Avin Patel

Delays to Joint Replacements

Waiting lists for joint replacements are at an all time high, and the 18 week target for hip and knee replacements has been scrapped. If you are already waiting for a replacement to an arthritic joint, we may be able to help with function and comfort in the meantime. Osteopaths are qualified to help with arthritis, and the earlier you start treatment, the more we can do.

Joint replacements

Early Stages of Osteoarthritis

Osteoarthritis is a condition of the cartilage within a joint. Cartilage has a poor blood supply, so relies on movement to keep nutrients flowing into the joint where it can absorb them. It exchanges nutrients for waste, and movement again helps to flush this away. If movement is limited, the nutrient input is reduced, and waste products are stuck close to the cartilage for longer than ideal. These changes to the local environment play a role in reducing the health of the cartilage, from which point a vicious cycle can develop.

Even without you consciously realising, if the cartilage in a joint becomes roughened, the body might respond by adapting movement. This can be particularly evident in the hip. As movement is now sub-optimal, the fluids in the joint are not flushed through as much as they should be. There may also be areas of cartilage that are no longer compressed and decompressed, so the tissue relies purely on diffusion to exchange those products.

Avoiding Joint Replacements: Managing Arthritis

If spotted early, your osteopath can start to improve movement again. Muscles will be tight to try and protect the joint, which only reduces movement further. By working on those muscles and encouraging joint movement directly, we aim to restore some lost movement and improve cartilage health. Osteoarthritis responds really well to exercise too, so you can expect to have an exercise plan throughout your time with us.

Relief While Waiting for Joint Replacements

In some cases, a joint replacement is the only real solution. But with long waiting times, it can be difficult to make it to the surgery date. Even when cartilage is significantly reduced within the joint, what is left can still respond to treatment. We can also help to relax muscles that are trying to protect the area and potentially causing more pain than they solve. Finally, if other areas are overworking to compensate for the joint pain, there may be things we can do to reduce the burden on them.

If your joint pain leads you to walking with a stick or a frame, we may be able to offer advice for using them in a more efficient way.

Prehabilitation

Just like you would expect physical therapy after your surgery to improve your joint function, we can help to get your body ready for surgery. If your joint pain affects the way the rest of your body moves, we can work to improve the function of those areas that are adapting. This means that when you do get walking on your new joint, there’s one less thing to iron out.

Make an appointment in Leicestershire or Rutland for your joint pain here.

Perthes’ Disease

Perthes’ Disease is a rare childhood disease affecting the shape of the hip joint. It eventually burns itself out, but can be a cause of arthritis later in life. It also goes by the name “Legg-Calve-Perthes Disease”.

Perthes' Disease

What Is Perthes’ Disease?

This is a condition in which the blood supply to part of the thigh bone is disrupted. Specifically, it is the head of the femur (the ball of the ball and socket) that is affected. Bone is living tissue, and in children affected by Perthes’, it is still growing. Reduction of the blood supply causes part of the bone to die (necrosis), and become misshapen. Long term effects depend on the details of the repair stage described below.

Frustratingly, we don’t know exactly what causes the disease to develop. Some cases are associated with rapid growth spurts that somehow disrupts the blood supply. Other cases are associated with trauma or infection, or even congenital hip dislocation. In about 1/10 cases the other hip develops the same condition after the first.

Symptoms of Perthes’ Disease

Perthes’ begins between the ages of 4 and 10, and many more boys are affected than girls. Early signs often include a limp, which is likely to be worse after exercise. This may be completely painless or persistently painful. Where there is pain, it may spread to the groin or as far as the knee (illustrated above).

The Repair Stage

Once blood flow returns, the body begins to heal the damaged tissue. Some cases heal perfectly, and even an X-ray would not clearly show that there was ever a problem. Other cases can lead to a deformed femoral head, which may have a flat portion or a rough texture compared to a healthy one. This is likely to impact range of movement and may cause a limp. Sometimes a brace will be recommended by the orthopaedics team, in order to hold the femoral head in the roundest part of the socket. This aims to encourage the bone to grow into the correct shape.

