FROM an orthopaedic and sports medicine point of view the most useful thing a skier can do post season is to maintain fitness and treat any injuries.

Most of us who go skiing sustain minor injuries in various tumbles while on holiday and expect the residual discomfort/bruising/swelling to resolve itself. Fortunately, it does so in the vast majority of cases with most skiers treating themselves with a degree of neglect, rest, ice and anti-inflammatories.

This is probably entirely appropriate for the most part. However, there are a few common, persistent or nagging injuries that are best not ignored.

A common injury among skiers and snowboarders alike is a fall on to the shoulder or a fall involving the shoulder. This can produce a common condition of subacromial impingement syndrome (painful arc syndrome). This is a condition manifested by people experiencing pain when their arm is utilized up at around shoulder height or once they take their arm right up into full elevation the pain either disappears or subsides.

The pathology with this condition is of an injury to a tendon in the shoulder called the rotator cuff which becomes either partly torn or simply inflamed. In either case it swells and this swollen enlarged tendon gets caught as it runs through a bony ligamentous tunnel in the shoulder. The condition becomes a bit of a vicious circle in that the more the tendon is swollen the more it rubs and so on and so forth.

Fortunately, the condition is easy to treat either with a programme of physiotherapy and/or a course of up to three injections. If the condition is allowed to persist it usually deteriorates steadily and can lead to a complete tear in the tendon.

The second most common complaint you are wise not to ignore is that of ongoing symptoms of pain, swelling, clicking or giving way following a minor knee injury If you had sustained a major ligament injury to your knee while skiing you would certainly have known all about it and would probably have to be blood wagoned down and possibly flown home.

It is, however, possible to sustain relatively minor cartilage tears in the knee which can grumble on for months with symptoms as I have described above. If you have such knee symptoms after a minor skiing injury then I would recommend referral to a local orthopaedic surgeon with an interest in sports medicine. He or she is likely to investigate with an MRI scan to confirm the diagnosis and can either put your mind at rest by saying that there is no evidence of any cartilage injury and that your symptoms will settle, or that the scan may confirm the diagnosis, in which case arthroscopic surgery will cure you quite quickly

If you leave such meniscal tears without treatment the tears can extend and lead to secondary degenerative change.

In summary, therefore, any symptoms from minor injuries sustained while skiing that persist for more than six weeks should be taken seriously.

From an original article published in THE SKIER & SNOWBOARDER MAGAZINE, MARCH 2001

Use ice to decrease pain

Physiotherapists and orthopaedic surgeons spend significant amounts of time and effort treating shoulder injuries and conditions, of which there are many. The shoulder, an unstable joint with a very large range of movement, the greatest in the body, is vulnerable in many situations to injury or mechanical stresses. Its instability means it can be relatively easily dislocated in a fall or activity at end range. We use the arm to save ourselves if we fall, making fractures common and heavy or overhead work over time leads to rotator cuff tears.Physiotherapists pay close attention to the shoulder as there are many different operations, fractures and degenerative conditions which can affect this area and have an important role in the management of shoulder conditions after elective surgery or trauma, ensuring adherence to the surgical and rehabilitation protocols. On initially seeing the patient a useful strategy is to quickly go over the presenting problem from the beginning as this can indicate errors or misunderstandings which can then be corrected. Physiotherapists should also give the patients an opening so that they can feel they have told their story.After operation or injury the weight of the arm hanging from the shoulder may need to be supported in a sling to reduce pain and allow damaged tissues to rest. The broad arm, triangular bandages are cheap but not comfortable around the neck and difficult to customise to the patient’s specific needs. Putting some foam round the strap at the neck may help slightly but a better solution is to use a Velcro based sling such as the Seton sling. Seton slings are greatly preferred by patients, are more comfortable and are easier to adjust to the specific requirements of the shoulder condition.When fitting the Seton sling the elbow should fit right back into the gutter with the sleeve folded back slightly if necessary to allow the hand to be clear of the sling. There may be a small Velcro strap to place across the upper forearm to keep the gutter closed but this should not be tight or it can cut in to the tissues, especially if there is a lot of thick swelling such as after humeral fracture. The long strap is then taken from the elbow side of the sling over the opposite shoulder and down to the wrist. Tightening this up is where it gets trickier.Due to the materials from which the slings are made there is a degree both of elasticity and friction against surfaces when they are adjusted. As the sling is adjusted and tightened up the elbow is often not well supported by the sling at all and patients are usually aware that the support is not that good. The physiotherapist can easily feel that the sling is not giving the correct support and if they just tighten up the strap it solely tightens up at the front but does not improve the support of the arm. This needs another strategy.Two people are needed to adjust the sling in co-operation, a helper and the patient. The patient is asked to relax the arm as much as they can while the helper lifts the weight of the arm at the elbow, holding it there as they pull the strap from its attachment at the back of the gutter up and over the shoulder, then fixing it there with one hand. Continuing to hold onto the strap which has been pulled forwards the helper unstraps the Velcro fastening of the main strap and tightens it up. Checking the support of the elbow now will show it to be much better supported.Sling management advice is useful for washing and dressing, for which the sling can come off. Putting clothes on should be using the affected arm first and the arm needs to be kept in by the body during the process with no active lifting of the shoulder. For washing if the patient keeps the arm bent by the tummy and bends forward they can get access to wash their armpit easily.

