How Can Physiotherapy Aid Joint Injuries

Joint related pain is a common complaint seen within a clinic setting. To shed some light on such injuries I will discuss anatomy, function and how physiotherapy can assist to alleviate pain and return a person to full recovery.

Movement

The human movement system is a physiological system of the body that produces motion of the body or its component parts, or the functional interaction of the structures that contribute to the act of moving (Stedman’s dictionary). Shirley Sahrmann states that kinesiopathological refers to excessive, imprecise and insufficient movement contributes to the development of pathologies.  Understanding how the body moves is important and what structures are involved. This leads nicely into the anatomy section which will provide some insight into the structures of a joint and the role of some structures within a moving joint.

Anatomy and function

A joint is where two or more bones of the skeletal body join together. The bones are surrounded by structures such as cartilage, ligaments and muscles. Joints are classified in regards by how much movement they allow and the kind of material that is present in the joint. Most joints in the body are known as a synovial joint which allow free movement. These joints consist of fluid-filled space between the smooth cartilage pads at the end of articulating bones. The joint is surrounded by a tough dense irregular connective tissue lined with synovial membrane, which is otherwise known as a capsule. The capsule can extend into a thick, strong band called ligaments that reinforce the joint and prevent undesired movements and dislocations. Synovial membrane lining provides the oily synovial fluid that lubricates the joint and reduces friction and wear.
The joints around our pelvis and spine do not move as much as a synovial joint but provide more stability. These joints are known as semi-moveable.
The joints between the bones in our skull are fixed joints, meaning there is no movement between these joints.
What is important to understand in relation to joint movement and joint injuries is that movement is controlled by muscles. Yes the cartilage reduces friction between bone surfaces, capsule and ligaments provide stability but it is the muscles surrounding the joint that control that joints movement. Therefore poor and imprecise muscle control and function can lead to joint abnormalities and dysfunction.

A list of common joint injuries 

• artilage – wear and tear/ degenerative changes

• Ligament strains or tears – excessive movement of the joint, or excessive load to the joint

• Mechanical abnormalities causing pain – rotator cuff for example main group of muscles to stabilise the shoulder become irritated and inflamed, resulting in instability of the joint and therefore the mechanics of the joint change, this can result in the impingement of tendons.

• Repetitive injury to the same joint / posttraumatic injury – playing sport

• Bursitis or tendonitis

• Traumatic injuries – SLAP tear in shoulder, labral tear in hip or ACL rupture to knee for example, dislocation

• Specific trauma such as road traffic accident – resulting in whiplash associated disorder.

Injury is caused when excessive force is applied to a joint, muscle, ligament and other soft tissue and the body responds by producing pain and inflammation. Inflammation is the body’s way of healing, forming scar tissue. The body although releases excessive amounts, which is a thick, gluey substance otherwise known as adhesions which causes stiffness and restricts movement of the joint.  Pain tells us that there is something wrong. Persistent pain is understood to inhibit muscle function and therefore can lead to secondary problems as well as the original injury. Early physiotherapy intervention will help reduce the secondary problems.