Your Osteopath’s Role

We cannot resolve the blood supply, but we may be able to help with the compensatory patterns that develop in response to the pain. A child with suspected Perthes’ Disease requires referral to their GP and on to the orthopaedics team. We can support with symptom management and ensuring the hip maintains as much normal movement as possible.

Longer term complications of the condition can include a limp or early onset arthritis. We may be able to help manage the arthritis, especially if addressed at the earliest symptoms. A limp caused by asymmetry of the thigh bones is not an inherent problem- a well managed limp can be pain free. This depends on the body’s ability to adapt to the demands of the limp. As long as the legs and back can compensate for these changes indefinitely, it should be comfortable. This might require intermittent treatment over years, or it may be perfectly manageable with prescribed exercises.

Make an appointment in Leicestershire or Rutland here

Osgood Schlatter Disease

A common knee complaint among adolescents is Osgood Schlatter Disease (OSD). It is more prevalent among active people, and although the pain always resolves, there is usually a palpable bony lump on the knee for life. This lump is often an incidental finding in adult patients who present with another issue- they may not know they ever had the condition.

Osgood Schlatter Disease

What Happens in Osgood Schlatter Disease?

The muscles of the quadriceps (front of the thigh) converge into the quadricep tendon at the front of the knee. The knee cap sits within this tendon, and the tendon joins onto the front of the shin bone, right at the top. Exactly where the tendon meets the bone is a growth plate. This is like a cross between cartilage and bone, which eventually hardens when the area has finished growing (in the late teens). Girls tend to develop OSD at a slightly younger age than boys, as their growth plates mature a year or two earlier. Typically we expect their resolution to be earlier than boys’ too. Onset anywhere between about 9 and 14 years of age is within the expected range.

If the quadriceps are under a lot of strain, they can pull on this soft area. This causes pain, inflammation, swelling, and sometimes bone avulsion. Avulsion is where a small part of the bone is pulled away in a micro-fracture. The precise area is likely to be tender. A few bursae are often irritated by the process of OSD, in which case the pain may be more widespread.

Quadriceps strain could be due to increased activity, especially sports that involve lots of running, jumping, or kicking. Growth spurts may also be significant if the thigh bone grows rapidly, causing relative tension on the muscles.

Other areas in the body can undergo a similar process. The process that happens in OSD is traction apophysitis. This literally means inflammation and pulling on the growth plate. When it occurs in the heel, it is known as Sever’s disease.

Managing OSD

OSD is aggravated by activity that demands strong and sudden contraction of the quadriceps. Running and jumping sports are particularly significant. Proper stretching and exercises pre and post sport are important. Cool compresses may also help. Massage techniques for the quadriceps are recognised as part of a conservative treatment plan. Completely stopping sport is often not realistic, and it certainly is not a guaranteed cure. However an exercise plan with enough rest days to reduce irritation may be sensible. Your osteopath can help devise this.

Ultimately, symptoms will largely pass as the growth plate matures. However, it is noted that people who had OSD may be more likely to present with other issues later in life. This may or may not be statistically significant, but any strategies that minimise the bony change to the area could be useful. If you are an adult with a history of knee problems including OSD, your osteopath will assess the body as a whole to work out how these conditions are liked together. You may find it beneficial to seek osteopathic treatment to manage your symptoms and then to help keep them at bay.

Make an appointment in Leicestershire or Rutland here.

Knee Problems

The knee is more than just the big hinge joint: it is made of three joints and a lot of connective tissue. Problems with one part often lead to symptoms in another, so your osteopath will look at the area as a whole at your appointment.

The Knee Cap (Patella)

The knee cap sits within the quadriceps tendon and slides up and down the front of the main knee joint. Its presence makes knee movements much more efficient, so when it becomes symptomatic it can be quite debilitating.

Because of how it sits in the tendon, it is subject to forces from the quadriceps. Something as simple as tight muscles on the front of the thigh can put pressure on the joint between the patella and the rest of the knee. This might cause a feeling of tension or friction. If there is an underlying problem, or this persists, it can lead to cartilage injury or osteoarthritis.

Sometimes the quaricep muscles are unbalanced. Often this means the one on the inside of the thigh (vastus medialis) is relatively weak. When the muscle group contracts, force is not equally placed on the knee cap, and it is encouraged off-centre. This can cause similar problems to those listed above, along with a feeling of instability or clicking.

