), injuries (e.g. chronic ankle sprains), weight gain (e.g. carrying children or shopping), footwear (e.g. safety boots or flip flops), muscle weakness, and the terrain (e.g. walking on a pavement versus a jungle trail).

If the foot moves incorrectly, joint tendons and ligaments will become overused, leading to pain and injury. A simple way to assess this yourself is to look at the way your feet are pointing whilst walking. In a normal gait, the feet are pointing straight ahead. If the feet are pointing in or out, it could be due to one of the previously mentioned factors. Of all the factors, footwear is the easiest one to modify.

Advice on preventing heel pain:

Problems with heel pain and seeking treatment?

Please get in touch with us today and book a physiotherapy session with the team.

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Tendon injuries in children - What are they and how do we fix it?

The last thing we want our active and growing children to experience is growing pains. Growing pains can be a very broad term, but it generally refers to injuries experienced by adolescents as they advance in both height and weight during puberty. Typically the injury and pain is not caused by a single ‘strain’ or ‘sprain’, but a gradual and insidious onset.

Common injuries that affect tendons in children:

Osgood schlatters disease (pain at the front of the knee)

Osgood schlatters disease

Sever’s disease (heel and Achilles pain)

Sever’s disease (heel and Achilles pain)

Traction apophysitis – rectus femoris (front of the hip joint)

Traction apophysitis – rectus femoris (front of the hip joint)

These conditions all have a few things in common:

  1. All lower limb based
  2. Linked to muscles that provide power when running

The injury process for these conditions is based at the tendon to bone attachment at the site of the growth plate. It relates to the excessive pull of the muscle from the bone, via the tendon. This creates a microtrauma close to the growth plate, a structure that is busy building new bone. This process will only become a problem when the rate of tendon injury is faster than the body's ability to heal the structure. This is often the case in very active children, who are playing multiple sports throughout the week. The tendon simply does not have adequate time to heal itself.

Causes of tendon injuries in children:

Unfortunately its not as simple as just a ‘growth spurt’. The following factors will lead to an increased chance of experiencing these injuries:

  1. Tight muscles

As we grow, our skeleton grows slightly faster than the muscles that attach to it. Essentially, our bones grow quicker than our muscles. This leaves us with tight muscles, relative to the longer bones. This will increase the physical pull and tension from the muscle into the tendon, attaching onto the bone.

  1. Poor biomechanics

Any number of biomechanical faults will increase the load on different tendons.

  1. Sports specific repetition

Simply put, the more sports played, the higher the risk of sustaining such injuries. I often see children who engage in 6-7 sessions per week of running/weight-bearing activity. This is not to say that children should stop doing this amount of activity - my advice to patients and their parents is to listen to your body. If you start to feel any isolated ache or pain in the hip, knee or foot, then seek treatment to remedy the situation. If not, lengthy delays in returning to sports are often required - patients need to be most diligent when monitoring excessive running loads before and after growth spurts.

  1. Weight gain

Part of growing is also increasing your body weight. This will naturally place extra gravitational load through all structures in the body. Continued sports and exercise while this weight is increasing is one of the risk factors for growing pains.


  1. Reduce inflammation around the tendon to bone attachment

This is crucial in the early stages to reduce pain and to reduce the excessive inflammation that can slow healing. Taping is also very helpful. Icing and anti-inflammatories are  commonly used, but have a debatable effect, as shown by literature.

  1. Activity modification

It may be as simple as reducing the amount of exercise that involves running, jumping and other power-based sports. This allows time for the body to heal the affected structures, while corrective massage and strength exercises take hold.

  1. Massage

Reducing the tension on the tendon to bone structure is paramount. This will include a mix of therapist massage and self massage at home with a foam roller and release ball.

  1. Stretch program

Massage mixed with a stretch program will provide the best way to lengthen muscle. This will be a mix of static (very short duration only) and dynamic stretches.

  1. Strengthening to correct biomechanics

Depending on what the physiotherapist assesses as the main muscles that need strengthening, an individual plan will be provided to target the muscles that need the most work. This could include gluteal, core, quads or calf muscles. This will all then come together with exercises that are specific to your sport, to best train the body to return to full fitness.

Overall, the treatment is very successful for children with tendon injuries. If managed correctly, no long-term effects should be experienced. If there's a delay to the treatment or poor management early in the process, lengthy time on the sidelines can be a common and frustrating part of tendon injuries in children.