Physiotherapy Treatment

Whether it is a specific incident or gradual onset of pain, the first port of call in regards to treatment is R.I.C.E ( Rest, Ice, Compression and Elevation). This protocol will assist with reducing inflammation and a course of anti-inflammatories may also be appropriate. Recommendation is to see a physiotherapist sooner rather than later after onset of pain. 
Physiotherapy assessment will allow the therapist to gain a thorough history ( when it happened, how it happened, what caused the injury – specific or non-specific onset,  any change to routine, pain) and  complete an objective assessment (assess movement, palpate muscles, special tests where appropriate) of the injury to assist them with the diagnosis. It is important for the therapist throughout the assessment to gain an understanding of the pathology and mechanism of injury which will assist with diagnosis. From the diagnosis the therapist will plan the treatment programme to combat the injury and return the client to full recovery. The recovery time from an injury is really depends on the history of the injury (depends on the extent of the injury and how old the injury is). 
Physiotherapy has a vital role in early diagnosis and management of injuries. A physiotherapist has a bundle of treatment interventions available to them for treatment of such injuries. Modalities such as deep soft tissue massage, trigger points, myofascial release, acupuncture or dry needling, manipulative techniques, strength and conditioning and biomechanical correction will be the go to treatments during a physiotherapy treatment session. 
Deep soft tissue massage, acupuncture or dry needling and joint manipulations will assist in reducing tension in the muscles, soft tissue and joint affected or the surrounding joints. Encouraging fresh blood to the affected area will promote the healing process, breaks down the adhesions and provides the new tissue with nutrients. Reasoning behind using joint manipulation is to increase joint space which may have been narrowed from increased tonicity, reduce viscosity of synovial fluid (only within a synovial joint), impact on neural overspill which may be a result of increased tissue scarring or adhesions.  
Strength and conditioning is important to assist with reinstating normal function of a joint. It will also help strengthen the affected muscles, ligaments and surrounding soft tissue. Strength training is understood to impact on the newly formed tissue by realigning the fibres in the desired path of stress whether it is muscular or ligament. This will mean the muscles and ligaments are stronger and are able to tolerate further stress, therefore reducing the tension applied to joints resulting in reduced pain. There needs to be a balance between the group of muscles controlling the joint. Balance between the muscles and sufficient amount of strength in the muscle will allow the joint to move in the correct way. It is important for people who suffer with degenerative changes to joints to undergo a strengthening programme to provide stability for the joint and make the persons symptoms more manageable.
It is important that the physiotherapist has an understanding of biomechanics in particular when someone presents with lower limb or lower back pain from a non-specific mechanism of injury. When the word ‘biomechanics’ is used people get confused but people understand the terms flat feet, high arched, over-pronation etc.  Having any issues like this with your feet will cause problems in regards to how the body absorbs force, incorrect loading/excessive loading over a period of time can cause problems. A physiotherapist can assess your biomechanics and advise you in regards to a generic orthotic or refer to podiatrist for customised orthotic. The purpose of an orthotic is to reinstate normal gait (walking pattern) and reduce abnormal loading through the joints and muscles.  

There are some injuries mentioned above under ‘traumatic injuries’ which require early diagnosis from Physiotherapist or Doctor as high proportion of these injuries require onward referral to a consultant for surgery. Early physiotherapy intervention is also beneficial even if surgery is required as it will help promote tissue healing and advice exercises which will assist pre and post-surgery. On other injuries such as impingement in the instant of rotator cuff or tendonitis which do not settle/improve following 3-4sessions (depends on History of injury) of physiotherapy, a steroid injection may be recommended to provide pain relief and reduce inflammation to the tendon which is being impinged between the bones of the joint. 

Pregnancy Pilates

Pilates is a form of exercise that focuses on strengthening the body’s core muscles from the pelvis into the rib cage and diaphragm usually with the spine and pelvis in a neutral position. It is when the lumbar spine and pelvis are in neutral, that there is least pressure on the intervertebral discs compared with if the lumbar spine is flat or too arched. The body’s core muscles work to maintain posture, and support the spinal column and pelvis. The main muscles that make up this core are the transversus abdominis (TA) (deep abdominal muscle), multifidus (at the back of the lumbar spine/lower back), pelvic floor muscles, rectus abdominis (RA) (superficial abdominal muscle), and the internal and external obliques (abdominal muscle between the RA and the TA. Pilates is named after its inventor Joseph Pilates who developed the exercises in the 1920s.  

“Pilates is a form of exercise that focuses on strengthening the body’s core muscles”

— Aileen O'Rourke - Chartered Physiotherapist & Stott Pilates Instructor Galway

What is Pregnancy Pilates?

Pregnancy Pilates modifies the original Pilates exercises and movements as necessary for each stage of pregnancy. The goal is to maintain strength of the postural muscles, especially the muscles of the lumbo-pelvic region, with the spine in a neutral position. Several changes occur in the body during pregnancy, and pregnancy Pilates can help to minimise the impact of these changes. 

Changes in the Body during Pregnancy

During pregnancy a lot of changes occur in the body. The weight and pull of the feteus, the deconditioning that results from lack of exercise and the hormonally-induced ligamentous softening can lead to a number of musculoskeletal problems, for example, aches and pains in the lower back, pain in the one or both sacro-iliac joints and /or pubic joint pain. The increased size and weight of the breasts can cause the muscles at the front of the chest to shorten and tighten, which can lead to poor posture and upper back ache. Also the abdominal muscles stretch in all directions during pregnancy. This can lead to back ache due to decreased support from these muscles. Lastly, there is a lot of strain on the pelvic floor muscles in pregnancy which can lead to which can lead to some form of incontinence pre and post-natally. 

