Common Achilles tendon injuries and their treatment

The Achilles tendon is the longest tendon in the body, connecting the heel bone to the calf muscles.

Achilles Tendonitis/Tendinopathy 

Characterised by pain and inflammation of the Achilles tendon or its covering, Achilles Tendinopathy is an overuse injury that is most common in joggers, jumpers and other activities that require repetitive actions. This pain and stiffness is sometimes worse in the morning and at the start of exercise, and may disappear as you warm up. You may also notice the area is swollen and tender to touch.

The suffix ‘itis’ implies inflammation. Previously called ‘tendinitis’ or ‘tendinosis’, physios have moved on from these terms as modern science has proven that inflammation is not the driving force in tendon overuse injuries. So taking anti-inflammatories for your tendinopathy may not have great long term relief.

A more appropriate term is tendinopathy which means dysfunctional tendon health.

Common causes of Achilles tendinopathy include:

  • Tight hamstrings and calf muscles
  • Walking on your toes (or excessive high heel wearing)
  • Overtraining and failing to warm up or down
  • Poorly supportive footwear

Achilles tendon rupture

The dreaded ‘snapped’ Achilles tendon. The mere thought of it brings a tear to the eye.

68% of all acute Achilles tendon ruptures occur during some form of athletic activity.[1] Eccentric movements put an enormous amount of stress on the tendon and stop-and-go sports like volleyball, basketball, soccer and squash are commonly involved.

If you have ruptured your Achilles tendon you will probably experience:

  • A loud crack or popping sound at the moment of injury
  • A sharp pain at the moment of rupture
  • An inability to raise or flex your heel
  • The back of your heel may swell

How can a physio help?

Achilles injuries do not usually get better on their own. They may feel a little bit better with rest, but once you start doing an aggravating activity again it will become painful. Continuing to do aggravating activities despite pain or dysfunction is a great way to prolong your recovery time.

The goals of physiotherapy are to treat any acute issues associated with your Achilles injury:

  • Rest from aggravating activities
  • Ice or heat (as directed)
  • Massage
  • A targeted stretching and strengthening program
  • Dry needling

They will also look to identify predisposing factors, reduce pain and inflammation, and promote healing to restore the muscle and tendon.

Your physio will look to address the factors that caused the injury in the first place, to help reduce the risk of re-injury, commonly including:

  • Abnormal lower limb mechanics (foot, knee and hip)
  • Calf weakness
  • Poor muscle flexibility
  • Stiff ankle joints
  • Training: inappropriate training load and recovery time between training sessions
  • Poor footwear, footwear wearing out

Fixio will also provide you with a targeted tendon rehabilitation program to make your Achilles stronger and more flexible. Finally, we will provide you with advice regarding when and how you can return to sport and/or activity. It is important to follow this advice to prevent recurrence, or worsening, of the tendon injury. Rehabilitation can be frustratingly slow but with perseverance it will get better!

[1] Raikin SM, Garras DN, Krapchev PV. Achilles tendon injuries in a United States Population. Foot Ankle Int. 2013;34:475–480.



How do excellent physiotherapists use Evidence Based Practice for better results?

All physiotherapists want the best for their patients and we aim to provide the most effective treatment for each and every person on the Northern Beaches that walks through our doors. But how do we know that our physiotherapy is making a difference and that it is the best care for every individual’s circumstances?

Everybody and every body is different, which means there are going to be nearly an infinite number of ways to treat individuals suffering from chronic pain, musculoskeletal disorders and muscular or ligament injuries. It is up to physiotherapists to identify the best methods for each individual client and implement them in a broader strategy to meet their goals. This is where utilising evidence based practice techniques and taking a results based approach to treatment and injury management can shave weeks from your recovery period and result in less pain and a decreased risk of suffering a re-injury.

What is evidence based practice?

Evidence based practice (EBP for short) isn’t a new concept, it has been utilised in the medical world for a number of years now and has become a popular method of treatment for physiotherapists around the world over the last decade.