Problems with tendon injuries in children?

Please get in touch with us today and book a physiotherapy session with Joel and the team.

Thanks for reading!

This post has been written by PhysioActive physiotherapist Joel Bates.

Thoughts or questions?

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Managing Acute & Chronic Pain

What Is Pain?

Pain, although unpleasant, is normal. And it is perfectly normal, once you have it, to want to get rid of it. Even though pain is unpleasant it is your body’s way of protecting you in times of injury or disease. Pain helps you make decisions about what you should and should not do. When you are in pain you move, think and behave differently. Think back to when you have cut a finger; you probably kept your finger still. By holding it straight, your pain reduced. This sort of pain is important as it allows you to protect your body whilst it heals.

Pain generally occurs when your body’s alarm system alerts your brain to actual or potential danger of injury by issuing a “warning.” For example, if your hand touches a hot surface your body reacts by pulling your hand away to prevent you from getting burned.

Acute Pain

This pain is usually linked to a problem that can be fixed. If you break a bone, cut a finger, or suffer from a tooth abscess, you have acute pain. This pain will resolve when the bone is fixed, the wound healed or the abscess drained. Acute pain is a sign that something is wrong and something should be done. The pain only lasts while the problem is there. Pain killing medication will generally help relieve acute pain.

Chronic Pain

So what about Chronic (or persistent) pain? This is pain that has lasted for longer than 3 months. It affects approximately 20% of people. It impacts people’s lives, from causing minor restrictions to complete loss of independence. It is different to acute pain. In chronic pain, the most up-to-date research tells us that something different is going on: the pain is no longer serving a useful function. This pain is a real sensation, but no longer helpful.

No physical cause of pain

Often, no obvious physical cause can be found for chronic pain. This can be frustrating and confusing – after all, you know you have pain. In many cases even the best scans are not able to identify the part that is hurting from parts of you that are not hurting. Even when doctors can pinpoint physical changes on the scans or X-rays (for example, arthritis, a disc problem) it is still impossible to say whether these are the actual source of your pain or not.

Chronic pain conditions

Most chronic pain conditions are not life threatening e.g. low back pain, arthritis and recurrent headache. They may start as acute pain associated with a problem such as a slipped disc, operation or injury. The pain may be continuous or occasional, you may feel more sensitive to pain and it may sometimes be prone to flaring up or getting worse very quickly. However, when the problem has been sorted the pain doesn’t seem to switch off. The pain system is no longer working normally. It has become “wound up”, sensitive and flares up easily.

Is there a cure for chronic pain?

Even though there may not be a specific diagnosis it does not mean the pain is not real but just that there’s nothing nasty to worry about. However, there is no cure for chronic pain. This pain generally does not go away with rest; warm baths or massage and some types of medication are not very effective. However, these things may give temporary relief.

Things that would usually settle or treat an acute pain are often not successful in treating chronic pain. This is because the problem is within the pain system, rather than being located in any specific part of your body. The pain system does not appear to be functioning normally.

Living with pain that won’t go away can be discouraging at best and unbearable at worst. But it is important to remember that there are treatment options that can reduce your pain and improve your quality of life. Your doctor may recommend the use of over-the-counter or prescription medications, in addition to other therapies like physiotherapy or exercise, to manage your physical pain.

However, if you are living with chronic pain, overcoming the emotional challenges can be the hardest step in the coping process. The following list can help you cope with your chronic pain.

However the first step is to change your attitude towards your pain- this is the first and most vital step. A change from “being a patient” to “being a person who has a chronic condition” is vital. Being/starting to feel in control and knowing how to manage your pain is the next step.

How To Manage Chronic Pain

1. Accept the Pain

Chronic pain should not be ignored or taken lightly. If you have been living with chronic pain, it is important to recognize it as a problem, learn about your condition, and see your Doctor/Physiotherapist to talk through treatment options.

2. Get involved

Take ownership of your pain relief. Understand your treatment plan, engage with your Doctor/Physiotherapist and be an active partner in your own health care. The accountability will help you overcome emotional challenges and keep you motivated to continue improving your overall health and quality of life.