Your osteopath can help with tight or weak muscles, and work with a suffering joint to give it a better chance at healing itself.

Knee anatomy

The ITB (Iliotibial Band)

The ITB is a broad piece of tissue that runs down the outside of the thigh and attaches to the side of the knee. It is not very stretchy or contractile, and is controlled by a muscle on the outside of the hip (TFL). The role of the ITB is to stabilise the knee. When it feels tight, it’s usually the TFL pulling on it to try and support the knee.

Runners are often quite aware of the ITB, and may have been advised to foam roll it. This is controversial, as studies show mixed results about whether the band even responds to direct pressure. It makes more sense that the TFL muscle would respond more to rolling, but we need to think about why it’s overworking in the first place. There may be a problem developing in the joint that the body is trying to limit and protect. We will assess the whole knee complex at your appointment to get to the bottom of your symptoms. The sooner we can address this the better, as tightness in the ITB is associated with bursitis and snapping hip syndrome.

Ligaments and Cartilage

Inside the main hinge joint, there is a lot of cartilage to help support and stabilise the joint. The ACL and PCL ligaments are also present for stability. A hinge joint under as much pressure as the knee is vulnerable to injuries caused by slipping. This is exactly what the PCL and ACL are there to prevent.

Beyond the usual cartilage at the ends of the bones that make up the main joint, there are also two C-shaped pieces. These are called the menisci, and they provide cushioning as well as improving the connection between the bones. The menisci can be injured by twisting through the knee while weightbearing, making it a common sports injury. Cartilage is slow to heal, but we can help to support the joint and maximise nutrient flow to the area. Injuries like this can also affect the way you move generally, so we will look to the rest of the body and ensure nothing is overworking to compensate.

Start addressing your knee problems today: click here for an appointment in Leicestershire.

Snapping Hip Syndrome

Painless “snapping” in the hip, whether heard too or just felt, can be worrying. Most of the time it’s just a muscle flicking over, but it’s still worth checking it out.

Snapping hip: lateral and anterior types

Muscular Causes of Snapping Hip

The formal name for snapping hip is Coxa Saltans, which only applies when the cause is a muscle. There are three categories of this:

  1. lateral or external (most common)
  2. anterior or internal (relatively common)
  3. posterior (rare)

The category refers to the muscles involved. The common two involve a muscle of the glutes, or a deep abdominal muscle. The rare type involves a muscle from the hamstrings.

If this is caused by a tight muscle, your osteopath will work out whether this is an isolated symptom. Sometimes muscles become tight because of posture- your hip flexors will shorten if your hip is always flexed. Other times, there may be tightness in response to instability or hypermobility. If this is the case, we want to release the muscle but also strengthen it so that it can do the job more comfortably.

Snapping Hip as a Sign of Something Else

Although the syndrome is painless, it may still be an indicator of something else. In the lateral type, the ITB can be the tissue that flicks over. The ITB is something between a muscle and a joint, and it runs from the outside of the hip to the knee. Runners often find that it is tight and may be sore, but it might be tight for a reason. The role of the ITB is to stabilise the knee, so treating the tightness without looking at the knee is not the best idea.

Sometimes, especially in the second type, the snapping may be caused by muscle flicking over a bursa. Bursae are little fatty cushions that prevent friction between muscle and bone. They are found all over the body. If irritated, they can become very sore and develop bursitis. If a click hip is a warning sign of this, it would be ideal to prevent its development.

Your osteopath will look at everything going on, and determine the root cause of your snapping hip.

Snapping Within the Joint

When the cause of a hip clicking is not muscular, it might be due to something within the joint. This is more likely to be the case if the clicking is painful, or if there is ever locking of the joint.

Labral Tear

There is a lip of cartilage around the ball and socket joint of the hip. This can become injured, and tear. When the labrum is damaged, the joint may become painful and less stable. You can read more about labral tears here.