EBP utilises ‘the integration of best research evidence with clinical expertise and patient values’[1] in order to shape the treatment of patients and include them in the processes of treatment in order to prevent pain and injury in the future.

The goals of evidence based practice are:

  • To improve the care for clients, resulting in more effective treatment and injury recurrence
  • To use evidence from high quality sources to help shape physiotherapy practice
  • To challenge treatment views based on anecdotal evidence
  • To integrate patient preferences into the treatment and decision making processes
  • To take the guess work out of treatments, using education to shape future activities

What are the 5 steps of evidence based practice?

Because evidence based practice relies on consistency and clinical fact in order to make diagnoses and frame the best treatment, a framework of steps has been outlined in order to help physiotherapists design and implement and evidence based approach to treating musculoskeletal conditions.

Step 1 – Ask an answerable and measurable question

One of the fundamental skills needed by musculoskeletal physiotherapists in designing an evidence based program is the asking of to the point clinical questions. By asking the right questions you can focus your efforts specifically on the areas needed, instead of non-important matters.

Step 2 – Acquire relevant research evidence

With the easy part out of the way, your physiotherapist will move onto extrapolating the answers to their questions in order to find relevant, recent and scientifically proven methods for treating your specific condition. Physiotherapists will use a combination of their own data collected over years of practicing in the field and scientific studies located in databases specifically designed to provide a workflow in order to come to the right conclusions.

Step 3 – Analyse the evidence

This is where the expertise and experience of your physiotherapist is really going to come in handy. For example, a Titled Musculoskeletal Physiotherapist has likely spent over a decade studying and practicing in the field and has gained an advanced insight into what evidence is important and what evidence may not be supported by clinical practice and other data. By critically analysing the scientific data your physio is already piecing together your treatment plan in their head and focusing on your goals in relation to the evidence for treatment techniques.

Step 4 – Implementation of the evidence

Now that your physio has conducted their full body assessment, questionnaire and compared data with high quality evidentiary sources, the real fun is ready to begin. Physiotherapists will implement their treatment plans usually by combining the best available evidence with their clinical expertise and their patient’s values and goals. During the implementation phase, your physio will be documenting and assessing your treatment and recovery in order to make any adjustments to your program and to ensure your recovery is progressing. Implementation isn’t a single process; it is the sum of all their experience and knowledge that can be altered and updated to suit your progress.

Step 5 – Evaluate the outcome

If your original treatment plan isn’t getting results, this is where your physio has the knowledge and flexibility to alter what’s required to get you back to 100% health. By documenting your progress and implementing evidence based methods, your physio is able to alter your treatment based on results and at the end of the day, that’s exactly why you see a physio in the first place. To get results. If it’s not working, fix it.

Evidence based practice in physiotherapy is a constantly evolving concept and allows for a flexible and science based approach to combating common musculoskeletal problems. Find yourself a Northern Beaches physio with the expertise and experience to create and implement an evidence based, patient-centred and results focussed program and you’ll be on the right track to a pain free future.


[1]  Sackett DL, Rosenberg WMC, Gray JAM, Haynes RB, Richardson WS: Evidence based medicine: what it is and what it isn’t. BMJ 1996;312:71-2


ACL injuries: surgery, recovery and prevention

Australians in general and those of us on Northern Beaches especially are an active bunch. Unfortunately, activities that are great for the waistline can spell trouble for the musculoskeletal system when injuries occur. More people are playing sports, running or participating in some kind of physical activity than ever and that means more injuries. Aussies are world leaders in most sports and unfortunately we’re also world leaders in ACL injuries and that rate has been climbing consistently.[1]

Between 2000 and 2015 nearly 200,000 ACL reconstructions were performed in Australia with men aged 20 to 24 years and women aged 15 to 19 years the most common patients, but the fastest growing demographic was 5–14-year-old children.[2] Apart from being painful and ongoing, ACL repair can also be painful to the back pocket, costing on average over $8000 including hospital fees.

What, if anything can physiotherapists do to help prevent ACL injuries, and how do we make sure that a full recovery after ACL surgery occurs?

What is an ACL, what does it do and how are they injured?

