Suffering From Joint Pain in Brampton ON?

This condition affects the synovium of the tendons that bend your fingers. This usually occurs at the base of the fingers on the palm side of the hand. As the tendon glides through its sheath, it passes under a structure called a pulley. The role of the pulley is to keep the tendon close to the surface of the bone. If the tendon sheath has become thickened the tendon will not glide very well under the pulley.

There is usually pain at the base of the finger in the palm or over the front of the thumb as it joins the palm. The finger or thumb can click or catch as it moves and can become ‘stuck’ in a bent position. The joints further down the finger or thumb can become stiff if the symptoms go on for some time.

The most commonly affected digits are the ring finger and thumb.

Factors that may make this tenosynovitis more likely are outlined above. Unaccustomed loading of the tendon with tasks that involve repeated gripping or bending of the fingers is also a major cause.

Essentially wearing a splint which holds the digit straight can help to reduce pain levels. With any splint it is particularly important that you remove it regularly and do not become overly reliant upon it.

Using the treatment principles for tenosynovitis (detailed above) plus a splint which can hold the finger straight overnight may see symptoms settle after a period of weeks.

Exercises that encourage tendon gliding are shown below; only perform these within a comfortable range. Where possible perform the exercises with both hands at the same time.

The Achilles tendon is the largest tendon in the body and is the common tendon of the calf muscles (gastrocnemius, soleus and plantris). It connects the calf muscles to the heel bone. The Achilles tendon plays an important role in walking and running. Achilles tendinopathy or tendinosis is the most common type of Achilles tendon injury. It is characterised by pain most commonly in the mid portion of the tendon, it can also be localised more to the calcaneus but this is less common.

Although thought to be a condition related to people participating in sport only 35% are attributed to people involved in sport or active people.

The most common reason that symptoms start is through overload of the tendon. This can be because of:

• Beginning a new sport or hobby that requires high load in the tendon, running and jumping for example
• A sudden increase in how much you are training or exercising, such as: Starting to train for a long distance race
• Going on a holiday that requires a lot of walking or hills
  Others factors that may put you at risk or impact the ability of your symptoms to improve:
• Diabetes (type 1 or type 2)
• Smoking
• Having a high BMI
• A diet that is high in fat

Not addressing these factors may limit your overall recovery from Achilles tendinopathy.
Achilles tendinopathy is also more common in inflammatory conditions such as psoriatic arthritis or axial spondyloarthropathy (also known as ankylosing spondylitis).

Management of Achilles Tendinopathy

Initial management should involve altering the amount of the aggravating activity that you perform. For example change the how often, how long or how intensely you exercise.
This does not always mean stopping completely. As an example, pain may only begin after 2-3 miles of running; therefore running one mile allows you to still complete the activity that is meaningful to you without aggravating the pain too much.

Maintaining activity through discomfort whilst avoiding high levels of pain will be helpful for recovery. You are not waiting for the Achilles tendon ‘heal’, rather you are spending time helping it to adapt to what you require it to be able to do.

The key here is to load and use the tendons to promote adaptation.

In some this may allow symptoms to settle. There are some exercise examples on this page, to make sure you get the right exercises in the right dose for you an appointment in physiotherapy may guide you more. You can either self-refer on this page or your GP can refer you.

If you are not particularly active and your pain appears to have come on for no reason or with no change in activity it is worth addressing some additional issues. This might mean managing your weight or quitting smoking. There are resources on this website to help you to do that.

Rehabilitation

There is no one size fits all recipe to rehabilitation and exercise for Achilles tendinopathy. But following these three simple points has been shown to be successful.

1. Loading with exercise is done in a progressive way
2. A pain monitoring model is used (up to 5 out of 10 pain has been shown to be safe)
3. Exercise program are for a minimum of 12 weeks.

Speed of exercise has shown to be important, the term heavy slow resistance training is used. Approximately 6 seconds of loading per repletion is recommended. When applied to a heel raise exercise below:

• 2 seconds to raise
• 1 second pause at the top
• 3 seconds to lower

An ankle sprain is an injury to the tough bands of tissue (ligaments) that surround and connect the bones around the ankle joint. It typically happens when you accidentally twist or turn your ankle in an awkward way. This can stretch or tear the ligaments but can also affect tendons and blood vessels in the surrounding areas.

It is more common to damage the outside ligaments of your ankle when you have an inversion sprain (the bottom of your foot rolls inwards) but the inside ligaments can also be affected too.

Following an ankle injury, you will normally experience pain, bruising and sudden swelling and you may find it difficult to weight bear on that side.

Ankle sprains are commonly associated with sports that include running, jumping and rapid changes of direction. However they can also happen in day to day life such as stepping of a curb when not paying attention or missing a step when walking up and down stairs.

Grading of Ankle Injuries

Sometimes a grading system is used to assess the severity of your ankle injury.
Grade 1: mild swelling/bruising with minimal ligament fibres damaged
Grade 2: moderate swelling/bruising with potentially some partial tearing of the ligament fibres. You may experience some mild instability initially
Grade 3: severe swelling/bruising with partial; earing or potentially full rupture of the ligaments. You will likely have trouble mobilising

If you are unable to put weight through your foot and ankle following an ankle sprain you should get checked by your GP or attend accident and emergency to make sure you haven’t sustained a broken bone. This would require a different management and would not be appropriate for physiotherapy in the early stages.

Early treatment

Mild sprains can be treated at home with the RICE principle;

• Rest the affected area for at least the first 48 hours. You may require crutches to avoid putting weight on your leg.
• Ice can help to reduced swelling and inflammation. Only use ice for 20 minutes at a time but do not apply directly to the skin, use a damp cloth between the ice and the injured area.
• Compression can help to prevent additional swelling. Wear an elastic compression bandage and remove for sleeping.
• Elevation can help to reduce swelling. Recline when you rest, and put your leg up higher than your heart. The compression should be snug to the skin but not restricting blood flow

What is Anterior Knee Pain?

Anterior Knee Pain is a general term used to describe pain originating from the structures at the front of your knee.

The most common structures that cause pain in this area are the patellofemoral joint (between your knee cap and your thigh bone), and the patella tendon (which attaches your thigh muscles to the bone, just below the knee cap).

Symptoms are localised to the front of the knee and are typically aggravated with activities such as squats, going up and down stairs, or high impact exercises such as running and jumping.

What causes Anterior Knee Pain?

Research shows that the biggest risk factor for developing patellofemoral joint pain is weakness of your quadriceps (the muscles at the front of the thigh which help to extend the knee). Because these muscles help to support the knee and are important in controlling how the kneecap moves, weakness of these muscles can lead to dysfunction of the joint.

However, weakness is unlikely to be the only contributing factor in developing pain, and it is likely that lifestyle and activity levels are also important considerations.

This is certainly true for the patella tendon, which typically becomes painful when it is overloaded through high impact or repetitive activities. This is called a “Patella Tendinopathy.” For more information on this, visit our page on Patella Tendinopathy.

