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Contents Introduction 3 Neck Pain 7 Shoulder Pain - Gradual Onset 9 Shoulder Pain Acute onset 11 Elbow Pain 13 Low Back Pain 15 Knee Pain Gradual Onset 17 Knee Pain Acute Onset 19 Shin Pain 21 Ankle Injury 23 Foot Arch Pain 25 2
Knowing What Steps to Take If you sustain an injury, it is important to know when the injury requires more than your own basic management, and where to go to for help. Injury management can be more difficult if you travel a lot, or if you are an expat or digital nomad. In these situations, the desire to act fast often competes with the upheaval and cost of travelling for specialized services. Accessing health services is becoming easier than ever before. This is largely due to the growing popularity of telehealth initiatives. Telehealth simply refers to normal health consultations that happen to be performed online, using digital technologies. Research has proven that googling generic health information online can be inaccurate and unsafe. Online consultation, however, where the 3
assessment and advice is by a qualified professional, has been shown to be as effective as face to face consultation. This certainly is true for online Physiotherapy consultation, meaning that quality diagnosis and management of musculoskeletal injuries is now increasingly accessible to people who find it challenging to access traditional care. When you sustain a musculoskeletal injury, you have to decide between three main action steps: Do I need to make the effort to travel to a health service, such as a Doctor or Physiotherapist? Is my injury suitable for online consultation with a Physiotherapist, saving the time and cost of travel? or Do I administer basic medical management, and simply self-monitor the injury, to be followed up only if symptoms do not progress as expected. In this book, we have simplified these three options with the following terms: Take Flight? ie, when do I need to make the effort to travel for review by Doctor or Physiotherapist? Certain symptoms or conditions require assessment by a Doctor or Physiotherapist in a face to face consultation. This is generally recommended when there is: 4
Severe pain A possibility of permanent disability if treatment is delayed Requirement for investigations (eg xray, MRI), or specialist referral. Referral to a Medical Doctor, is always required if the following signes are present: night sweats waking in the night due to pain unexplained weight loss change in bladder or bowel function severe and escalating pain history of tumor Website? Ie, when is it appropriate and effective to seek consultation online, such as Physiotherapy? In many cases, musculoskeletal injury can be very effectively managed through an online consultation. Ensure that your online Physiotherapist has a recognized degree (minimum of Bachelor), and is registered with a National Registration body, such as AHPRA in Australia. Online Physio, for example, uses only Australian qualified Physiotherapists who are AHPRA registered, and are specifically trained in the use of the online consultation format. 5
Sit Tight? ie, when is it OK to perform some basic medical management on yourself and just see how you go? Sometimes injuries simply require basic management, such as RICE (Rest, Ice, Elevation, Compression), or basic medications, such as those available at the supermarket. Ensure you follow the directions and warnings on the pack. If the injury does not settle as expected, follow the Take Flight or Website guidelines. It is not the intention of this book to cover first aid training, but there are many books and courses that do so adequately. The Fast Track Guide to Managing Your injury outlines the action steps you should take, for the ten most common musculoskeletal injuries. It is designed to assist your decision making process, but you should always consult your doctor if you are unsure or very concerned about your injury. To ask questions or give feedback, please contact karen@online.physio. 6
Summary COMMON INJURY ONE: NECK PAIN Shoulder trauma can range from reaching quickly to grab a falling object, to forceful dislocation from body contact. Dislocation can sometimes cause damage that requires review by a surgeon. Despite this, dislocations can often be managed conservatively, unless they keep happening. Forcefully resisted muscle contraction around the shoulder can also cause cartilage damage, or a rotator cuff tendon tear. A fall onto the shoulder can cause acromio-clavicular joint separation, or clavicle fracture. 7
Take Flight Travel to see a Medical Doctor if any of these factors are present: History of a full dislocation Marked weakness with arm elevation persisting past 5 days Unsatisfactory improvement with 6 weeks of a rehabilitation program with a physio Website Seek a Physiotherapy consultation online if there is: Shoulder pain lasting more than 1 week Sit Tight A fall or yank on the shoulder can cause some tendon inflammation that feels painful the day after, but settles over the course of a week. If symptoms persist, it is important to refer as recommended above, to get the shoulder structures assessed. Mild injuries to the ac joint require minimal management, except for avoiding painful activities. 8
COMMON INJURY TWO: SHOULDER PAIN GRADUAL ONSET Summary A gradual onset of shoulder pain is often caused by issues with the rotator cuff tendons. Severe pain or marked functional limitation can require an Ultrasound investigation, to examine the tendons for tears. Unless a tear is diagnosed as full thickness, conservative (nonsurgical) management is often adequate. 9