Ligaments are strong bands of tissue connecting bone to bone and are among the most commonly injured part of the musculoskeletal system. Your anterior cruciate ligament or ACL for short is one of the four ligaments in your knee that keep your knee joint stable. Your medial and lateral collateral ligaments stop your knee from moving side to side, while your anterior and posterior cruciate ligaments keep the knee from sliding front to back.

ACL injuries can occur at some pretty random and innocuous times but usually are a result of rapid changes in direction at speed, typically in non-contact sports or events. ACL tears also commonly occur during sports that involve sudden stops, jumping and landing such as soccer, AFL, basketball and netball.

It’s common to hear a “pop” in the knee when an ACL injury occurs accompanied by some pretty rapid swelling, instability and an unbearable pain that won’t let you put weight on it. Depending on the severity of your ACL injury, treatment is likely to include a good chunk of time on the sidelines and probably some surgery.

What does ACL surgery involve?

A surgeon chops out a piece of another tendon (usually the hamstring), removes your damaged ACL (because it can’t heal itself) and replaces it with the new tendon. Your new replacement tissue is called a graft which will be attached to your bones with screws (airport security just got more fun) or other fixation devices and serves as the point where new ligament tissue can grow. Fun fact, if the tissue is taken from you, it’s called an autograft but if it was donated by another person it is known as an allograft.

How long until I can play sport after ACL surgery?

The recovery period after ACL reconstruction surgery varies from one person to the next and there are many factors that determine how quickly and adequately you will recover and how low it will take until you can get back into the full swing of things.

One of the biggest factors influencing how long ACL surgery recovery takes is whether you have an orthopaedic pre-habilitation and rehabilitation plan and you stick to it. A well designed pre ACL surgery body strengthening regime can shave weeks and pain off your post-surgical recovery. The physical shape your affected area is in is one of the strongest predictors of the chances of a fully successful recovery. It is likely that you have pain and weakness operating in tandem leading up to surgery, but you’re going to need every ounce of strength you’ve got to recover fully. In prehab your local physio will help you build strength and stability where you need it most to ensure you get the most out of your rehabilitation.

Your surgeon and musculoskeletal physio will be able to advise you when you’re good to go for most activities, but this is usually only once you have adequate flexibility, strength and fitness.

Can physiotherapy prevent an ACL injury occurring?

Because ACL injuries have been becoming increasingly common, more time and research is being devoted to understanding the mechanisms behind ACL injuries and what steps can be taken to reduce the possibility of an ACL tear happening. Prevention is much better and less painful than a cure.

Over the last two decades multiple randomised controlled trials have shown that anywhere between 50–80% of ACL injuries can be prevented by regular neuromuscular agility training programmes.[3] A number of these studies have shown that many ACL injuries are caused by faulty mechanics during dynamic movements performed under fatigue.[4]

These prevention programs include various modes of exercise such as plyometrics, neuromuscular training, and strength training designed to teach the body to perform movements deliberately and with precision even under fatigue. A trained musculoskeletal physiotherapist will be able to observe your technique and address the faulty movement patterns in a personalised injury prevention program.


[1] Janssen KW, Orchard JW, Driscoll TR, et al. High incidence and costs for anterior cruciate ligament reconstructions performed in Australia from 2003–2004 to 2007–2008: time for an anterior cruciate ligament register by Scandinavian model? Scand J Med Sci Sports 2012;22:495–501.

[2] Increasing rates of anterior cruciate ligament reconstruction in young Australians, 2000–2015 David Zbrojkiewicz, Christopher Vertullo and Jane E Grayson Med J Aust 2018; 208 (8): 354-358. || doi: 10.5694/mja17.00974

[3] Caraffa A, Cerulli G, Projetti M, et al. Prevention of anterior cruciate ligament injuries in soccer. A prospective controlled study of proprioceptive training. Knee Surg Sports Traumatol Arthrosc 1996

[4] Mandelbaum BR, Silvers HJ, Watanabe DS. Effectiveness of a neuromuscular and proprioceptive training program in preventing anterior cruciate ligament injuries in female athletes: 2-year follow-up. Am J Sports Med 2005;33:1003–10


Understanding the difference between an injury and pain

Whether you’re a novice runner or a seasoned veteran, chances are you’re well acquainted with pain. Right from the get-go we’re taught to run through the pain to push through it to get to that next PB. When you’re new to running long distances it’s normal for your body to take some time to adjust and being a regular runner is all about dealing with those niggling aches and pains. My right knee certainly lets me know all about it for a few days if I run too many stairs between Manly and Dee Why.