How is this problem relieved?

Research shows that the most effective treatment for anterior knee pain is a combination of activity modification and exercise therapy.

Activity modification aims to reduce further overloading of the structures at the front of the knee. This often means taking a period of “relative rest” during which you should refrain from activities which cause significant discomfort such as running and jumping, whilst continuing comfortable, lower impact exercise to maintain fitness and tissue health.

Please note, this will be different for everyone and you should be guided by your own symptoms. Any activity which causes significant discomfort which does not settle quickly once you stop, should be temporarily reduced or avoided.

Once symptoms begin to settle (usually after a few weeks of relative rest), exercise therapy should be commenced. This aims to strengthen the muscles that support the knee and gradually increase the amount of load that the knee can tolerate. Research shows that the most effective exercises are those which target the quadriceps muscles, as well as the muscles around the hips.

Carpal tunnel syndrome is a common condition that can cause tingling, numbness or pins and needles or pain into the palm side of the hands and fingers.

You’ll usually feel it worst in the thumb, index and middle fingers, but sometimes it might feel like your whole hand is affected.

The symptoms tend to be worse at night and can disturb your sleep, but you may also notice it when you wake up in the morning. Hanging your hand out of bed or shaking it around will often help reduce the pain and tingling.

You may not notice the problem at all during the day, though certain activities such as writing, typing, DIY or housework, can bring on your symptoms.

There are eight small bones within your wrist which are known as the carpal bones. These naturally form a small space (tunnel) at the wrist joint for the median nerve and all of the forearm tendons to pass through. The top part of the tunnel is covered by a ligament known as the flexor retinaculum. The job of a nerve is to supply your hand with sensation and the ability to move.

What causes carpal tunnel syndrome?

It is not always known what causes the nerve to have a problem however there are many factors that increase your risk of carpal tunnel syndrome. These include:

• Pregnancy (this is due to hormonal changes and usually resolves a few months after childbirth)
• A previous broken or injury to the wrist
• Arthritis of the wrist (this can cause localised swelling that can compress the nerve)
• A family history of carpal tunnel syndrome
• Strenuous repetitive work with the hand
• Underactive thyroid gland
• Diabetes
• Obesity

Care for Carpal Tunnel Syndrome

Carpal tunnel syndrome can often resolve without any form of treatment. If there is a particular cause for your problem, e.g. underactive thyroid, then your symptoms may improve by treating that.

It can be helpful to modify or reduce any aggravating activities. Common activities that can provoke symptoms include activities which involve the wrist being held in a bent position (this closes down the space in the carpal tunnel) or sustained pressure over the wrist.

What is cervical radiculopathy?

Cervical radiculopathy is the technical term for pain caused by irritation of one of the small nerves in the neck. It often causes pain to be felt all the way down the arm and can sometimes be accompanied by pins and needles, and, in rare instances, weakness in the affected arm. It is often called a 'trapped nerve'. The term is often incorrectly applied to neck pain that causes pain to be felt in the muscles at the side of the neck. A true cervical radiculopathy, or trapped nerve, will cause pain that runs down the arm; , the exact site of the arm pain depends on which of the small nerves are involved.

The first diagram shows a 3D model of the bones, discs, and nerves in the neck . As you can see, the nerves (coloured yellow) pass out from inside the neck between the bones, these are called nerve roots and they eventually join together to form three nerves that run down your arm.

Nerves are quite big structures; the second picture gives an artist’s impression of a nerve running from the neck down the arm.

The three nerves that run down your arm are responsible for sensation in different areas of skin and tissue in your arm. Because each of these big nerves is made up from connections made by the nerve roots in the neck we can actually assign different areas of skin to specific nerve roots. When these are mapped out they are called dermatomes. They are pretty similar in everybody.

The multi coloured picture here shows these dermatomes. Each colour represents a different nerve root. They are numbered according to which one of the bones in the neck they are near to (an extra number 8 is added at the bottom, just to confuse things!).

The blue line on the diagram opposite represents the area of skin supplied by the C6 nerve root (the bit of the nerve that exits between the bones in the neck). If this nerve root becomes irritated then usually you will feel pain in the area of the blue line. If your C7 nerve root was irritated you would feel pain in the area of the orange line.

As you can see, with cervical radiculopathy, although the problem is up in the neck, the pain is felt down in the arm; this is called referred pain.

What causes cervical radiculopathy?

As its nickname suggests, for a long time it was thought that the nerve had become 'trapped', usually by a disc ( the cartilage structures that sit between the bones in the neck).

However we know from MRI scans that many people with symptoms of radiculopathy don't having anything pressing or putting pressure on their nerves, and we know from anatomical studies that the discs in the neck tend to be fairly stable structures by our mid 20's meaning that a sudden change to their size or shape is unlikely, unless there has been physical trauma.

What all this means is that, for the majority of people, the physical environment around the nerve is unlikely to be the primary reason they are experiencing pain.

More recent research has indicated that inflammation, in the vicinity of the nerve root, (either from one of the small joints, connective tissues, or muscles) is a likely trigger for radiculopathy. Inflammation causes a build up of chemicals associated with healing which result in a change in the acidity of soft tissues. This change in acidity can cause a consequential swelling response in a nerve root, making it sensitive to movement, causing pain.

What help is available?

If your symptoms have just begun they are likely to settle fully within 6-12 weeks.

As we have shown, there is often an inflammatory cause for the pain you are experiencing, so taking a course of non-steroidal anti-inflammatory (NSAID's) tablets may be helpful. Although these are available over the counter at your local pharmacist, we would always recommend checking with the Pharmacist that this medication is suitable for you. Additionally, if your pain is severe, you may want to speak to your GP about pain relief specifically for nerve pain.

Exercises can be helpful in resolving an episode of cervical radiculopathy. We advise trying to maintain mobility in your neck and in the nerves down your arm.

What is Frozen shoulder?

Frozen shoulder is a condition that affects the lining of the shoulder joint. The lining becomes very inflamed (causing pain) and thickens (causing stiffness). Eventually both the inflammation and thickening lessen but this can take a long period of time, 18 months to 2 years is the average. While most people make a full recovery, about 1/3 will have some long term symptoms.

In the early stages frozen shoulders are usually characterised by severe pain , which can be worse at night and there is usually concurrent joint stiffness.
Frozen shoulders have classically been described as following a set pattern of three stages:

1. Freezing stage: the shoulder is very painful and begins to lose movement
2. Frozen stage: the shoulder is very stiff and painful
3. Thawing stage: the shoulder pain resolves and the movement slowly returns

We now know that not every frozen shoulder will follow this linear path and that the length of time for each stage will vary considerably from person to person.

A frozen shoulder can last for as little as 9 months in less severe cases, or up to 3 or 4 years in the most severe cases.

Given the often severe nature of the pain it is usually recommended that you have some treatment to improve things.