Use ice to decrease pain

What are the Pain Conditions that can be Treated by a Singapore Physiotherapist?Physiotherapy, also known as physical therapy, offers another pain treatment option besides medication and surgery. Below is a list of common musculoskeletal and orthopedic Pain Conditions that can be treated by Physiotherapist (aka physical therapist) in one of the foremost Singapore Physiotherapy Clinic at ‘THE PAIN RELIEF PRACTICE’• Arthritis • Ankylosing Spondylitis• Back pain • Carpal Tunnel Syndrome• Cervical Spondylosis • Degenerated Discs• Elbow Pain • Fractures• Frozen Shoulder • Fibromyalgia• Golfer’s Elbow • Hip Pain• Knee Pain • Lumbar Spondylosis• Migraine/ Headache • Neck Pain• Post operative conditions  • Plantar Fasciitis• Repetitive Strain Injury • Rheumatoid Arthritis• Rotator Cuff Tendonitis • Sciatica• Scoliosis • Slipped/ Herniated Disc• Shoulder aches & stiffness • Sprains & Strains• Sports Injuries • Tendonitis• Tennis Elbow • Trigger FingerEffective pain management of a condition comprises a joint effort of the physiotherapist and the patient. Other medical and healthcare practitioners (eg doctors, surgeons, chiropractor, acupuncturist, traditional chinese medicine) can also play integral roles in the pain management program. The relief from pain brought about by physiotherapy might not be as immediate as with the intake of any medication intake but the effect is sustained. It does only deal with the symptom but it addresses the cause of the pain.Now, the inclusion of advanced physiotherapy treatments in a pain management program provides for a faster, safer and more effective way to cope with pain at ‘The Pain Relief Practice.’PAIN! You must not ignore…If you are unsure whether physiotherapy is a suitable treatment option for your pain condition, you can call ‘The Pain Relief Practice’ which offers a FREE phone based consultation to see if your pain conditions can be helped by physiotherapists.

Use ice to decrease pain

Low back pain is very common and most people have some experience of a back pain episode at some time of life. Attendances at physiotherapy clinics for low back pain are very high so physios have a variety of assessment and treatment techniques to manage spinal pain and improve patients’ function.

A serious medical condition such as cancer or infection is a very uncommon cause of back pain, but several medical problems can present this way and physiotherapists need to be aware of this so they can refer the patient on to the appropriate doctor. The physio will ask about past medical history (cancer, arthritis, diabetes, epilepsy), any loss of weight or appetite, bladder and bowel control, feeling unwell, sleep disturbance and worse pain when lying down to sleep.

The physio is looking for the patient to react as if they have mechanical spinal pain, a condition where normal physical stresses such as sitting or walking have a worsening or easing affect on the pain. The examination starts by observing the posture and movement of the patient during the questioning and the physio follows this by examining the spinal posture and ranges of movement. Abnormalities of posture are common and not always important, with leg length differences, a reduction or increase in the back curves and a scoliosis being common findings.

Next the physiotherapy examination moves on to active movements. Lumbar flexion is bending over forwards as if the hands are to touch the toes, and the range of movement and any pain is noted. This is repeated for extension and perhaps side flexions and side gliding, all adding to the picture forming in the physio’s mind. The physio may test the hip joints, the sacro-iliac joints, the sensibility, the reflexes and muscle power. Palpation of the spinal joints can tell a skilled physiotherapist about the stiffness and reaction of individual spinal segments, thus localising a problem to a specific level.

With all the information from the subjective and objective examinations the physiotherapist will use their diagnosis to form the goals and plan of treatment. A pain problem will need to be approached with respect, using gentle mobilisations, TENS, stabilising exercises and painkillers. A stiff spinal segment can be mobilised more vigorously with direct manipulations and stronger exercises.