But how much pain does it take to gain and when does pain point to an injury? While pain and injuries go hand in hand, pain doesn’t necessarily mean you’ve got an injury and there are plenty of injuries that sneak by without causing pain where you’d expect it. Minor running “injuries” can be treated with a bit of good old fashioned R’n’R but more chronic or serious injuries require the expert guidance of a musculoskeletal physiotherapist.

Assessing pain: am I sore, or am I injured?

Before you can get to the treatment stage for those aches and pains, we’ve got to work out what we’re dealing with. At an initial consultation with a physio they will usually ask you a number of questions regarding your pain/injury to get a better idea of its causes and how best to treat it.

  1. Did the pain start abruptly or come on over time?

It is normal for your body to feel sore after a big run or a workout; delayed muscles soreness (DOMS) is a common occurrence and normally improves after a few days, whereas an injury will likely cause you pain for weeks or more at a time. If you heard a pop or snap and felt a twinge or an abrupt sensation of pain during your run, chances are you have suffered an injury. Around 70% of all running injuries are caused due to overuse, but they often show themselves in a straw breaking the camel’s back fashion.

  1. Is the pain persistent or does it only come on during certain activities?

Unfortunately, what your pain is trying to tell you isn’t always clear cut and chronic or persistent pain is notoriously difficult to pinpoint and treat. That being said, when muscle or joint soreness hangs around for longer than a few days, is accompanied by sharp pains or aches and is persistent even when not engaging in a physical activity it’s likely you’ve done yourself an injury.

  1. Is the area swollen, sore to the touch or bruised?

When you tear a ligament or cause substantial soft tissue damage, the body usually (not always) reacts by causing some pretty obvious external symptoms. It may not happen immediately, but swelling and bruising commonly accompany major injuries and can be more easily diagnosed by comparing one side to the other and checking for differences.

  1. Is there a loss of function?

Loss of function tests are one of the most common methods musculoskeletal physiotherapists use to identify the nature of pain. One of the biggest indicators of an injury as opposed to regular pain is the presence of a loss of function independent of any sensation of pain or an inability to complete certain movements due to severe pain.

Preparation is the first step to avoiding a running injury

  • See a physio to identify potential musculoskeletal and health problems that may contribute to injury
  • Always warm up and cool down by jogging slowly
  • Injured runners should consult a professional about how to prevent re-injuries
  • Hydrate prior to running and consider taking water on longer runs
  • Get a running assessment if niggles persist

Use the R.I.C.E method to treat running soreness

If you’re suffering from the DOMS or you’ve just pushed yourself a little hard and feeling it, you can’t go wrong erring on the side of caution and giving your body a bit of a recovery pamper session.

Rest properly and resist the temptation to down a number of celebratory alcoholic beverages. If you must go out, keep hydrating, don’t party too hard and let your body recover.

Ice – this will help constrict the blood flow to sore areas and help to reduce inflammation and soreness. If you feel up to it, you can always take your second ice bath as you likely already took your first one during the race.

Compression of the legs and arms will help flush out the lactic acid that has accumulated. Wearing compression gear will work great for this. Pairing compression and icing will ensure they work symbiotically and will shorten your recovery period.

Elevate your legs as you lie in bed thinking about how awesome and tough you looked covered in mud, running through electroshock stations, carrying logs and kicking butt.

If you have a persistent ache or pain whether it be the result of running or another physical activity, it needs to be identified and addressed. Nobody likes being injured, but allowing something as simple as shin splints to go untreated with continued overtraining, can cause tibial stress fractures, which will put you on your butt for at least 6 weeks. The moral of the story is from little things, big things grow; this includes injuries.