In the first instance you should speak to your First Contact Practitioner, Pharmacist, or GP about anti-inflammatory medications.

What is happening to cause the symptoms?

There is still a great deal of uncertainty as to what causes frozen shoulder. There is evidence that the bodies immune system targets the lining of the shoulder joint and that this triggers lots of inflammation (which causes the pain). As part of this process cells in the joint lining become very active and cause the lining to thicken and stick, this causes the stiffness.

Because it usually affects people at a certain age (45-65), and can run in families there is a thought that there may be a genetic link to the condition but this has not been proven.

If you are diabetic or have thyroid problems you are at a slightly higher risk of developing the symptoms, and slightly higher risk that these will take longer to go.

If your frozen shoulder has come on after a traumatic injury you should ask for a referral to us from your GP so we can make sure you haven't injured the bones or tendons.

What is the care plan?

For some people the condition will be mild and clear up on its on so no specific treatment is indicated.
For most people the pain is quite severe. As suggested above the first course of action is to get some good pain relief from your First Contact Practitioner, GP, or Pharmacist.

If these aren't working then a steroid injection into your shoulder is likely to help. Please refer yourself to the MSK team for this here.

Golfer's elbow is the term used to describe pain arising from the tendons on the inside of your elbow.
The tendons insert onto the medial epicondyle of the humerus (the long bone of the upper arm) as can be seen in the anatomical diagram. This gives the problem its other name which is medial epicondyopathy.

The tendons that insert here are responsible for movements of both the wrist and fingers and are involved in wrist stability during gripping activities.

The main symptoms of golfer's elbow are:
Pain on the inside of the elbow. It is worse on movements of the wrist and gripping activities.It can be worse when first starting to use the arm after a period of rest and then eases off a little.There can be a sensation of stiffness in the tendon first thing on a morning.
It's important to note that you don't need to play golf to have golfer's elbow.
Golfer's elbow can be viewed as any other tendinopathy problem. We will therefore give an overview of what tendons are and why they sometimes develop a problem.

What is a tendon?

A tendon is the end part of a muscle that attaches to bone. It is made up (and looks) different to the rest of the muscle. It is made up mainly of collagen (type 1) which is a very strong, slightly stretchy type of tissue. The tendon isn’t just one piece of collagen, infact it is made up of many tiny fibres. These amazing structures have the capacity to self repair small areas of injury, and can adapt to increasing demand, although they do both of these things very slowly.

Why do we get tendon pain at the elbow?

There are many reasons why we might develop tendon pain- here are the main ones:
The most common reason is a sudden increase in load or activity. Overloading can occur because you do a lot of a new activity, or a one of activity (e.g decorating a room) or you have been exposed to a sudden external force (such as catching yourself if you trip or fall. Because the change is sudden the tendon struggles 'to keep up', leading to pain.

The second most common scenario is constant exposure to overload (i.e sustained heavy activity) for example because of your occupation. Again the tendon is strugling to adapt to the demands you are placing on it. Occupational and lifestyle factors relating to loading are very important in elbow tendinopathy. Infact the ability of the individual to be able to change day to day loading relating to work activity is strongly linked to outcome. People who are able to change or adapt their work activities tend to get better, an inability to change is linked to an increase risk of persistent pain.

Thirdly we may get tendon pain because we don’t use our elbow very often. Tendons can become deconditioned and if they do, normal day to day activities can start to cause changes we normally see with overload.

As you can see the main factor in the development of tendon pain is how the tendon relates to load.
There are however a number of a ‘risk factors’ for tendon pain we need to be aware of.

Some health problems can predispose us to tendon pain for example diabetes, rheumatoid arthritis, depression, and anxiety. It’s important if you have any coexisting health problems that these are well managed.

Lifestyle factors have also been linked to tendon pain. Smoking and being overweight are both associated with a higher likelihood of tendon pain. Why not visit our lifestyle and MSK health page for help managing these risk factors?

What can I do about the problem right now?

1. Deload
   If your symptoms have just come on because of a sudden increase in load, they are probably as a result of local inflammation within the tendon. They will usually settle within 6-12 weeks, as long as you are able to ‘deload’ the tendon. This essentially means not repeating the heavy activity again and again, and making sure you modify your day to day activities for a couple of weeks so they don’t cause excessive pain.

   If your symptoms are due to constant exposure, then again you may want to ‘deload’. You can do this for example by modifying your work tasks, getting help with heavy lifting, or using more equipment.

   A useful technique to employ during this deloading phase is ‘relative rest’.

   Relative rest refers to a technique where by you limit your activities based upon your symptoms.

   To start with you have to rate your pain on a scale of 0 to 10 where 0 is no pain at all, and 10 the worst pain imaginable. The aim with relative rest is not to let you pain go anymore than 2 points up this scale with your day to day activities (i.e if your rest pain is 2 you should not provoke pain more than 4). This can mean cutting activities short or modifying how you do them for a short period of time. You should apply the principles of relative rest for a few weeks until the pain begins to settle.

   If you think you are going to struggle with deloading because of the nature of your job, come and see us. There are other strategies we can employ to achieve deloading which we can teach you, but they do require a detailed face to face assessment.

2. Reload
   If you completed the deloading phase or you think you have a tendon underuse problem the next thing to do is to gradually start exposing the tendon to load again.

   Why do this? Because these strong amazing structures get their ability to cope with loading by exposure to it. The tendon needs to know in the long term what the normal demand on it is going to be and has to relearn how to cope with this. Once the tendon has ‘settled down’ you can start this gradual education.

   The best place to start is with isometric exercises. These are static contractions of the muscle and tendon. These have been shown to reduce short term pain (so are good for self administering pain relief) and help to prepare the tendon for beginning to accept loading through movement.

Greater Trochanteric Pain Syndrome (GTPS) is a common condition whereby people experience persisting pain and often tenderness towards the outside of their hip. In the majority of cases, symptoms appear gradually over time. Alternatively, symptoms manifest after a specific activity or event.

The incidence of greater trochanteric pain is reported to be approximately 1.8 patients per 1000 per year with a higher prevalence in women. Patients with co-existing low back pain, osteoarthritis and obesity are more likely to suffer GTPS symptoms. The latter, obesity, is a recognised musculoskeletal health risk factor. To learn more about the interaction of obesity and musculoskeletal health, click here.

The primary cause of Greater Trochanteric Pain Syndrome is thought to be an insertional tendinopathy of the Gluteus medius and minimus muscles. The gluteal muscles are the bottom muscles and they form a tendon which then attaches or inserts to the thigh bone on the outside of the hip. A tendinopathy is a breakdown of collagen fibre within the tendon and is associated with a failed healing response to an overuse injury or sudden stress onto the tendon.