Take Flight Travel to see a Medical Doctor if any of these factors are present: Unsatisfactory improvement following a 6 week rehabilitation program with a physio (ie continued impairment of daily activities or sport) lasting more than 6 weeks Marked weakness with arm elevation past shoulder height, Pain interrupting sleep for more than 2 weeks Website Seek Physiotherapy consultation online if there is: Shoulder pain lasting more than 1 week Sit Tight If a shoulder develops pain due to overload with a particular activity, and the duration has been less than a week, avoid the aggravating activity, and see if it settles. If pain persists, use the Take Flight and Website guidelines. 10
SHOULDER INJURY ACUTE ONSET Summary Shoulder trauma can range from reaching quickly to grab a falling object, to forceful dislocation from body contact. Dislocation can sometimes cause damage that requires review by a surgeon. Despite this, dislocations can often be managed conservatively, unless they keep happening. Forcefully resisted muscle contraction around the shoulder can also cause cartilage damage, or a rotator cuff tendon tear. A fall onto the shoulder can cause acromio-clavicular joint separation, or clavicle fracture. 11
Take Flight Travel to see a Medical Doctor if any of these factors are present: History of a full dislocation Marked weakness with arm elevation persisting past 5 days Unsatisfactory improvement with 6 weeks of a rehabilitation program with a physio Website Seek a Physiotherapy consultation online if there is: Shoulder pain lasting more than 1 week Sit Tight A fall or yank on the shoulder can cause some tendon inflammation that feels painful the day after, but settles over the course of a week. If symptoms persist, it is important to refer as recommended above, to get the shoulder structures assessed. Mild injuries to the ac joint require minimal management, except for avoiding painful activities. 12
ELBOW PAIN Summary Elbow pain is most commonly a gradual onset of pain through overuse, but a direct blow, forced movement, or fall onto the arm can also cause issues. Tennis elbow is the most common cause of pain in the elbow, which is irritation of the tendon/bone junction caused by repeated use. Bony tenderness following trauma generally requires investigation. 13
Take Flight Travel to see a Medical Doctor if any of these factors are present: Significant trauma, particularly in the presence of bony tenderness and swelling Unresolving pain lasting 3 to 6 months Website Seek a Physiotherapy consultation online if there is: Elbow pain lasting more than 2 weeks Sit Tight If elbow pain flares up due to a specific overload incident (like a weekend of pruning, first squash game in a while, or intensive use of a hammer), then rest from the painful activity until the pain settles. If the activity has to be returned to, do it with frequent breaks at first, and gradual progression of load. If pain persists, follow the Take Flight and Website guidelines. 14
LOW BACK PAIN Summary Low back pain may sneak up on you gradually, or hit you all of a sudden. Pain can be due to muscle tension, or from damage to joints, discs or nerves. The longer the back pain lasts, the more factors tend to contribute, such as stress, posture, muscle weakness and chronic soft tissue changes. Back pain that includes pins and needles, numbness and/or weakness in the leg/s must be investigated, and may require surgery in severe circumstances. 15
Take Flight Travel to see a Medical Doctor if any of these factors are present: History of trauma to the back, eg a fall Noted change in bladder or bowel function General back pain lasting more than 3 months Pain with spinal extension and/or rotation, linked with a history of repeated extension/rotation load eg gymnastics, fast bowling Lower limb pins and needles and/or numbness and/or weakness lasting more than 2 weeks Severe, or sharp, shooting pain lasting more than 2 weeks (bad enough to interrupt sleep) Website Seek a Physiotherapy consultation online if there is: Back pain, that is not improving, lasting more than 3 days Sit Tight It is generally important to seek consultation for all episodes of back pain, lasting more then 3 days, from a Physiotherapist or Doctor. The main time when it is OK to leave it to settle on its own, is if back soreness simply results from muscles following a weights/gym workout, or a new activity. If pain persists, follow the Take Flight and Website guidelines. 16
KNEE PAIN GRADUAL ONSET Summary Knee pain that develops gradually can often be due to issues with the kneecap, but can also be due to degenerative changes like arthritis, cartilage damage or tendon issues. Persistent locking, catching or giving way can be indicators of structural damage requiring medical review, as can persisting swelling. 17
Take Flight Travel to see a Medical Doctor if any of these factors are present: Can t bend the knee past 90 degrees Can t weight bear for more than 4 steps Significant swelling Pain which is unresolved after 12 weeks Regular locking, catching or giving way despite rehabilitation Website Seek Physiotherapy consultation online if there is: Knee pain lasting more than 2 weeks Sit Tight If you develop knee pain, but can walk around OK and have no swelling, it can often be good to leave it for a week or two to see if it settles down. Avoid impact activity (or aggravating activity). If pain persists, follow the Take Flight and Website guidelines. 18
ACUTE KNEE INJURY Summary Acute knee trauma often occurs on the sports field, but can also occur through motor vehicle accidents, slips and falls. A knee with a history of twisting mechanism, click or pop at that time, and instant swelling, must be reviewed by a doctor, and potentially undergo MRI scan. Most other knee ligament injuries are managed conservatively, particularly if no other accompanying damage is found. Persisting mechanical failure must be investigated. 19