Loose Body of Cartilage

There is also cartilage on the joint surfaces of the ball and socket. Through injury or arthritis, a piece of the cartilage can break off and float loose within the joint. Symptoms of this can be quite unpredictable, as they are only caused when the loose piece is in a specific condition. When aggravated, there may be stiffness or locking alongside the snapping, and pain within the hip. Hip pain often refers to the groin, so let your osteopath know if you also have pain here.

You can book an appointment for your snapping hip here.

Shin Splints

Avin has a special interest in sports injuries, of which shin splints are a common example.

Signs and symptoms of shin splints

Symptoms of Shin Splints

Also known as Medial Tibial Stress Syndrome, symptoms affect the inner side of the shin. Pain may come on at the start and end of exercise, disappearing in between. As it gets worse, pain may persist through the day. There will be an area on the shin that is tender to press into, and there may also be some slight swelling over the same area.

Running is commonly associated with the development of shin splints, but other sports can cause them too. The exact science of what happens anatomically is unclear, but there is a link with repetitive high force from the muscle onto the bone. Powerful movements such as jumping are also associated.

It is important to note that this is not the same as a stress fracture. However, a stress fracture may follow if the condition and its cause are not managed. Although the two have similar symptoms, initially a stress fracture will feel better after rest, whereas shin splints will feel worse.

The muscles around the shin bone (tibia) are involved in shin splints. Their role is to move the ankle, which explains why running and jumping are the common causes. Typically, there is an inflammatory reaction where these muscles meet the bone. This may involve inflammation of the outer layer of bone itself, or it might be the connection between the muscle and bone.

Prevention of Shin Splints and First Aid

We know that shin splints tend to come on when either:

  • an action is performed incorrectly
  • too much is done in too short a period

So when thinking about prevention, we need to be thinking about form and graded exposure.

There is also a connection with running on hard surfaces, or with poor shock absorption from inadequate footwear. Proper running shoes that are replaced after about 300 miles may help. If possible, running on softer ground might also help to prevent the development of shin splints.

As the condition is involves inflammation, a cool compress is ideal for first aid. You never aim to numb the area, just to cool it down. This takes the edge off the swelling and pain without hindering the healing process. The NHS has advice for painkiller use here.

Your Osteopath’s Role

The appropriate management will depend on how soon you come to clinic after your injury. A brief period of rest is recommended in the first few weeks. After this period, we can support you in graded return to your chosen exercise. This might mean running for shorter distances, or running fewer days per week. We may also ask you to choose a flatter, more even surface in this phase.

As always, we will also look elsewhere for other relevant factors. For example, if your ankle movement was restricted, the muscles may have to work harder to perform the action you’re trying to do.

Your osteopath may be able to help you with your training programme, or put you in touch with someone who can. If the problem has been that you have overloaded the area, we can help with strengthening and rehabilitation.

You can book an appointment here to start managing shin pain.

Labrum Tears

“Labrum” is latin for “lip” and refers to the ring of cartilage that supports some ball and socket joints. Both the hip and shoulder joints have labra.

Labrum Injuries

Ball and socket joints are particularly mobile, and the labrum helps to keep movement within a healthy range. But it is possible for the labrum itself to be injured, often by a forceful injury.

Cartilage is slow to heal, so symptoms can persist for a while if not addressed. Your osteopath will aim to improve local joint health to aid healing. They can also advise you on how to best look after the joint as it heals.

Shoulder Labrum Injuries

The shoulder is a very mobile joint. This is due to the small and shallow socket. Unfortunately, this means that it is not the most stable joint. We rely on the soft tissues (ligaments, muscles, and cartilage) around the joint to protect the it.

SLAP Lesions

SLAP stands for Superior Labrum Anterior + Posterior. This kind of injury is particularly prevalent among throwing athletes, but can also be caused by a fall or other trauma. It occurs near the point where the biceps tendon attaches to the labrum- an area under a lot of stress during throwing movements.

This problem may present with pain, stiffness, and clicking or locking of the shoulder on certain movements. It may be particularly difficult to use the arm in overhead movements, or performing movements like putting on a coat sleeve.