Visit a pain and injury clinic on the Northern Beaches for more information on identifying the difference between pain and injury and how to treat those niggling aches and pains before they progress to something more serious.


Cure back pain once and for all with expert physio treatment.

At this very moment 1 in 6 people on the Northern Beaches is suffering from back pain due to a variety of different back problems.[1] Back pain doesn’t discriminate and its causes are as varied as its symptoms. Back pain can be caused by sitting too much, by standing too much and by running too many loops of the Manly to Dee Why coastal walk. Back pain can affect your work, sports, mental health and especially your sleep. Getting a good night’s sleep is so important for recovery and back pain is notorious for being worse at night, creating a self-perpetuating loop of poor sleep that exacerbates the back pain.

What causes back pain?

Having spent my career as a musculoskeletal physiotherapist on the Northern Beaches, many of my clients suffering from back pain have injured a muscle in or surrounding the back. In fact, studies have shown that around 70% of all back pain is a direct result of muscular injury? Repeated heavy lifting and sudden awkward movements are the big causes of back pain and as we get older it gets easier to give it a twinge. Other common back pain causes we see here at Dee Why include:

  • Arthritis – Nobody likes the A word but it’s something that will affect around 1 in 7 Australians during their lives. Lumbar arthritis pain is caused by movement and inactivity so you can’t win and affects the lower back and can extend to the pelvic area, sides of the buttocks and can even be felt in the thighs.
  • Sporting injuries – Northern Beaches physios treat back pain every day that has been the result of an injury caused by playing sport. Sports like volleyball, gymnastics, surfing and running are the cause of plenty of sore backs between Manly and Dee Why, that’s for sure!

How do physiotherapists treat back pain?

How long have you got? Titled Musculoskeletal Physiotherapists can draw on years of study, observation and curing back pain of all varieties and use literally dozens of different techniques for treating back problems. First things first though, your physio will take you through an in-depth physical examination in order to determine the exact cause of your back pain – back pain can have a variety of root causes.

Titled Musculoskeletal Physiotherapists understand the complexity of lower back pain and use an evidence based approach to injury management in order to get results. Musculoskeletal physiotherapy is the most common form of intervention for chronic back pain and your back pain physio on the Northern Beaches will create and prescribe a bespoke program to not just combat the pain, but to protect and strengthen your back against future problems.

If you are suffering from back pain on the Northern Beaches and avoid seeing a physio you are increasing your chances of your back pain persisting longer and a recurrence of the injury in the future. Don’t wait until the pain becomes severe or chronic, give Fixio a call on (02) 8964 4086 or email us to book at




Treating knee injuries such as torn ligaments, fractures and dislocations

Knee injuries are among the most common type of injuries treated by physiotherapists on the Northern Beaches and are also at the top when it comes to re-injuries. I don’t know how many times I’ve seen a patient who ended up having a serious knee injury and they said they just tried to ‘run it out’. If you are involved in physical activity or sports such as netball, volleyball, beach volleyball, soccer, AFL and rugby league, you are at a much higher risk of suffering a serious knee injury compared to the rest of the population. If you are suffering from pain or swelling in the knee, please don’t try and run it out, jump in the car and head down to your local Northern Beaches physio for some hands on treatment and get a plan for recovery so you don’t end up suffering ongoing pain or movement issues.

These are the most common types of knee injuries treated by musculoskeletal physiotherapists:

Torn ligaments and ligament strains

Like a lot of musculoskeletal injuries, it’s the most active people who get the wrong end of the stick when it comes to suffering them. Your knee contains a number of ligaments connecting bones to other bones in and around the knee joint that are susceptible to damage when you take a sharp change in direction, land wrong from a jump, or commonly from force directly to the knee, such as in soccer or footy tackle. The knee is made up of 4 ligaments that can all be torn or strained:

ACL – The ACL is the big daddy of knee injuries, the most painful and also the most common. The ACL connects the thigh bone to the shin bone and is most likely to strain or tear when pivoting or landing from a jump, around 80% of ACL tears are non-contact injuries.

