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.
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.
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.