Common myths about Osteoarthritis

Popular misconceptions about Osteoarthritis

In my Osteopathic and Physiotherapy practice there is probably few conditions that create as much confusion and misunderstanding as Osteoarthritis.

The most frequent are

• Its an inevitable part or aging
• Its wear and tear.
• The bone is on bone.
• Using it more makes it "wear out" more quickly
• Can,t be treated and have to live with it.
• Will only get worse with time. 
• It will spread.
• Physical therapy - (Osteopathy/Physiotherapy) can,t help
• It will end in surgery. 

The wear and tear myth

  This is one of the most frequent explanations put forward to patients, often by GPs. "Normal wear and tear for age" is a commonly used phrase. Joints don,t in fact "wear out" and its not part of the normal aging process. Joints like to be used. The nutrition to the cartilage comes from the joint movement and compression. The ligaments and muscles get stronger with use - thus leading to a healthier joint.

 What is Osteoarthritis

 Traditionally Osteoarthritis is defined as a narrowing of the joint space due to thinning of cartilage. Though this is true and evident on X-Ray, it is only part of the picture.
 Rather than seeing it as "wear and tear" process it is more helpful to view Osteoarthritis as an inflammation of the whole joint that involves the capsule and ligaments. The inflammation is the bodies repair process at work. Therefore the swollen joint is a sign your body is at work trying to repair itself - and not a bad sign in itself.

Its my Arthritis
People will often say to me "its my Arthritis" to cover all their musculo skeletal pains. However arthritic changes in a joints does not mean this is responsible for your symptoms. Sometimes it is a incidental finding and may have be present for many years before present symptoms. It is importance that X-rays and MRI are interpreted within the whole context of signs and symptoms.

Surgery
Osteoarthritis in joints don,t just get worse and worse ending in surgery. Quite often the symptoms can follow a fluctuating course, or even improve with the right treatment and management.
  It is however true that joint replacement sometimes becomes the best option. This most frequently is the hip joint and also the knee. With joint replacements the better you go in the better you come out - so treatment, increased muscle strength and weight loss can all help if done prior to surgery.

Treatment of Osteoarthritis

Pain associated with Osteoarthritis usually responds well to physical therapy such as Osteopathy or Physiotherapy. As well as hands on treatment. it may include exercises, lifestyle and nutrition advice.

Chronic Ankle pain treatment Osteopathy & Physiotherapy

The Ankle and foot structure

The foot is made up of 26 bone, 33 joints and more than 100 muscles, tendons and ligament.

This makes it a complex area structure with a lot of tendons, ligaments, muscles and joints that can get into trouble.

Common diagnosis errors. 
Medically one can get a large range of so called "diagnosis" ranging for sprained ankle, peroneal tenonitis, planter fasciitis or  Achilles tendonitis. However, this "specific" description creates difficulties as the actual underlying cause of the problem that may be coming from elsewhere can be overlooked. For example Achilles tendon pain, could be resulting from a talocrural joint restriction or peroneal tendonitis from a subtalar joint restriction.

Joints of the foot and ankle restrictions
Because there are so many joints in the foot if there if a restriction in one / or more joints they often are unnoticed by a patient. Additionally it requires a high level of palpation skill on the part of the practitioner to identify these often quite subtle restrictions. Therefore it is not uncommon for this to be missed altogether.

Importance of the Subtalar joint in sprained ankles

This is the joint between the Talus and the Calcaneus. It allows your foot to Evert  (move out) or invert (move inwards). It is very important in balance or walking on uneven surfaces. Often balancing on one leg is improved when normal movement is restored to this joint.

   The subtalar joint often becomes restricted after a sprained ankle (the person may not notice this). Practitioner will often get too focused and the ligaments after a sprain and not notice restriction in this joint.

When a joint is injured it frequently become stiff and restricted as a result. In ankle sprains that fail to improve this is commonly the case.

 Tibio talar joint (Ankle joint)

The main movement in this joint is dorsiflexion (pulling foot up) and plantarflexion (pushing foot down). It is often injured in football when the toes get stuck in the ground and leg continues forwards (forcing into plantar flexion). Here again like with the sprained ankle, the injury to the joint often results in a restriction in this joint that goes unnoticed - and thus ongoing problems.

  Another common injury to this joints is a sudden stop while running or tripping while going down steps. Here, the tibia shunts forwards on the talus.

Treatment

All the above respond well to treatment. I have focused on the above, as they (in my experience) are the most common reasons for pain continuing longer than expected and becoming chronic (more than 6 months).  

Greater trochanteric pain syndrome GTPS

Greater Trochanteric Pain Syndrome GTPS (trochanteric bursitis)

Greater trochanteric pain syndrome GTPS is the term that has replaced Trochanteric Bursitis. It describes all pain on the outside of the upper thigh (near the greater trochanter).  GTPS is a broad term and covers a range of possible problems including trochanteric bursitis, tears or tendonitis of the gluteus medius and minimus tendons and the Iliotibial band (ITB).