PCL – The PCL is there to stabilise the tibia and prevent it from being bent too far backwards, commonly tearing or becoming strained due to forced hyperextension. It is the least common of the knee injuries, accounting for around 10% of them in total.

MCL – Your MCL is located on the inner side of your knee and connects the medial femoral condyle and the medial tibial condyle. MCL injuries usually take place during a sharp change in direction, when the knee is twisted while your foot stays in place, landing incorrectly from a jump, or from a hard direct hit to the knee, commonly in a footy tackle.

LCL – Like the ACL and MCL, your LCL helps control the sideways motion of the knee, connecting your femur to the fibula. LCL injuries only account for less than 5% of knee injuries, but they are known to be pretty darn painful.

Once your physio has conducted a thorough physical examination, they will be able to give you a good idea of the grading of the injury (1 being the lowest, 3 the highest) and begin treatment. Depending on whether you have suffered a strain or a tear, you may be required to undergo surgery and your physio will be able to design an in-depth prehab and rehab program for you that will aim to:

  • Reduce pain and swelling
  • Return the joint to its full range of motion
  • Strengthen the area surrounding the knee such as hamstrings and quadriceps
  • Improve your proprioception, agility and balance
  • Improve your technique and function specific to any sports or your circumstances
  • Get you back into your sport, regular activities and exercises
  • Minimise your chance of re-injury


Fractures and dislocations

Musculoskeletal physiotherapists commonly see knee fractures and dislocations paired with ligament damage, they tend to go hand in hand unfortunately. Not only are patellar fractures relatively common, they are also painful and can take a good deal of healing time. A patellar fracture is a break in the patella, or knee cap which is a small bone sitting at the front of your knee. The knee cap acts like a shield for your knee joint and is vulnerable to fracturing if you fall directly onto your knee or cop a big hit in sport or commonly in a car crash.

A patellar fracture may be a clean and even two-piece break or the bone can break into many pieces (ouch). If you are lucky enough when suffering a patellar fracture and the pieces of bone are not displaced, you may not need surgery. [1] Because treatment for a patellar fracture includes a period of time where you need to keep your leg immobilized in a cast, it’s not uncommon for your knee to become stiff and your thigh muscles to shrink. During the rehabilitation your physiotherapist designs, will be given a number of specific exercises to help improve the range of motion in your knee, strengthen your leg muscles surrounding the knee cap and manual therapy in order to decrease stiffness.

The most painful part of dislocating the patella is the immediate time after; with most people having a sort of relief in the hours after it is re-located. Because a dislocation or fracture commonly occurs with a ligament strain or tear, your rehabilitation will take at least 8 to 12 weeks to successfully heal the area and decrease your chance of a recurrent dislocation.

If you have:

  • Sudden or severe pain in the knee
  • Heard a loud pop or snap during sport or exercise
  • Swelling in the knee after feeling pain
  • A feeling of looseness in the joint
  • An inability to put weight on the joint without pain, or any weight at all

Get down to your local physio ASAP. You’re only doing yourself further damage and increasing your chances of re-injury by putting it off.

[1] Schuett DJ, Hake ME, Mauffrey C, Hammerberg EM, Stahel PF, Hak DJ. Current treatment strategies for patella fractures. Orthopedics. 2015;38(6):377-84.


4 common treatment techniques used by musculoskeletal physiotherapists

Physiotherapy is a broad and multi-dimensional treatment process designed and ever expanding to treat a huge number of conditions. While physiotherapy mostly focuses on the diagnosis and rehabilitation of musculoskeletal and circulatory system issues, a growing number of practitioners also treat conditions like sports injuries, various forms of arthritis and respiratory problems such as cystic fibrosis. From bone breaks to bursitis to Temporomandibular Joint Pain, physiotherapists have a special knack for canvassing the human body for the cause of pain and dysfunction and getting it back to full performance using a number of high-tech and low tech treatment options. For all the technology in the world, a musculoskeletal physiotherapist gets the best results with their hands.