One of the most common therapies for athletes, gym attenders and those undergoing rehabilitation after injury or illness is to perform core stability work. Many Pilates classes are available using this approach to holding a mid-range spinal posture while performing activities. Initial technique is taught on a plinth until the patient has good control then progressed to keeping their stability control whilst performing harder and harder activities, finishing off with relevant functional work.

Spinal joints do not appreciate being at end of their range for too long such as remaining slumped in sitting for a long period. This stretches the ligaments and can cause and maintain a pain problem. Physios teach patients to understand the new strange posture they are being asked to perform is the norm and that they need to perform it regularly until they do it naturally.

Many back pain physios use the McKenzie technique which uses repetitive movement to change the forces which the disc nucleus exerts on the walls of the disc, the annulus fibrosus. An increase in pressure against the posterior disc wall can worsen symptoms while a decrease can improve pain. Repeated movements in one plane establish a “directional preference”, a direction of movement which improves the presenting symptom. McKenzie therapists treat patients depending on whether they have postural syndrome, dysfunction syndrome or derangement syndrome. McKenzie therapy is a popular technique, based on the idea that the disc nucleus exerts a force on the walls of the disc and can cause pain problems.

The treatment from the physio is backed up by advice to the patient to reduce the aggravating stresses on their back by pacing their activity to avoid overdoing. This gives the problem an opportunity to settle and allows the person to get themselves fitter with weight training and aerobic exercise such as swimming or cycling. Many therapies have no supporting evidence, but increasing our fitness has been shown to reduce both the severity and impact of low back pain.

Use ice to decrease pain

The gleno-humeral joint, known in lay terms as the shoulder, is a vital part of the links in the upper limb and responsible for our ability to place our hands where we can see them to perform activities. Because flexibility is a prime requirement the shoulder is a less stable joint with moderate muscle power and a large range of motion. It is described as a “soft tissue joint”, implying that the joint’s functional ability is dependent on its soft and not its hard components. Physiotherapists are closely involved in treating and rehabilitating the shoulder, dealing with the muscles, ligaments and tendons. The shoulder joint is constructed from the socket of the scapula and the humeral head, the ball at the top of the upper arm bone. The head of the upper arm is a large ball and important tendons insert onto it to move and stabilise the shoulder, but the shoulder socket, the glenoid, is small in comparison and very shallow. A cartilage rim, the labrum of the glenoid, deepens the socket and adds to stability. The acromio-clavicular joint lies above the shoulder joint proper and provides dynamic stability during arm movements, being made up from part of the scapula and the outer end of the clavicle. The glenohumeral and scapulothoracic joints of the upper limb are acted on by large, strong, prime mover muscles as well as smaller stabilisers. The major back and hip muscles keep the shoulder stable to allow strong movements, the thoracic stabilisers keep the scapula stable so that the rotator cuff can act on a stable humeral head. The deltoid can then perform shoulder movements on the background of a solid base and allow precise placement and control of the arm for hand function to be optimal. Around the shoulder all the muscles narrow down into flat, fibrous tendons, some larger and stronger, some thinner and weaker. All these tendons are anchoring themselves to the humeral head, allowing their muscles to act on the shoulder. The rotator cuff includes a group of relatively small shoulder muscles, the subscapularis, the supraspinatus, the infraspinatus and the teres minor. The tendons form a wide sheet over the ball, allowing muscle forces to act on it. The rotator cuff, despite its name, acts to hold the humeral head down on the socket and allow the more powerful muscles to perform shoulder movements.  With age, small degenerative tears occur in the tendons of the cuff, in some cases painful and in others not, causing loss of movement and strength. As tears progress they can become massive, cutting off the cuff muscle power from the humeral head and severely reducing function. Rotator cuff strengthening work is performed by physiotherapists and if the tears are severe they concentrate on anterior deltoid strength to improve functional ability in the absence of cuff power. Shoulder surgeons can repair many rotator cuff tears and physiotherapists rehabilitate patients following the shoulder protocols. Osteoarthritis (OA) more commonly affects the hips and the knees, however the shoulder can be severely affected in which cases physiotherapy can help with advice, mobilisation of the joints and work on strength and joint motion. Once physiotherapy treatment has been tried then total shoulder replacement is the only remaining treatment option, surgical replacement occurring of the head of the arm bone and the socket of the shoulder blade. As the shoulder is referred to as a “soft-tissue joint” it is the balance and strength of the tendons, muscles and ligaments that determines a good outcome for the replacement. Physiotherapists closely follow the surgical protocols to get the optimal results. Physiotherapists treat many other types of shoulder problems such as impingement, tendinitis, hypermobility, abnormal muscle patterning, fractures and dislocations. Impingement is treated by strengthening the rotator cuff or by subacromial injection or acromioplasty operation, where the end of the acromion can be excised. Tendinitis is treated by direct treatment of the tendon and graded strengthening and hypermobility by stability work and accepting the limitations dictated by the condition. Abnormal muscle patterning is managed by teaching normal patterns functionally and fractures and dislocations by the protocols laid down by the surgeons and trauma physiotherapists.