Hip Labrum Problems

Hip labrum injuries may be caused by road traffic accidents, falls, or shearing forces as with twisting. Although the hip socket is deeper and therefore more stable than the shoulder, the cartilage can still be injured. Symptoms are often quite generic to a number of hip problems, and may include:

  • Pain in the groin or front of thigh
  • Clicking of locking of the joint
  • Pain on activity

FAI: Femoral Acetabular Impingement

FAI is slightly different. Rather than being a form of labral tear, its presence can predispose the development of a tear. In this condition, part of the ball and socket is misshapen. This can affect the “ball” after childhood issues: Perthes Disease, repetitive movements, or some fractures can predispose this. The socket can cause the same problem if it extends further than it should.

The problem with FAI is the ball makes excessive contact with the socket, causing pain and stiffness. These symptoms are particularly evident after periods of prolonged or repeated hip flexion, such as sitting or performing squatting exercises. This unusual force can play a role in the development of FAI later in life. FAI is also associated with the development of osteoarthritis in the hip, so it’s well worth doing something about it.

Management

Cartilage is slow to heal, but benefits from full, gentle movement. This can be difficult to achieve on your own, as the necessary movement may be painful. Your osteopath can do this movement for you, and give you exercises to achieve the movement yourself. When a joint is painful, the muscles around it often tighten it up to protect it. Unfortunately, this prevents the required movement from happening organically. We can help relax these muscles too, to give your body the best conditions in which to heal itself.

If your hip or shoulder injury sounds like this, get in touch with us today.

Bunions

Bunions are a common foot condition that can cause episodes of pain. When these episodes occur, there are things you can do to manage the symptoms.

Bunion

What is a Bunion?

A bunion is a soft tissue swelling on the outside of the foot at the base of the little toe. This joint is the 1st metatarsophalangeal joint (1st MPJ). More specifically, the exact area affected is the metatarsal head. This part of the foot does stick out slightly in everyone, but is more prominent with a bunion.

Over time, the swelling will progress to misalignment of the joint, with the toe pointing into the rest of the foot. The swelling looks larger, as the joint begins to push outwards. Symptoms can include redness over the area, a callus, and tenderness. Symptoms may come and go over months or years.

Inappropriate footwear is a significant factor in the development of bunions. Pressure on the joint from tight fitting or high heeled shoes can cause enough irritation to start the process. It is also possible for local trauma to cause the initial irritation. Another name for the condition is “tailor’s bunion” in reference to the pressure of sitting cross-legged as a tailor might.

Some people are more predisposed to developing the condition due to their anatomy. If the 5th MPJ naturally sticks out (and the toe points in), they may be more likely to irritate the area. There is also a strong genetic link.

Rheumatoid Arthritis and Bunions

The small joints of the feet are among those most commonly affected by Rheumatoid Arthritis. For people with RA, bunions can be harder to manage. Joints affected by rheumatoid conditions like these need frequent, gentle movement. Prolonged rest or excessive exercise will aggravate symptoms.

Management

Typical advice for an aggravated bunion is to rest and ice it. Some people also find that a bunion cushion or pad can help take some pressure off. Rest and ice are measures used temporarily to manage acute symptoms. They aim to reduce redness and swelling, but it is important not to over-ice. Rest is also only beneficial in the short term- healthy movement will do more for the joint than keeping it still over a longer period.

Sometimes a bunion is caused by supination (or under-pronation) of the foot. That means that your foot has rolled out, and often comes with higher arches. Walking like this puts direct pressure on the area a bunion may form. Your osteopath can look at the way you walk to determine what has caused this supination, and address it with treatment if appropriate.

Your osteopath can give you advice beyond the standard recommendations:

  • Avoid excessively tight footwear
  • Avoid high heeled shoes that apply extra pressure to the ball of the foot

Exercises may be useful to keep the small joints of the foot mobile.

Book an appointment here to start managing your bunion.

Tennis Leg

Racket sports encourage movements that can lead to Tennis Leg. This is a colloquial term for an upper calf injury. The muscles at the top of the calf are involved in ankle plantarflexion (pointing the toes). Sports like tennis, squash, and badminton sometimes require powerful use of this muscle, for example when lunging forward quickly with a straight knee.

Tennis leg: muscles and actions involved

What is Tennis Leg?