Below are the 5 most common treatment techniques used by physiotherapists every day in order to get their patients back to optimal health and performance, free of aches and pains.

  1. Physical examination and assessment

The first and most important step in the treatment process is the physical examination and assessment your physiotherapist will complete on your first visit. Expect to have a real deep and meaningful chat with your physio where they will ask you a number of detailed questions about your general health, activities and how your aches or pain came about. It’s at this point a good physio becomes a bit like Sherlock Holmes, sometimes it takes a bit of sleuthing to get to the bottom of some injuries and pain as they can be the result of an injury that starts in another area of the body.

Following the getting to know you part, your physio will begin to lay out a treatment plan personalised to your current situation. Depending on where you are on the injury and pain scale, the first course of action might be a prescription for some recovery and icing of the affected area before moving forward with physical therapy.

  1. Joint and soft tissue mobilisation

Joint and soft tissue mobilisation techniques are forms of manual therapy that have been tried and tested over decades. When joints and other soft tissue become painful due of trauma, overuse or disuse, they can become dysfunctional and unable to perform the movements they were designed for. Soft tissue injury is an umbrella term used to describe injuries affecting your muscles, tendons, or fascia that usually occur as a result of sprains, strains, contusions, tendonitis, bursitis and stress injuries. Soft tissue mobilisation has also been called therapeutic massage and has been designed to relax a patient’s muscles and reduce swelling in certain areas, making it a perfect treatment for relieving pain associated with sporting injuries.

Joint mobilisation is a technique used by physiotherapists by performing a back and forth oscillation of the joint in order to restore full range motion and limit pain. Joint mobilisation is helpful in cases where pain and joint tightness limit motion such as frozen shoulder. Joint mobilisation treatment varies depending on your circumstances but will generally include gentle joint mobilisations, joint manipulation and none of the old school snap, crackle and pop techniques that have little long term benefit.

  1. Acupuncture and Dry Needling

Dry needling and acupuncture are two of those treatments that always raise my patient’s eyebrows. At first, not many people are keen on the prospect of being jabbed with tiny needles, it sounds counterproductive to kicking pain doesn’t it? But after one session, they’re converts.

Contrary to popular belief, dry needling is not the same as acupuncture, although there are similarities between the techniques. The main difference between dry needling and acupuncture is found in the theories behind why each of the techniques works. Dry Needling focuses on the reduction of pain and restoration of normal function by releasing myofascial trigger points in muscle. In contrast, acupuncture is dedicated to the treatment of medical conditions via the restoration of the flow of energy (chi) through key points in the body to restore balance.

  1. Ergonomic, biomechanical and sports specific technique correction

If your visit to the physiotherapist was brought about by suffering an overuse or acute injury at work, during sport or just by living your normal life, you’re really doing yourself a disservice and increasing your chances of re-injury if you don’t take adequate steps at changing your movement patterns or technique. Poor technique and posture are two of the most common sources of repeat injury observed by physios. Biomechanical assessment, technique observation and diagnostic skills are all part of the skill set of your musculoskeletal physiotherapist and allowing them to observe you in your environment or using your regular physical techniques will ultimately help you to avoid musculoskeletal and sports injuries in the future.

Think of your local musculoskeletal physiotherapist as a pain doctor, or body mechanic. They have at their fingertips a range of tried and true methods of getting you back into 100% health and kicking that pain to the curb. If you are experiencing any muscular, joint or physical pain don’t hesitate to make a booking at your local 5 star rated physiotherapist on the Northern Beaches. Your body won’t regret it.


Putting up with chronic pain causes more problems

I was down at Manly Beach the other day sucking in some big ones having been worked for 90 mins solid by my beach volleyball coach Martine and couldn’t help but overhear a conversation two men were having. As a long practicing physio there are a few buzzwords I can’t help but tune into and when bloke 1 said to bloke 2 “hopefully my back sorts itself out soon, I haven’t had a surf in months” I was instantly hooked. Unfortunately, it’s common for me to see new clients who have been suffering a form of chronic pain or immobility due to a condition or injury for months, even YEARS, but every time I’m still shocked. Look, I know not everybody loves seeing the GP or attending to annoying medical issues when there are other things going on in life, but chronic pain is not something anybody should be living with for any extended period of time. It’s not only uncomfortable at the time, but chronic pain and the underlying causes can eventually cause permanent physical and even neurological damage to parts of the brain if left undiagnosed and untreated.