Use ice to decrease pain

The function of the human arm is to allow placement of the hand in useful positions so the hands can perform activities where the eyes can see them. Because of the huge range of positions required the shoulder is very flexible with a large motion range, but this is at the expense of some reduced strength and greatly reduced stability. A “soft tissue joint” is often a description of the shoulder, indicating it is the tendons, muscles and ligaments which are important to the joint’s function. Shoulder treatment and rehabilitation is a core physiotherapy skill. The shoulder joint is constructed from the socket of the scapula and the humeral head, the ball at the top of the upper arm bone. The head of the upper arm is a large ball and important tendons insert onto it to move and stabilise the shoulder, but the shoulder socket, the glenoid, is small in comparison and very shallow. A cartilage rim, the labrum of the glenoid, deepens the socket and adds to stability. The acromio-clavicular joint lies above the shoulder joint proper and provides dynamic stability during arm movements, being made up from part of the scapula and the outer end of the clavicle. The major stability and flexibility joints of the upper limb shoulder girdle are the scapulothoracic and glenohumeral joints and these joints are held steady and moved by large and powerful muscles. The pectoralis major and latissimus dorsi muscles stabilise and perform strong movements, the serratus anterior stabilises the scapula on the thorax, the rotator cuff stabilises the humeral head on the socket and the deltoid and other muscles perform movements. The shoulder blade and thorax need to be kept in a stable relationship for the glenohumeral joint to perform precise and controlled movements. Around the shoulder all the muscles narrow down into flat, fibrous tendons, some larger and stronger, some thinner and weaker. All these tendons are anchoring themselves to the humeral head, allowing their muscles to act on the shoulder. The rotator cuff includes a group of relatively small shoulder muscles, the subscapularis, the supraspinatus, the infraspinatus and the teres minor. The tendons form a wide sheet over the ball, allowing muscle forces to act on it. The rotator cuff, despite its name, acts to hold the humeral head down on the socket and allow the more powerful muscles to perform shoulder movements.  With age, small degenerative tears occur in the tendons of the cuff, in some cases painful and in others not, causing loss of movement and strength. As tears progress they can become massive, cutting off the cuff muscle power from the humeral head and severely reducing function. Rotator cuff strengthening work is performed by physiotherapists and if the tears are severe they concentrate on anterior deltoid strength to improve functional ability in the absence of cuff power. Shoulder surgeons can repair many rotator cuff tears and physiotherapists rehabilitate patients following the shoulder protocols. Osteoarthritis (OA) more commonly affects the hips and the knees, however the shoulder can be severely affected in which cases physiotherapy can help with advice, mobilisation of the joints and work on strength and joint motion. Once physiotherapy treatment has been tried then total shoulder replacement is the only remaining treatment option, surgical replacement occurring of the head of the arm bone and the socket of the shoulder blade. As the shoulder is referred to as a “soft-tissue joint” it is the balance and strength of the tendons, muscles and ligaments that determines a good outcome for the replacement. Physiotherapists closely follow the surgical protocols to get the optimal results. Physiotherapists treat many other types of shoulder problems such as impingement, tendinitis, hypermobility, abnormal muscle patterning, fractures and dislocations. Impingement is treated by strengthening the rotator cuff or by subacromial injection or acromioplasty operation, where the end of the acromion can be excised. Tendinitis is treated by direct treatment of the tendon and graded strengthening and hypermobility by stability work and accepting the limitations dictated by the condition. Abnormal muscle patterning is managed by teaching normal patterns functionally and fractures and dislocations by the protocols laid down by the surgeons and trauma physiotherapists.