You may have heard the term ‘Trochanteric Bursitis’? This is a historical term commonly used to describe these symptoms. The trochanteric bursa or bursae (pleural, as there are more than one) are natural fluid filled sacks in our body that can be a source of pain. They sit between the bony prominences and the soft tissues of the lateral hip to act as biological cushions. The largest of these bursae is the subgluteus maximus bursa. This is found on the outside of your hip (over the bony area you can often feel with your hand). Although this is the largest bursa, there are many others in this region of variable size and location, all of which have the potential to cause various symptoms. This is one reason we now use the term greater trochanteric pain syndrome or ‘GTPS’. It captures the variability of presenting symptoms and acknowledges the myriad of other causes such as gluteal tendinopathy, muscle pain or tears and iliotibial band (ITB) pain. GTPS is a regional pain syndrome that often mimics pain generated from other sources, including degenerative joint conditions, i.e. osteoarthritis of the hip and spinal problems. Indeed, 20-35% of people with low back pain experience GTPS.

What are the symptoms of GTPS?

Symptoms of GTPS typically consist of persistent pain towards the lateral (outer) hip. Pain can radiate down the outside of the thigh to the knee but rarely below the knee. Classically, individuals with GTPS will have point tenderness over the lateral hip consistent with the site where they experience their pain. This may be over the bursae, gluteal tendons or associated soft tissue and is why people often struggle to lay comfortably on their side. In GTPS, it can be painful to push your leg out to the side against a resistance and climb stairs. In some people it can be much more intrusive and affect their ability to participate in sport, run or even walk. When examined, the hip joint and lower back can range from pain free to displaying a complex array of symptoms and clinical features.

How can GTPS be managed?

In the majority of people who experience GTPS their symptoms will be self-limiting. Conservative treatment strategies can help treat and ease the symptoms of GTPS. These can include physiotherapy, weight loss if your BMI is elevated (to check your BMI clinic here), use of appropriate pain relieving medications from your GP or pharmacist and activity modification. Physiotherapy helps to optimise the soft tissue health of your lateral hip, usually through a specific and personally tailored exercise program.

Ligaments are tough bands of tissue that connect the bones in your body. There are four main ligaments around the knee: the anterior cruciate ligament (ACL), posterior cruciate ligament (PCL), medial collateral ligament (MCL) and the lateral collateral ligament (LCL). Too much stress on these ligaments can cause them to stretch too far or even snap completely. The ligament injured usually depends on the mechanism of the injury.

Ligaments of the knee may be injured by:

• Sudden twisting on the knee
• Over extending the knee
• Direct impact to the knee
• Landing awkwardly

After injuring the ligaments of the knee there can be sudden swelling, pain, limitation of movement and an inability to weight bear. The joint could feel loose or there could be a snap or popping heard at the time of injury.

The management of a ligament injury depends on the ligament involved and the severity of the injury. If you feel you have a mild knee ligament injury you can follow the advice on this page. Signs of a more serious injury are immediate severe swelling into the knee and difficulty walking. If you have these symptoms you should attend your local A&E department for further assessment and advice.

Finding Relief

Initially it is important to follow the RICE principle;

• Rest the affected area for at least the first 48 hours. You may require crutches to avoid putting weight on your leg.
• Ice can help to reduced swelling and inflammation. Only use for 20 minutes at a time and do not apply ice directly to the skin.
• Compression can help to prevent additional swelling. Wear an elastic compression bandage and remove for sleeping.
• Elevation can help to reduce swelling. Recline when you rest, and put your leg up higher than your heart.

Menisci are the cartilage disks that are found in our knees. There are two in each knee (one lateral and one medial) which act as shock absorbers and cushions to minimise the stress on the articular cartilage, which cover the ends of our bones.

There are two different ways which we can develop problems with our menisci. One is an acute injury where a sudden high load or force causes a tear across the meniscus, such as might happen with a sports injury. The other is known as a degenerative meniscus injury which is a more gradual onset. We are looking at an acute meniscal injury here but if you feel you have a degenerative meniscal injury please click here.

Acute meniscus injuries usually happen during sports. The injury is usually caused by a specific incident such as a twisting injury or following direct contact such as a rugby or football tackle. The severity of meniscus injuries varies.

The most common symptoms of meniscus tear are:

• Pain
• Reduced range of movement and stiffness
• The sensation of your knee "giving way"
• Painful catching or clicking sensations
• Swelling – usually immediately or within 2 hours of the injury
• Inability to fully straighten the knee
• Inability to weight bearSigns of a more serious injury are immediate severe swelling into the knee and difficulty walking or inability to fully straighten the knee. If you have these symptoms you should attend your local A&E department for further assessment and advice. If you feel you have a mild meniscal injury you can follow the advice on this page.

Finding Relief

Initial treatment after an acute injury involves the RICE principle. For more detailed information visit our acute soft tissue injury page here.

• Rest the affected area for at least the first 48 hours. You may require crutches to avoid putting weight on your leg.
• Ice can help to reduced swelling and inflammation. Only use for 20 minutes at a time but do not apply ice directly to the skin.
• Compression can help to prevent additional swelling. Wear an elastic compression bandage and remove for sleeping.
• Elevation can help to reduce swelling. Recline when you rest, and put your leg up higher than your heart.

We have previously mentioned labral tears on our page discussing impingement of the hip joint, otherwise known as femoroacetabular impingement (FAI). Labral tears can exist with or without hip impingement (FAI). To review this information click here. The acetabulum is the socket part of the ‘ball and socket’ hip joint. The acetabular labrum is the supporting circular, gristle-like cartilage or ‘fibrocartilage’ around the rim of the socket. It deepens the hip joint by 21%. It functions to seal the hip joint, protect inter-joint cartilage, enhance stability, distribute load evenly throughout the joint and provide proprioceptive feedback (meaning that it helps relay messages to the brain regarding hip joint position).

A labral tear is characterized by either a defect or a small rip in the labrum itself or when the labrum pulls away from the acetabulum. Only the outer third of the labrum is penetrated with blood vessels. Given the poor supply of blood to the labrum, it is a structure that does not heal well. It typically affects just one side. Symptomatic labral tears may cause a sharp catching pain, giving way and a sensation of locking of the hip during activity. We tend to call these features ‘mechanical’ symptoms. Some people may experience a grinding or popping sensation when they rotate their hip outwards, especially when the affected leg is already positioned away from the other leg (in abduction).

Typically, people with a labral tear experience a subtle, dull, activity and/or position-related hip pain. This pain is often felt towards the outside of the hip joint and towards the groin. Individuals often cup their hip with their hand to display the area of pain; this is known as the ‘C’ sign.

Some people experience referred pain. This means pain from the hip is felt in other areas such as the buttock, leg and lower back. Unlike osteoarthritis, hip range of movement may be well preserved. At times, movement is reduced and the hip can feel stiffer. It is worth noting that even if you have a known labral tear, this does not necessarily mean you will suffer symptoms. Indeed, it is known that 25% of individuals over the age of 50 have labral tears, but no symptoms. The incidence of labral tearing increases with age, indicating that some deterioration may be associated with the normal aging process.