Most often, this is a tear of one of the muscles of the calf: the gastrocnemius. Less often it is a plantaris tendon rupture. It comes on suddenly, and can be directly caused by the movement mentioned above. Sometimes it will feel like the calf was kicked, or something popped. After onset, pain is brought on by stretching or engaging the calf. Therefore, you may find yourself walking on tip-toes on the affected side.

This injury can present with a tracking bruise. Alongside potential local bruising, there may be a significant bruise in the foot or ankle- immediately below the injury. This is the same process that happens with some ankle sprains: a bruise is made of blood, and blood can pool under gravity.

Osteopathic Treatment

As Tennis Leg is a minor sports injury, your osteopath is qualified to help you.

The first two weeks after onset make up the acute period for soft tissue injuries like this. There are a lot of things you can do at home to minimise discomfort and facilitate healing at this time, and your osteopath can give you tailored advice. However, the basics are:

  • Apply a cool compress
  • Elevate the leg to prevent excess swelling
  • Use a support with gentle compression
  • Reduce weight bearing temporarily: crutches may be beneficial

After the initial inflammation subsides, the body begins to repair. At this point, it is important to be using the leg to some extent in order to help with remodelling. Your osteopath can help with work to the soft tissues as well as more advice.

Recurrent Injury

As part of your treatment plan, your osteopath will want to work on prevention of future episodes. Alongside stretching and warming up before exercise, we will look for other factors that may have played a role. Restrictions in the hip or ankle may cause overloading of the calf, so treating these issues could help with prevention in the future.

About 1/5 people report having felt some general calf tightness in the days leading up to their injury. If this applies to you, it will be especially important to work on calf tension as part of your rehabilitation.

Regular stretching is easiest to do when it becomes part of a routine, but establishing that routine can be the hard part for some people. If this applies to you, you might find that having a visual reminder helps- such as a foam roller. Seeing the tool you need to use can be enough to get you into that routine, so mention this to your osteopath if it would help you.

Book an appointment online to manage your sports injuries

Plantar Fasciitis

The plantar fascia is a layer of connective tissue on the sole of the foot. When it becomes inflamed, you have plantar fasciitis (PF).

Plantar Fasciitis

Symptoms of Plantar Fasciitis

The bone of the heel is called the calcaneus. PF usually starts with a sharp pain at the front-most tip of the calcaneus. It may be located more towards the inner arch than the centre of the foot, and pain may radiate towards the toes. It may be worse when stretched- so walking can be painful. However, as you continue to walk, it may ease up. Symptoms return after rest.

There are a number of conditions that behave similarly, such as problems with a nerve. Your osteopath can give you a diagnosis at your appointment.

What Happens in Plantar Fasciitis

Fasciitis is inflamation of the layer of tissue between skin and muscle. There is a thick layer of fascia on the sole of the foot (the plantar aspect) which behaves like a tendon to some degree. Plantar fasciitis may begin with micro-tears to the tissue, similar to what happens in a ligament with a minor sprain. This may be an injury associated with sports, or it could be the result of normal ageing and degeneration. The symptoms become more significant if they don’t self resolve. Some consider it a degenerative condition leading to inflammation, rather than an inflammatory condition in itself. This is not to say that there is no way out of it- improving local tissue health will enable better healing.

Sometimes it is called “policeman’s heel” in reference to the repetitive trauma of persistent walking. You may also hear people talk about “heel spurs” in reference to plantar fasciitis, but this is misleading as heel spurs are protrusions made of bone, and not present or relevant in all cases.

Plantar fasciitis is a common injury in runners, but it also affects 10% of the non-athletic population. Onset does not have to be traumatic as such, but wearing unsupportive or restrictive footwear can play a role. Flip flops and high heels are noted as common factors in the development of PF.

Treatment and Advice

Dry needling and acupuncture have been investigated as potential treatment methods, and results suggest that they may provide some benefit. In the same paper, manual therapy was found to be more effective than corticosteroid injections for plantar fasciitis.

PF can take a while to clear up, so it’s worth doing everything you can to help it on its way. Your osteopath can help you with the details, but the NHS recommends avoiding shoes that are tight or lack support, and to limit the time you spend standing.

If you’re suffering with foot pain, book an appointment now.