Benefits of Pilates in Pregnancy

1. Pregnancy pilates promotes good posture and strong core strength, which helps support the lumbar and pelvic joints. Pregnancy pilates helps you to keep your spine in neutral which will in turn protect the discs in the lumbar spine.

2. Pregnancy pilates strengthens the pelvic floor muscles that control continence and support the pelvic organs. Stress incontinence (leakage of urine on coughing, laughing, sneezing) can occur as the pelvic floor muscles are stretched during pregnancy.

3. Pregnancy pilates increases abdominal strength, thus providing support for the weight of the baby, and helps keep the spine and pelvis in a neutral position.

4. Pregnancy pilates , therefore, reduces general aches and pains by improving posture.

5. Because pregnancy pilates is a form of exercise, it can lead to increased stamina of the mother, due to the release of endorphins.

6. The deep breathing in pregnancy pilates will not only relax the mother, but will ensure adequate oxygen and nutrients are being delivered to the baby.

7. Pregnancy pilates creates stronger, toned abdominal muscles that are less likely to separate severely. In stronger abdominal, if separation occurs, muscles will realign more quickly.

8. Although there is no scientific evidence to prove that Pilates in pregnancy assists in post-natal recovery time, it is well acknowledged that those who participate in this form of exercise can have a quicker recovery after the birth of the baby.

Who can benefit from Pregnancy Pilates?

• All stages of Pregnancy.

• Those with pelvic floor weakness.

• Those with back pain and /or pelvic dysfunction.

• Those with a back injury in the past.

• Postural dysfunction.

• Desk workers/Drivers.

• Involved in sport/physical activity.

• Can do Pregnancy Pilates even if you have never done Pilates before.

It is ideal to go to a Chartered Physiotherapist who is specially trained in Pregnancy Pilates. This is important especially if you have any medical problems, that the Chartered Physiotherapist can closely monitor. 

The mother should also get approval from their doctor before starting a course of Pregnancy Pilates especially if she has a heart or lung condition; diabetes; high blood pressure; history of premature labour; placenta previa (placenta implanted over or near the cervix); any physical impairments or diseases of the muscles or bone; had three or more miscarriages; experienced spotting, bleeding, or cramping in this pregnancy; and /or is carrying more than one baby.  

Dry Needling For Injury Recovery

It is often the case that an injury will need to be treated with a number of different techniques. One of the lesser known, yet highly effective technique is call Dry Needling. While it should gruesome (and even when explained it sounds no better), if you ask anyone that has had the procedure applied to them correctly they will tell you it's not all that bad and can really be effective.

So what is it exactly? Dry needling is a procedure where sterile acupuncture needs are inserted into the skin and muscle directly at a myofacial trigger point. This is a discrete area in a muscle or its fascia where a hyperirritable knot or band develops. These knots or bands are usually painful to compress and can refer pain. 

Dry needling works to deactivate the trigger point and relax the muscle. Inserting a needle into a trigger point can result in favourable biochemical changes which assist in reducing pain. A spasmed muscle has reduced blood flow resulting in less oxygen and nutrients. This in turn holds the muscle tight preventing muscle metabolites from leaving the muscle and causing continued spasm and pain. The muscle may respond to the needle with an ache or a twitch which are positive reactions

It is important to practice dry needling in combination with other physiotherapy interventions and a rehabilitation plan that covers exercises as appropriate will be chosen by your Physiotherapist and to remember that not all physiotherapists are qualified to carry out dry needling. Make sure to find someone who has proper training and is governed clinically. 

Dry needling is suitable for all, although caution must be taken with those on anticoagulants, skin infections near the treatment area, obesity, pregnancy, lymphoedema, vascular disease, epilepsy or children. Those with more recent injuries or younger people tend to require less frequent treatment than those who have had the injury for a long period of time. For most 3-6 treatments can make a significant difference.

There can be an achy, tired feeling in the muscles for the day of the treatment and unless you are used to the needling, its better not to train or compete that day. The technique is sterile and not classed under acupuncture by National blood transfusion services and does not affect ability to donate blood.  Dry needling is usually appropriate for any condition where muscle pain or tightness is an issue. This could include neck and back pain, tennis/golfers elbow, shoulder conditions or leg pain.

If you have any queries about dry needling click here to find out more about how it is applied and what injuries it can be used to treat.