However, some individuals do develop symptoms secondary to a labral tear. Pain from a labral tear is often due to repetitive movements or prolonged loading in static positions. Sports that produce high loads through the hip include running and sprinting. Alternately, football, ballet, hockey and golf generate repetitive lateral rotation through the hip. 75% of labral tears can just simply develop. The presence of a labral tear may predispose the hip to developing osteoarthritis (OA). There is evidence that shows the presence of a labral tear doubles the risk of an individual developing OA. However, it is worth noting that not everyone with hip OA suffers with symptoms.

Initial treatment for symptomatic labral tears is non-surgical. Non-surgical treatment involves addressing lifestyle factors which predispose an individual to excessively load their labrum through sport or occupation.

Morton’s neuroma is a condition where a nerve (the plantar interdigital nerve) in your foot is irritated or thickened. This is a nerve the passes between the bones of your foot. This most commonly involves your second, third or fourth toes. It is usually diagnosed between 40-60 years of age and more common in women than men.

It is often made more painful by wearing tight footwear that can increase pressure around the nerve. Other contributing factors can be repetitive heavy impact on the feet.

The main symptoms of Morton’s Neuroma are:

• A shooting, stabbing or burning pain in the forefoot
• Feeling like a small stone is stuck under your foot
• Local tingling and numbness
• Pain exacerbated by increased activity such as walking or certain footwear (tight, pointy or high heeled shoes)

Self Help

The following modifications may help your symptoms to settle:

• Wear wide, comfortable shoes with a low heel and soft sole and avoid tight, pointy or high heeled shoes
• Temporarily reducing or modifying activities that reproduce your symptoms may help the symptoms settle. E.g. if you notice your symptoms are worse when running, try reducing the amount you do for a short period
• Weight loss – reducing you weight will reduce the amount of pressure through your foot. Further information can be found here
  Further Treatment

Other management techniques include:

• If the above footwear advice doesn’t ease symptoms, a “metatarsal pad” (available over-the-counter) may reduce pressure on the nerve
• Non-steroidal anti-inflammatories can be considered if necessary - Please check with a pharmacist or your GP if this medication is appropriate for you.

If you are struggling to return to your normal activity levels or your foot is not settling, ask your GP for a referral to podiatry. If your symptoms persist after podiatry, your GP can refer you to the Musculoskeletal Service for further management.

Please Note: If you have diabetes and are experiencing a new onset of pain or sensation change in your feet we advise you see your diabetic nurse or GP in the first instance prior to referral to the Musculoskeletal Service.

Osteoarthritis is a term used to describe changes that occur at a joint that affect it’s health.
The first thing people usually think of when thet think of arthritis is 'wear and tear'. These two simple words paint a picture of a process of gradual decline of an affected joint. Recent research into the arthritis process shows that actually this view of arthritis is not correct!

Versus arthritis UK propose that instead we should think of arthritis as ‘tear, flare and repair’. This means that when the joint becomes inflammed and flares up it does it’s best to settle the inflammation and repair itself. The repair process leads to some of the symptoms associated with arthritis including tightness of the joint and a reduction in how far it can move.

Symptoms include:

• Neck and shoulder/shoulder blade pain – that comes and goes
• Problems getting comfortable in bed at night with discomfort or pain usually described as a dull ache
• Morning stiffness which takes around 10 minutes to ‘get going’
• Some people have headaches – often starting at the back of the neck
• Difficulty doing tasks for long periods such as gardening or hobbies

You could be more likely to get neck OA at any age, although it is rare under the age of 40. Risk factors for neck osteoarthritis are:

• a job that involves repetitive neck movements or a lot of overhead work – like painting and decorating
• previously had a neck injury
• a family history of the condition
• are overweight (this is associated with higher levels of inflammation in the body)
• are a smoker
  term.

Simple initial management:

If your symptoms have just started, or you are experiencing a flair up it could be worth modifying your activities, while things settle down. This could mean reducing the amount of time you spend in fixed postures or reducing the time performing activities that seem to aggrevate your pain. Its important that as things settle you try and return to your normal activity levels.

It may be helpful to perform some simple range of movement and strengthening exercises to help maintain your mobility and allow things to settle down.

Osteoarthritis is characterised by degeneration/ thinning of the articular cartilage and subchondral bone which subsequently leads to narrowing of the joint space. This can cause increased friction within the joint as well as tightening of the surrounding muscles. For a more in depth explanation of arthritis is then please follow the link here.

The most common site of arthritis in the hand is at the base of the thumb (see diagram above). This occurs at a joint known as the carpometacarpal joint (CMCJ). This joint is a saddle joint which means that the surfaces are convex in one direction and concave in the other to allow the thumb to be very flexible and mobile.

Symptoms of small joint osteoarthritis

• Joint stiffness (particularly if you haven’t moved the joint for a while)
• Joint pain with certain activities
• Weakness in grip strength
• Limited range of movement of a joint
• Joint swelling
• Slightly thickened or enlarged appearance to the joint
• A grating sensation of a joint known as crepitus

Why do we get small joint osteoarthritis?

There are some risk factors than can predispose you to developing osteoarthritis your shoulder, these are:

1. Advancing age - although this is not a normal part of aging, the risk of osteoarthritis increases with age – we all get grey hairs and wrinkles and the same changes occur internally.
2. Previous trauma to the shoulder is linked to subsequently developing arthritis. This might include fracture or dislocation.
3. An occupation that requires heavy manual work is thought to be associated.
4. Genetics - osteoarthritis can run in families.
5. Obesity – a high body mass index (BMI) is associated with osteoarthritis in the shoulder.
6. Smoking is also linked to poor joint health.
7. Gender – women are more likely to develop osteoarthritis

It’s important if you have any coexisting health problems or lifestyle factors that these are well managed. Why not visit our lifestyle and MSK health page for help managing these risk factors?

So… what can I do about my pain right now?

The current arthritis guidelines recommend the use of paracetamol and/or non-steroidal anti-inflammatories (NSAIDs) for the management of arthritic pain. Both types of medication are available over the counter at your local pharmacy. We would always advise discussing your suitability for the medication with the Pharmacist before starting a course of treatment.

Often people may report difficulties with specific tasks or activities that involve gripping. It may be helpful to modify or adapt how you complete these activities to make it more comfortable. Simply pacing or completing tasks to a tolerance level only can be helpful rather than pushing into pain. Where possible it may be helpful to purchase equipment or kitchen aids to help with difficult tasks.

What is Hip Osteoarthritis?

2.46 million people in England have osteoarthritis (OA) of the hip. 11% of the population aged over 45 years old has the condition.

Arthritis Research UK suggest that only 18% of people with arthritis have a care plan to help them manage their symptoms. Sub-optimal management of osteoarthritis permits people to suffer symptoms unnecessarily.

Not everyone who has arthritis will suffer with symptoms, but those that do can experience pain, stiffness, reduced mobility and function. The experience of OA is often unique to each individual.
Some people may just have pain, whereas others may simply have stiff joints. Typically, symptomatic people with hip OA will have a combination of symptoms. Stiff hips often hinder daily functional tasks like walking, getting in and out of the bath or car, putting on shoes and socks and cutting toenails.