Take Flight Travel to see a Medical Doctor if any of these factors are present: bony tenderness Twisting episode with an audible snap and swelling Inability to flex knee past 90 degrees Inability to weight bear for more than 4 steps Significant swelling Pain unresolved/ unchanging after 6 week rehabilitation History of a traumatic incident, particularly in the presence of Locking, catching or giving way persisting despite rehabilitation program Website Seek a Physiotherapy consultation online if there is: Knee pain lasting more than 1 week Sit Tight If you develop knee pain, but can walk around OK and have no swelling, it can often be good to leave it for a week or two to see if it settles down. Avoid impact activity (or aggravating activity). If pain persists, follow the Take Flight and Website guidelines. 20
SHIN PAIN Summary The most common causes of shin pain are often collectively labelled shin splints. There is usually a history of commencing or increasing impact activity, which results in overload of the muscles around the tibia bone. In severe situations, this can result in stress fracture, in which the pain is more severe and point specific. In non-responding shin pain, a differential diagnosis of compartment syndrome (nerve or circulatory entrapment) must be considered. 21
Take Flight Travel to see a Medical Doctor if any of these factors are present: bony tenderness eg motorbike accident History of a traumatic incident, particularly in the presence of Site specific pain with impact and specific tenderness over bone Escalating pain with activity, failed rehabilitation program with a physio Website Seek a Physiotherapy consultation online if there is: Shin pain lasting more than 2 weeks Sit Tight If pain develops quickly with a new impact activity or a dramatic increase in amount of impact activity, rest from the activity until pain settles. On return to the activity, do it on alternate days to begin with, and increase volume by only 10% each week. For persisting, or long duration pain, follow the Take Flight and Website guidelines. 22
ACUTE ANKLE INJURY Summary The most common acute ankle injury is the rolled ankle, with damage to the ligaments on the outside of the ankle. The same general mechanism of injury can sometimes cause a fracture, which may or may not require surgery, so any tenderness over bone needs to be investigated. Tenderness on the outside edge of the foot after this type of injury should also be investigated. An ankle sprain that is not recovering should be checked for damage to the cartilage with an MRI. 23
Take Flight Travel to see a Medical Doctor if any of these factors are present: Bony tenderness along the lower leg bones Inability to weight bear for more than 4 steps injury, despite physio rehabilitation Bony tenderness over the ankle bones or outside edge of the foot Significant pain and disability persisting 6 weeks post ankle History of recurrent instability (ie the ankle rolls repeatedly with minimal activity) Website Seek Physiotherapy consultation online if there is: Any acute ankle injury Sit Tight Once you have had one ankle injury, you are highly likely to re-injure again (and again!), particularly if a rehabilitation program is not completed. All injuries should therefore be referred for rehabilitation with a Physiotherapist. This can be performed via online consultation. 24
FOOT ARCH PAIN Summary The predominant cause of a gradual onset of pain in the arch of the foot is Plantar Fasciitis, with peak tenderness at the back of the arch next to the heel. It is often mistakenly referred to as a heel spur, however the finding of a heel spur on xray has proven to be unrelated to the condition. It can be stubborn to treat, but will usually resolve with time and persistent rehabilitation. Taping of the arch, as guided by a Physiotherapist, can be effective for shorter term pain relief. 25
Take Flight Travel to see a Medical Doctor if there is: 3 months of non improving pain, including failed physio rehabilitation program Website Seek Physiotherapy consultation online if there is: Foot arch pain lasting more than 2 weeks Sit Tight If foot arch pain, of less than 2 weeks duration, can be attributed to a change in activity or footwear, stop the aggravating activity. Once pain settles, return to the activity gently and progress gradually. For persisting pain, follow the Take Flight and Website guidelines.. 26
About the Author Karen Finnin Musculoskeletal Physiotherapist BAppSc(Physio), MMuscPhys Karen graduated as a Physiotherapist from LaTrobe University in Melbourne, Australia in 1998, and subsequently completed a Masters in Musculoskeletal Physiotherapy. With many years working in Private Practice settings, Karen has extensive experience in managing spinal injuries, general sporting injuries and work related conditions. Karen is the Director of Online Physio, an online Physiotherapy Practice that specializes in providing long distance consultations for people who are injured, but have trouble accessing traditional face to face care. Visit the Online Physio website at www.online.physio 27
ABOUT ONLINE PHYSIO www.online.physio Online Physio is an online Physiotherapy Clinic, specializing in providing long distance physiotherapy consultations. At Online Physio, Physiotherapists are trained in distance injury management. They can assess, diagnose and treat musculoskeletal injuries using a combination of digital technologies. For more information: www.online.physio 28