Use ice to decrease pain

The rotator cuff is a musculotendinous cuff which surrounds the humeral head and through which the shoulder stabilising and movement muscles exert their forces onto the shoulder. The cuff enables us to put our shoulder through a very large range of motion, the greatest range of any joint in the body, for the purpose of putting our hands in functional positions. The shoulder’s function is to allow our hands to be put in useful positions within our visual field so we can perform the intricate activities that define being human to a degree.As the muscles approach their insertions on the humeral head they become more and more fibrous until they become wholly tendinous. Many bodily tendons are cylindrical and long but the shoulder tendons are flatter structures which coalesce over the top of the humeral head. The rotator cuff has a relatively poor blood supply and little or no ability to heal and with time and physical stresses tears appear which are often painful but not always so. Rotator cuff tears are a major part of a shoulder surgeon’s work and rotator cuff surgery is common, complex and demands detailed physiotherapy follow up for successful outcomes.Many causes of rotator cuff tears have been postulated by there is no agreed single cause, with competing ideas which favour external factors to the tendon and its rival which favours internal degeneration of the tendon itself. The leading shoulder surgeon Neer named impingement syndrome as a condition where the shoulder tendons are repeatedly stressed against the anatomical structures which overlie them. These structures include the acromio-clavicular joint and the front of the acromion, the outside end of the shoulder blade. The supraspinatus tendon can be compressed regularly as the shoulder goes into repetitive flexion and medial rotation,The natural anatomical shape of our acromion plays a role in the likelihood of us having impingement type problems and therefore the tendency to get cuff tears. X-ray studies have shown that a hooked acromion is strongly related to the development of cuff tears although a proven causal link is not yet clear. The acromioclavicular joint develops degenerative outgrowths on its underside and the underlying cuff tendons are pressed against this area on repetitive movement. Repeated overhead work in younger people can cause bleeding and oedema in the tendon, with inflammation and scarring of the tendon after many such small injuries. With time in patients older than forty years complete or partial tears and bony spurs can develop.A third impingement type can occur in throwing as the arm is cocked back for the throw and the edge of the glenoid socket can be forced repeatedly against the lower surface of the supraspinatus tendon. Minor trauma is produced each time this occurs, gradually developing into small tears particularly in athletes who throw a lot. The biceps and supraspinatus tendons and the lesser tuberosity impinge against the coracoid process. Most rotator cuff tears are probably contributed to by these three impingement process.The intrinsic view holds that the external factors may be contributory but that the fundamental underlying process is age-related degeneration inside the tendons themselves. This helps explain why young people rarely suffer cuff tears and that tears increase strongly with age, for example after fifty years old. Under the supraspinatus tendon near to its insertion onto the greater tuberosity is an area which has been called the critical zone and postulated to have a poor vascular supply. This could increase the risk of injury and poor healing in this area but further studies have not confirmed this idea so degenerative changes in the tendons may still be important.It is likely that the cause of rotator cuff degeneration is a combination of both extrinsic and intrinsic causes, with the tendon tending to fail first in the areas of greatest load, leading to rupture of small tendon fibres. This causes increased forces being loaded onto close fibres, detachment of some fibres from bone, reduction in cuff power and compromised blood supply due to kinked fibres. Wound healing could be reduced and this would impair the possibility of repair.

Use ice to decrease pain

Are you suffering from immense pain in the shoulder and fed up of taking different medications to treat the same? It is a terrible situation and we just understand the importance of it only when we have some kind of problem like this. If you have got serious trouble you need to approach the best doctor to find the perfect shoulder pain treatment. The important part if the medication which has to be strictly followed and at the same if you are advised to take rest, this fact must not be neglected at all.There are certain proven and most preferred solutions for shoulder pain treatment advised by the experts. You can also get enough help from the internet to help you with the best kind of exercise of home physiotherapy to find a solution to your problem along with the advice of your doctor. Let use talk about some of the immediate and spontaneous steps to be done for shoulder pain treatment. · Enough rest is advised in the beginning for both mild and terrible injuries and make sure not to use that particular area for any kind of activities for the next 48 hours.· Try putting an ice pack on the site of pain for at least 20 minutes and repeat the same four to eight times every day until you get a little relief from pain. Make sure not to place ice directly on the affected site, instead make use of ice bag, cold pack or even plastic bag with ice crushed will do the trick.· Compress or make the area tight with an elastic bandage as it helps in reducing swelling.· Raise the affected area just above the heart level and for this you can make use of a pillow which could serve you in the best way. Following these simple steps along with medications and physiotherapy advised by the doctors can provide you the best shoulder pain treatment.

Use ice to decrease pain