What is happening in hip osteoarthritis?

The first thing people usually think of when they think of arthritis is 'wear and tear'. These two simple words paint a picture of a process of gradual decline of an affected joint. Recent research into the arthritis process shows that actually this view of arthritis is not correct!

Arthritis Research UK proposes that instead we should think of arthritis as ‘tear, flare and repair’.
The hip joint is a ball and socket joint, made up of two bones the 'accetabulum' which is the socket and the 'femur' which is the ball. whe the surfaces of the two bits meet the bones are covered in hyaline cartilage. This special type of tissue is very tough and copes really well with lots of load and force being put through it.

The 'tear' component of arthritis refers to small defecits that occur in the hyaline cartilage exposing the underlying bone. People often think that age is the biggest factor in development of these defecits however this is incorrect! The problem is much more multifactorial than that.

Development of these tears can relate to:

1. Biomechanics- How we use our hip joints and the shape of the joint can both be factors in developing osteoarthritis. Heavier manual occupations such as farming for example has been linked to a higher incidence of arthritis in the hip. Having a shallow hip socket can predispose towards developing hip arthritis.
2. Previous injury or trauma- a previous problem with the hip joint such as a tear of the rim of the joint (which is very common in natural child birth) can predispose to developing osteoarthritis.
3. Genetics- it is thought that there are genetic factors that predispose some people to developing osteoarthritis.
4. Obesity- Having a higher than normal body mass index (BMI) is associated with osteoarthritis in the hip. This is thought to be due to the 'switching on' of inflammation by a group of chemical messengers called adipokines. These chemicals are secreted by fat tissue (which we tend to have more of in our jont soft tissues if we are overweight).
5. Smoking- smoking is linked to poor joint health.
   The flare component refers to the inflammation that occurs within the joint when it is overwhelmed by a combination of the above factors.
   The repair refers to the fact that the joints have an inate capacity to self repair and try and do this following a flair episode.

What can i do about the problem

Osteoarthritis is a long term condition- it usually develops and evolves very slowly (there are some more aggressive types that tend to affect younger people where the osteoarthritis develops quickly, but these are the exceptions not the rule).

Just as with other long term conditions like asthma or diabetes there are steps that can be taken to manage existing symptoms, and lifestyle changes that can be made which will generally improve symptoms.

From time to time people with osteoarthritis can experience flare up of their symptoms and may require additional help or treatment at these times to setle things back down.

Managing existing symptoms

The main ways of managing existing symptoms are looking at medication useage, maintenance exercises, and activity pacing techniques.

The aim of medication in osteoarthritis is to minimise your experience of pain symptoms. For some people dipping in and out of pain relief as required is sufficient to do this, for others a more formal regime of taking medication regularly is required to acheive this aim. National guidance for the use of medication in osteoarthritis suggests that people should try and use paracetamol or a NSAID in the first instance. Because both sets of drugs are unsuitable for some people you should speak to your GP about which approach is right for you.

Maintenance exercises are designed to keep your hip strong and moving well, the following exercises are likely to be useful.

Actvity pacing techniques are useful to consider if either:
you are not able to complete activities you enjoy because of pain
or
you can complete activities but you suffer for doing so for a few days afterwards.

Pacing involves breaking bigger activities down into smaller chunks to acheive your goal. The short video below explains how to pace your activities.

Improving existing symptoms

Employing the above management strategies for your existing symptoms should have the net effect of improving your existing symptoms.

Symptoms may also be improved by thinking about lifestyle factors. The key areas where changing lifestyle can be beneficial to joint health are:

stopping smoking, losing weight, and exercising regularly.
Exercising regularly has been shown to have a strong effect on peoples self reported ability to function with arthritis. Here are two short videos on why exercise is good for your arthritis and getting going.

Here at the MSK service we run regular exercise groups to help people get going with exercise to improve their osteoarthritis symptoms. If you are interested in attending pease speak to your GP about an MSK referral.

If you are overweight, using a calorie controlled diet to try and reduce this has also been shown to reduce arthritis symptoms.

Smoking cessation improves not only joint health but will have a positive impact on almost every system in the body.

To find out more about the positive effect that managing your lifestyle can have on your pain visit our lifestyle page.

Managing flare-ups

If you experience a flare of symptoms this is usually linked to an episode of inflammation within the joint. It is therefore usual for a flare up to last between 6 and 12 weeks. If you are struggling with a flare it is worth considering your medication based option for managing this. Your GP may prescribe you a short course of medication to help with the flare up. You should also make sure your following all our advice above with regards symptom management. If you are and you are experiencing a very persistent flare a corticosteroid injection into the joint can be helpful to settle things down.Because the hip is a difficult joint to get to this often needs to be done under image guidance. We are happy to see people on a one to one basis for advice during a flare up period. Please discuss an MSK referral with your GP.

Joint replacement for osteoarthritis

Prior to considering joint replacement surgery it is important that you have tried to optimise the management of your arthritis with none surgical treatment methods. the short video below discusses the importance of this.

Whether to go ahead with a joint replacement is a big decision. The NHS has developed a tool to help you explore the issues around this decision. This can be accessed here:
Hip Osteoarthritis shared decision making tool

If you are experiencing an episode of low back pain, you are not alone. It is estimated that 80 percent of people will experience back pain at some point in their lives. If your back problem is new (you've had it for less than 3 months and it isn't a recurrent problem) we would recommend using our acute back pain information page.

If your back problem has persisted for more than 3 months, again your not alone. Back pain persists in about 20 percent of cases.

It's important if you have a persistent back problem to know what to do about. The thinking about how we decide which treatment will help an individual has changed rapidly in the last few years. New national guidelines recommend that the first thing you do is complete a simple online questionairre called the STARTBACK Tool.

The point of the STARTBACK Tool is to determine how likely your back pain is to persist and what support you are likely to need to help improve your symptoms.

Before proceeding complete the tool here.

Once you've completed the questionairre you'll be given a risk score and a recommended action.

LOW RISK- your in the right place! The information on this page has been designed to help you manage your back pain more effectively.

MEDIUM RISK- Speak to your GP about a referral to see a Physiotherapist. In the mean time use the resources on this page to understand how you can manage your own back problem most effectively.

HIGH RISK- Speak to your GP about a referral to a see a pain specialist Physiotherapist. In the mean time use the resources on this page to get a better understanding of how to manage your back problem most effectively.

What is non specific low back pain with or without sciatica?

This short video explains the basics about chronic non specific low back pain with or without sciatica.

Low back pain refers to pain in the area of your low back, while sciatica refers to pain that may travel down your leg.

Chronic means that the pain has been going on for more than three months.
Are there any risk factors for chronic low back pain?