Symptoms of GTPS

This involves pain on outside of the hip and thigh. It may also spread a little down the outside of the leg and into the buttock muscles. Often lying on that hip is difficult at night.

What is GTPS

 This can involve local tissues in area, or referred from elsewhere. Local tissues may be Gluteal muscle insertions, the Iliotibial band or Bursa. MRI scans have now found the bursa is not normally involved (less that 10%). Hence the move away from term Trochcanteric Bursitis.

 It is now felt that if Trochcanteric Bursitis is present it usually secondary to the involvement of the Gluteal muscles.

Osteopathic / Physiotherapy treatment of GPTS

Treatment first involves first doing a full structural. examination. There are many factors that may conrtibute to the development of GPTS. These may be local or quite remote from where the symptoms are felt. Usually local treatment such a deep tissue massage into the gluteals and trigger point therapy in gluteals / gluteal tendons will be enough to be effective. However, sometimes some of the below factors may also need to be addressed. My experience is that a short leg or foot pronation rarely needs to be addressed (and the person may of had these for years before with no trouble). Most common (in my experience) is the ITB band, Sacro ilac joint and back - in that order.

GPTS  from elsewhere

Pain on the outside of the hip and thigh is a very common referal  area from other structures. These may include the low back, sacro iliac joint or hip joint itself.

• Low back                   Back pain  for more info on back pain  
• Sacroilac joints
• Hip joints                    The Hip joint for more info on hip joint
• Iliotibial band (ITB)     ITB syndrome and runnersknee  for more info ITB syndrome
• Short leg
• Pronated feet

- Low Back. Pain, discomfort and tenderness in the gluteal muscles (buttock muscles) and outside of thigh frequently has its origin from the back. Just because one gets tenderness on local palpation to the trochanteric area it does not mean that this is GTPS. Symptoms that come from the back can also refer tenderness. As well as referred symptoms, there may be structure problems with the back that result in stress on the area that may need addressing.

- Sacroiliac joints. Sacroiliac problems can result in trigger points in the gluteus medius / minimus as well as referring pain into the outer hip. Additionally, a twist in the pelvis can result in a pelvic side shift with resultant stress on gluteus medius tendon.

- Hip joints. Though problems in the hip joint itself (osteoarthritis) most commonly are felt in the groin occasionally it can be felt in the buttock or trochanteric area.

- Iliotibial band (ITB syndrome). Tightness in the ITB band or ITB syndrome is often associated with GTPS.

 Deep tissue massage to the ITB can often be part of treatment. Note that the lower part of the ITB is often associated with runners knee. Sometimes people with GTPS will also have runners knee, and in this case it is likely that tightness in the ITB band is linking both.

- Short leg A short leg can be a factor in GTPS

Notice how the left side (looking at picture) is higher and thus putting the gluteus medius / tendon under more strain. The short leg may be anatomical (femur or tibia) or due to a twist in the pelvis.

- Pronated feet  Pronated feet (flat feet) as well as being connected with ITB syndrome has also been associated with GTPS.

                                           Chris Reynolds Osteopathy & Physiotherapy

What is frozen shoulder

What is true frozen shoulder?
Frozen shoulder is much misunderstood and frequently over diagnosed condition. It often mistakenly thought of by patients and sometimes general practitioners that any shoulder which is stiff and painful is  frozen shoulder. However, a shoulder that is stiff and painful can encompass a huge variety of different problems, ranging from shoulders that are actually too wobbly (but will feel stiff), subacromial impingement, rotator cuff tendinitis, to older patients with arthritis. A restricted or stiff shoulder is not diagnostic of frozen shoulder in itself.

Background and diagnosis
Frozen shoulder more commonly occurs in  women in the 50s age group. There has usually been no history of trauma or previous shoulder problems. The pattern is of insidious onset shoulder pain, often felt half way down the arm. This pain increases and lasts for a 6 to 7 week period. One noticeable feature at this stage is that any movement is painful and in all directions (including movements below shoulder level). This comes on straight away with active movement. In other kinds of shoulder conditions there are usually some movements which are ok.

Pain that develops suddenly, and is only apparent with certain movements - such as over head is more likely to be some other shoulder condition such as subacromial impingement.

After this 6 -7 week (painful phase) the pain will usually start to subside and then restriction and stiffness becomes more apparent over several months.  Eventually there is complete loss of movement in all directions. This is called a "capsular pattern" - which makes it different from other kinds of shoulder conditions. Following this, over time, the movement gradually starts to improve.


Key points towards a true frozen shoulder in first phase

• Insidious onset
• No apparent trauma (though sometimes secondary to a trauma)
• No previous history of shoulder problems
• Gradually increasing pain, (often felt midway down arm) over several weeks.
• Movement in ALL directions painful from start of movement
• Pain at night

Key points for Frozen shoulder in second phase

• Decreasing pain
• Gradual development of global restriction in ALL direction
• Then over time slow improvement in range of movement - but note natural history

Natural history
The commonly held concept that frozen shoulder returns to normal in 2 years is unfortunately is not true. It has been found in studies that  after 7 years 50% still have some discomfort and 60% some restriction of movement - especially external rotation.