3. Learn to set priorities/goals

Living with chronic pain can put the rest of your life on the back burner, as relieving pain becomes your top priority. Make a list of things in your life that you would like to do, whether it is exercising more frequently, visiting with family and friends, or traveling. Setting priorities and goals other than pain relief can help you enjoy life a little more, while also keeping you determined to relieve pain in order to achieve those goals.

4. Set realistic goals

Coping with chronic pain can be daunting, particularly as you try to resume everyday activities that once were easy and normal. Managing your pain in small steps can give you a sense of accomplishment, and also help you achieve your larger goals more effectively.

5. Recognise Emotions

Living with chronic pain can be stressful and is just as much an emotional issue as a physical one. Recognizing how your emotions affect your pain, and vice versa, can help relieve your pain and make everyday living more enjoyable. It can be difficult to manage things at home, work, with friends and family as well as many other things that can be difficult. You may not feel you have any control over the pain and don’t feel able to cope with it.

How do you feel about your pain?

Experiencing pain can lead to feelings of anxiety or fear about what might be causing the pain; especially where there is no obvious cause. It may feel like damage is being done to your body and you may feel some concern about what the pain might mean- what damage could have been done and what the future might hold.

Feeling pain can also make you feel tense, especially if you expect the pain to come back or get worse. You may feel easily angered and hostile towards people who you may meet that don’t understand your situation or how your pain affects you. Some people even feel anger towards the pain itself. When things aren’t going so well it can lead to feeling bad tempered, anxious, frustrated and having troubling thoughts. You may feel hopeless and very down about feeling this pain, which can result in depression.

The pain itself or worrying about it may cause difficulties with sleeping. You may be kept awake or find it difficult to stay relaxed. Being tired and having a sleepless night can make people feel more upset and bad tempered.

How do your feelings and thoughts affect your pain?

Our experience of pain always stays with us; we have a kind of memory for it. For example, if a person comes across pain every time we carry out an activity or task, then it is unlikely that they will continue with it, or for that matter, ever return to it. The more often we associate something with pain, the more we are likely to actively avoid it.

Thinking of pain before it happens can make it feel worse. A feeling of pain may even be set-off just by thinking of a past experience of pain. Depending on the situation, a person’s threshold for feeling pain may be altered. Sometimes what would feel a little painful may become excruciating and vice versa.

For example, during a rugby match a player may be injured but not feel significant pain until after the match. This is caused by a hormone called adrenalin, which prepares our body for action during circumstances that we perceive as risky.

Similarly, during an enjoyable activity that makes us feel good, pain is often dulled by chemicals called endorphins; there is often less of a focus on any pain experience. However, on the other hand, a person who is feeling very anxious, tense and wound-up in another circumstance may not be able to tolerate even the slightest touch. In these scenarios how a person feels has affected their perception of pain- a persons thoughts and mood can make a difference to how they feel pain.

6. Learn to relax

Persistent pain is a stressful experience, but it is important to find ways to relax the mind and body. Not only can stress make the pain worse, but it also causes other physical and emotional side effects. Find ways to relax in your own way- there are many things you can try:

• a good balance between rest and exercise (Pacing)
• massage
• regular use of heat or cold packs
• stretching
• deep breathing exercises
• relaxation
• distraction
• feeling more confident and having a positive mood
• having fun and socialising all help to gradually reduce your pain

To some people it may be as simple as just going outside to play with your dog.

7. Exercise

There is no need to fear or avoid exercise, even if you live with chronic pain. In fact, moderate exercise can actually help to decrease pain by building and toning muscles, increasing endurance and strength and improving your attitude and self-esteem. Your Physiotherapist can structure a specific regime for you. We can also use a device called a TENS machine which some people find helpful in giving them some pain relief.

8. See the total picture

Following the steps above will hopefully help you to realize that your pain does not define who you are. Concentrate on what you are able to do, not what you are not able to do. Chronic pain may be part of your life, but feeling confident in your knowledge and management of the pain can help put the rest of your life back on track.

9. Reach out

Millions of people suffer from chronic pain and don’t share their experience with others out of guilt, embarrassment or pride. Sharing what you’ve learned about successfully managing your pain can help others find their path to pain relief and encourage them to seek help and much needed support.

Thanks for reading!

This post has been written by PhysioActive physiotherapist Gail Craig, Grad Dip Phys, MCSP, HPC registered - Spinal Physiotherapist, Manual Therapist, Women’s Health

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