In terms of Risk factors for low back pain the main factors we are able to influence are around lifestyle. the key areas to focus on are eating healthly and maintainig a healthy weight, taking regular exercise, and if you are a smoker to get help quitting.

Our lifestyle section is filled with help and advice on these three areas and can be accessed here.
The other key area where risk's related to low back pain should be considered and managed is the workplace.

What care options are availalbe?

Medications
The most recent recommendations around medications and back pain are that non-steroidal anti inflammatories (NSAIDs) should be used as the first line treatment for pain providing that you are able to take these. The common versions of this type of drug are ibuprofen and diclofenac. You should check with your GP that you are able to take these. Sometimes they will prescribe a stomach protector to take alongside them or suggest you use the gel versions of the drug.

Regular exercise
Getting regular exercise is really important in managing the symptoms of your low back pain. Regular exercise can:

• Decreased pain (usually an improvement of 2-3 points on a 0-10 scale of pain)
• Enhance performance of work and recreational activities (strong improvement)
• Decreased fatigue
• Decreased number of tender points (joint and muscle pain)
• Improve physical fitness

Current guidelines suggest that the type of exercise doesn't really matter, but that it can include:

• Aerobic fitness
• Biomechanical exercise (i.e. pilates)
• Mind/Body exercise (i.e. yoga)

If you are new to exercise you might want to read our guide to exercising with persisting pain before you get going. This guide tells you what to expect when you first start exercising and how to keep flairing up your symptoms to a minimum.

To get you started here are some ideas.

Pilates
NHS Studio: Pilates for Back Pain (Beginners)

Yoga
NHS Studio: Introduction to Pilates

Aerobics
NHS Studio: Aerobics for beginners

Physiotherapy
Physiotherapy can also be useful in persisting Low back pain with or without sciatica. The core treatments offered in Physiotherapy are: Information session about persisting low back pain, help with activity pacing and getting more active, exercise classes for persisting low back pain.

What is the rotator cuff?

The rotator cuff is the name given to a group of four muscles around your shoulder. These muscles originate from your shoulder blade and attach to your upper arm via their tendons.
The rotator cuff is very important in helping to move your shoulder, as well as providing it with stability and support.

Why Do I Have Shoulder Pain and Weakness?

Like all structures in your body, the tendons of the rotator cuff are susceptible to age, lifestyle, and genetic factors that can cause them to wear.

This is a natural ageing process, and studies show that 15% of people in their 60’s, and 26.5% of people in their 70’s may have tears in these tendons, without any prior injury, although they can sometimes be brought to the fore through a traumatic injury.

These age related changes to the tendon are often described as “degenerative rotator cuff tears”, and can cause pain, weakness and reduced movement of the shoulder.

How is this problem helped?

Initial treatment for degenerative rotator cuff tears involves a combination of activity modification and exercise.

Activity modification aims to reduce pain by temporarily reducing the amount of stress put on your shoulder. For example, because people with rotator cuff pain often struggle with reaching up and out, consider whether you could

• Step towards things instead of reaching out for them
• Use both hands to lift things rather than one

Everybody is different, and this needs to be specific to your own activities and your own symptoms. Generally, if something causes significant pain that does not settle quickly once you stop the activity, you should consider whether you could adapt or reduce this activity.

Exercise therapy aims to gradually increase range of movement and strength of your shoulder, thereby improving the function of your arm.

What is rotator cuff related shoulder pain?

Rotator cuff related shoulder pain is pain that comes from the rotator cuff tendons and associates structures in your shoulder.

The rotator cuff are a group of tendons and muscles around the shoulder. Their main job is to control the position of the ball in the socket. A normally functioning rotator cuff allows for good movement of the arm and strength when working overhead or away from the body.

Just like every other structure in your body, the health of the rotator cuff is influenced by age, lifestyle, usage, and genetics.

In people under the age of 50 the most likely reason for developing rotator cuff related shoulder pain relate to activity levels. this could be a sudden increase in activity because of 'one off' projects or activities, or overloading the tendons beyond their capabilities for a prolonged period of time. How tendons react to activity very much depends on how prepared they are for it.

People over the age of 50 are also likely to have some age related changes to the tendons which may be contributing to the symptoms. It's important to recognise that how we age isn't just dependent upon the passage of time, but on our lifestyle too. it's thought that taking regular exercise, maintaining a healthy weight and not smoking contribute to how well our musculoskeletal system ages.

What is the treatment for rotator cuff related shoulder pain?

Research shows that the most effective treatment for this problem is a combination of activity modification, and exercise therapy.

Activity modification aims to reduce further overloading of the shoulder tendons, giving them time to settle down. Activities which typically aggravate this problem include reaching outwards or overhead. Therefore, to reduce this overload, consider whether you could:

• Temporarily reduce the amount of overhead work you do
• Step towards things instead of reaching out for them
• Use both hands to lift things rather than one

Everybody is different, and this needs to be specific to your own activities and your own symptoms. Generally, if something causes significant pain that does not settle quickly once you stop the activity, you should consider whether you could adapt or reduce this activity.

Exercise therapy aims to gradually increase the amount of load that your shoulder can tolerate.
Benefits of exercise therapy include:

• Reduced pain
• Improved range of movement
• Improved muscle strength
• Improved shoulder function

Tennis elbow is the term used to describe pain arising from the tendons on the outside of your elbow.
The tendons insert onto the lateral epicondyle of the humerus (the long bone of the upper arm) as can be seen in the anatomical diagram. This gives the problem its other name which is lateral epicondylopathy. The tendon involved in 90 percent of cases is called extensor carpi radialis brevis.
The tendons that insert here are responsible for movements of both the wrist and fingers and are involved in wrist stability during gripping activities.

The main symptoms of tennis elbow are:

Pain on the outside of the elbow. It is worse on movements of the wrist and gripping activities.It can be worse when first starting to use the arm after a period of rest and then eases off a little.There can be a sensation of stiffness in the tendon first thing on a morning.

It's important to note that you don't need to play tennis to have tennis elbow.

Tennis elbow can be viewed as any other tendinopathy problem. We will therefore give an overview of what tendons are and why they sometimes develop a problem.

What is a tendon?

A tendon is the end part of a muscle that attaches to bone. It is made up (and looks) different to the rest of the muscle. It is made up mainly of collagen (type 1) which is a very strong, slightly stretchy type of tissue. The tendon isn’t just one piece of collagen, infact it is made up of many tiny fibres. These amazing structures have the capacity to self repair small areas of injury, and can adapt to increasing demand, although they do both of these things very slowly.

Why do we get tendon pain at the elbow?

There are many reasons why we might develop tendon pain- here are the main ones:
The most common reason is a sudden increase in load or activity. Overloading can occur because you do a lot of a new activity, or a one of activity (e.g decorating a room) or you have been exposed to a sudden external force (such as catching yourself if you trip or fall. Because the change is sudden the tendon struggles 'to keep up', leading to pain.