For information treatment of frozen shoulder and exercises 
See my blog Treatment and management of frozen shoulder
My Website  Frozen shoulder

Treatment and management of frozen shoulder

For information on what frozen shoulder is read my blog What is frozen shoulder

Early painful stage - Management / advice
In the earlier stage the limitations are more to do with pain. For instance pain on lying on its at night, or catching pain on reaching movements. This pain can cause a person to "over guard" it or hold the shoulder / arm close to the side and not move it at all. It needs to be remembered here that the shoulder is not injured  
and that although one has to be somewhat more careful than usual with movements at this stage and not deliberately provoke the pain, one will not injure or damage it by using it as normally as possible, as long as the pain is respected and movement not forced.

Treatment in early stage  

These can include pendular (home exercise) and rhythmic harmonic osteopathic techniques, all well within pain free range. These gentle movement approaches can significantly reduce the pain. The aim here however, is not to try and prevent it freezing by forcing moment, but rather support the process.

                                                            Pendular exercise video

  A common mistake at this early stage of frozen shoulder is to try and prevent it freezing by forcing it to move. It is sometimes assumed by both patients and sometimes by practitioners, that if only they can keep it moving, the freezing can be prevented, or worse "if they don,t keep it moving it will freeze up." This will just lead to the early stage be more painful and  lasting longer.

The frozen phase - Management / advice

These two phase or stage in reality blend in to one. People don,t just wake up one day with the pain gone and movement restricted. It is a gradual process where one blends into the other, and therefore treatment and management need to be tailored accordingly.

When to start exercises to restore range and function 

This can start once any night pain is gone, and sharp catching pain on movement is gone. Rehabilitation then can become more active. This can bring the movement range and function back much more quickly than if just left.

Neuromuscular rehabilitation or stretching to improve function

Stretching
 Passive stretching exercises are not very effective in getting the movement back with frozen shoulder, though still widely used. Even if some extra movement is is achieved through stretching, if there is poor neuromuscular control of this extra range, it is usually quickly lost again.

Neuromuscular rehabilitation
It is much more effective to exercise in terms of "goal orientated movements" that are "active" and task based functional movements, than passive stretching.

  For example, rather than thinking about "lifting the arm" as an exercise the person will aim to "reach to grab or touch an object" This gives an "external focus" as rather than "internal focus". The reason for this is muscle recruitment is organized around external focus.

Lengthening hamstrings without stretching

Can the Hamstrings be lengthened without stretching

Traditionally the way most authorities have approached lengthening hamstrings is via passive or active stretching. I have looked at some of the underlying reasons for short hamstrings on my website page tight hamstrings. Discussed at there is the issue that stretching in itself may not be the solution. For instance the hamstrings may be taking over the roles meant to be performed by other muscles. This is also partly addressed on my website page exercises for back pain which looks at core stability and substitution movement patterns. This blog steps outside that model and look at some work done in the world of Feldenkrais and reported in the Journal of the American physical therapy association. This is a study of hamstring lengthening using Feldenkais based awareness through movement exercises.

How does it work
My understanding is that the changes in hamstring length reported are due to changes made via the nervous system. The amount of actual stretch during these classes are quite minimal. What is interesting is that a lot of the movements in these classes are initiated via the pelvis ie proximal attachment of hamstrings at ishial tuberosities. This will involve activation of the core as the prime mover in movement pattern, leading to a secondary lengthening of the hamstrings as part of a functional movement.

An mp3 recording of the original hamstring class can be found at Open ATM recordings under Jim Steven,s hamstring lessons. It is well worth listening to and following the class (can be done at home).

Correcting round shoulders

Round Shoulders
This blog compliments my website page Causes of round shoulders . Here I use videos to help demonstrate.

What are round shoulders
Round shoulders is a description of a "posture" where the shoulders appear further forward often accompanied by a hunching or bending forward of the upper spine. There are usually two reasons a person does not like having "round" shoulders. One is asthetic ie they don,t like the way it looks, and the other medical, they have been told its bad for the neck or shoulders.

How to "correct" round shoulders?
The main problem  here is how we look at the problem. This is one area where common "solutions" only serve to make the situation worse. These frequently involve such things as "pulling the shoulders back"or "sitting up straight". To explain "round shoulders" I have put together some short video as visual demonstration is essential. This subject is related to my article good posture  on my website.

Video 1

This is an overview round shoulders and how the problem comes about. It also looks at frequent mistakes people make in trying to "correct it"

Video 2

  This video starts to look at exercises focusing on separation of shoulder girdle and elbow movement.

Video 3

This continues with exercises now looking at separating hip and trunk movement.