The second most common scenario is constant exposure to overload (i.e sustained heavy activity) for example because of your occupation. Again the tendon is strugling to adapt to the demands you are placing on it. Occupational and lifestyle factors relating to loading are very important in tennis elbow. Infact the ability of the individual to be able to change day to day loading relating to work activity is strongly linked to outcome. People who are able to change or adapt their work activities tend to get better, an inability to change is linked to an increase risk of persistent pain.

Thirdly we may get tendon pain because we don’t use our elbow very often. Tendons can become deconditioned and if they do, normal day to day activities can start to cause changes we normally see with overload.

As you can see the main factor in the development of tendon pain is how the tendon relates to load.
There are however a number of a ‘risk factors’ for tendon pain we need to be aware of.

Some health problems can predispose us to tendon pain for example diabetes, rheumatoid arthritis, depression, and anxiety. It’s important if you have any coexisting health problems that these are well managed.

Lifestyle factors have also been linked to tendon pain. Smoking and being overweight are both associated with a higher likelihood of tendon pain. Why not visit our lifestyle and MSK health page for help managing these risk factors?

What can I do about the problem right now?

1. Deload
   If your symptoms have just come on because of a sudden increase in load, they are probably as a result of local inflammation within the tendon. They will usually settle within 6-12 weeks, as long as you are able to ‘deload’ the tendon. This essentially means not repeating the heavy activity again and again, and making sure you modify your day to day activities for a couple of weeks so they don’t cause excessive pain.
   If your symptoms are due to constant exposure, then again you may want to ‘deload’. You can do this for example by modifying your work tasks, getting help with heavy lifting, or using more equipment. If you have to lift, try to do so with a bent elbow and your palm facing upwards.
   A useful medical device for tennis elbow is called a Jura clasp. This is worn at the elbow during activities that are normally painful. These are readily available online and we include a picture for your reference. if buying online remember to measure your elbow circumference and pick the right size.

   A useful technique to employ during this deloading phase is ‘relative rest’.

   Relative rest refers to a technique where by you limit your activities based upon your symptoms.

   To start with you have to rate your pain on a scale of 0 to 10 where 0 is no pain at all, and 10 the worst pain imaginable. The aim with relative rest is not to let you pain go anymore than 2 points up this scale with your day to day activities (i.e if your rest pain is 2 you should not provoke pain more than 4). This can mean cutting activities short or modifying how you do them for a short period of time. You should apply the principles of relative rest for a few weeks until the pain begins to settle.

   If you think you are going to struggle with deloading because of the nature of your job, come and see us. There are other strategies we can employ to achieve deloading which we can teach you, but they do require a detailed face to face assessment.

2. Reload
   If you completed the deloading phase or you think you have a tendon underuse problem the next thing to do is to gradually start exposing the tendon to load again.

   Why do this? Because these strong amazing structures get their ability to cope with loading by exposure to it. The tendon needs to know in the long term what the normal demand on it is going to be and has to relearn how to cope with this. Once the tendon has ‘settled down’ you can start this gradual education.

   The best place to start is with isometric exercises. These are static contractions of the muscle and tendon. These have been shown to reduce short term pain (so are good for self administering pain relief) and help to prepare the tendon for beginning to accept loading through movement.

   The video shows you how to do a basic isometric contraction. You should start by only working at about 50% of your maximum push, less if 50% is uncomfortable. Eventually you want to get up to about 70% of your maximum. You should hold the push for about 50 seconds and repeat 2-3 x per day.

Osteoarthritis is the most common form of arthritis. Contrary to popular belief osteoarthritis is not caused by aging and does not necessarily deteriorate. Osteoarthritis can affect people in different ways – some people may only experience mild symptoms whereas others can experience more severe symptoms. Interestingly some patients can even have osteoarthritis and be completely pain free!
At the end of each bone we have a type of cartilage known as hyaline cartilage. Over our lifetime a variety of traumas may trigger this cartilage or a joint to repair itself. Your body attempts to lay down extra bone to repair the area. This is a very slow and efficient inflammatory process. Usually we are left with a structurally altered but pain free joint. However, if a trauma is too significant or the joint is unable to compensate then people may become symptomatic. If you break the word arthritis down, “arth” means bone and “it is” means inflammation. Often people will go through an inflammatory phase with can settle with good management and time. See below for further advice.

Osteoarthritis can effect may people in different ways. Interestingly, the severity does not always reflect There is a known poor correlation between changes visible on x-ray and symptoms of osteoarthritis – minimal changes may cause a severe amount of pain and severe changes may be symptom free.
Osteoarthritis may be suspected if you are over 45 years old, experience activity related joint pain and morning stiffness/stiffness related to inactivity. Further tests such as X-rays and blood tests are often not required although may be completed to rule out other possible causes of symptoms.

The symptoms associated with osteoarthritis usually are:

• Joint stiffness and pain (particularly if you haven’t moved the joint for a while)
• Limited range of movement of a joint
• Joint swelling
• Slightly thickened or enlarged appearance to the joint
• A grating sensation of a joint known as crepitus

There are certain factors which may lead you more prone to osteoarthritis – these include:

• Family history of osteoarthritis
• Repeated traumas or significant injury to a joint
• Gender – women are more likely to develop osteoarthritis
• Obesity
• Age – although this is not a normal part of aging, the risk of osteoarthritis increases with age – we all get grey hairs and wrinkles and the same changes occur internally

Osteoarthritis can affect any part of the body but the most common areas are the weight baring joints of knees/hips and the small joints of the hands.

The most common site of arthritis in the hand is at the base of the thumb (see diagram above). This occurs at a joint known as the carpo-metacarpal joint. This joint is a saddle joint which means that the surfaces are convex in one direction and concave in the other that allow the thumb to be very flexible and mobile.

If you were to develop osteoarthritis at this joint you may notice a reduction in range of movement of the thumb, increased pain with certain activities and weakness in grip strength. Maintaining your range of movement and strength will be beneficial in order to maintain good levels of function.

The current arthritis guidelines recommend the use of paracetamol and/or non-steroidal anti-inflammatories (NSAID’s) for the management of arthritic pain. Both types of medication are available over the counter at your local pharmacy. We would always advise discussing your suitability for the medication with the Pharmacist before starting a course of treatment.

Often people may report difficulties with specific tasks or activities that involve gripping. It may be helpful to modify or adapt how you complete these activities to make it more comfortable. Simply pacing or completing tasks to a tolerance level only can be helpful rather than pushing into pain. Where possible it may be helpful to purchase equipment or kitchen aids to help with difficult tasks.

If symptoms are becoming unmanageable, a night resting splint may be provided which can help to give the joint some relative rest to help symptoms settle. The most effective splint is thermoplastic and requires moulding to the individual. Your physiotherapist could supply and fit one if required. If you would like further physiotherapy advice for this condition, you can always be referred to our service.

Should symptoms fail to settle, an anti-inflammatory corticosteroid injection maybe helpful to ease symptom. Your GP or the MSK team may be able to perform the injection for you.