What is pain?

The simple version of pain as endorsed by The International Association for the Study of Pain is that it is as an unpleasant sensory and emotional experience associated with actual or potential tissue damage. But pain is not simple. Pain is not only a physical sensation, it can be influenced by a number of external factors such as personal attitude, personality, resilience and has the ability to negatively affect emotional and mental wellbeing. For example, take two people suffering the same ACL injury – they are experiencing the same condition, yet their experience of living with the pain will be vastly different and their recoveries will differ based on their physiological make-up along with their psychological attitudes.[1]

There are two main categories of pain that physiotherapists see and treat: acute and chronic.

Acute pain only lasts for a short time but can be incredibly intense. Commonly occurs after surgery or due to physical trauma such as a motor vehicle accident or a sporting injury. Acute pain is the body’s warning alarm telling you to seek help. Although acute pain usually improves as the body heals, sometimes it doesn’t.

Chronic pain is the type of pain that stays with you long after surgery or an immediate injury and is commonly caused by underlying conditions. Conditions like migraines, osteoporosis, arthritis and other musculoskeletal issues are all commonly diagnosed chronic diseases that musculoskeletal physiotherapists see all the time. Just to keep us on our toes, chronic pain can exist without a clear reason or underlying cause. Remember the definition above of pain; actual OR POTENTIAL tissue damage. Yes, you can have pain without any damage! Chronic pain is commonly a symptom of other diseases but can actually be a disease in its own right, caused by changes within the central nervous system.

How does pain work?

Your lower back pain, knee pain, neck pain, ankle pain and every other pain all the way to your little pinky pain comes from the brain itself. Pain is the end result of your brain evaluating information and coming up with a best guess of how to translate that information and to where. Your body contains nerves called nociceptors that detect any dangerous changes in temperature, chemical balance or pressure in your body and send alerts to the brain, but the pain you feel is all in the brain and controlled by the brain. Thanks heaps brain.

Most of the time your brain gets it right, but sometimes it doesn’t. For example, referred pain in your leg is common to experience when it is actually your lower back causing the issue. Another example of the brain’s power is phantom limb pains commonly experienced by amputees in limbs that are no longer there. If that’s not the perfect example of the power of the brain, I don’t know what is. They have pain when the limb doesn’t even exist!!

How can ignoring chronic pain lead to more problems?

I’m sure other physiotherapists on the Northern Beaches are just as sick of hearing ‘no pain, no gain’ applied to every painful scenario as I am. Even during and after short term bouts of experienced pain, your brain increases stress hormones in your body, which can make it harder to think, cause anxiousness, lethargy, fatigue, slower recovery and lead to muscle tightness. Even that “dicky knee when it gets cold”, that “sore back” or “dodgy shoulder” is capable of causing long term physical and psychological effects. Pain affects the proper functioning, strength and efficiency of the human body. This often leads to altered movement patterns, compensatory tightness in other areas of the body, limb weakness and can cause chronic stiffness and exacerbate the pain.

It is imperative to address any pain as soon as you realise that it is not just going to disappear in a couple of days. Your GP will agree with musculoskeletal physiotherapists that the evidence supporting early treatment in almost any acute injury or painful condition is well documented.

Don’t let your pain today progress and evolve into more than something that can be relatively easily fixed with physio intervention. Instead of thinking “no pain, no gain” when you get an injury, focus on allowing yourself to understand that we need to heal, we need to relax and we need to look after ourselves because putting your body and brain through continuous pain is doing much more harm than good.

[1] McArdle S. Psychological rehabilitation from anterior cruciate ligament-medial collateral ligament reconstructive surgery: a case study. Sports Health. 2010;2(1):73–77. doi:10.1177/1941738109357173


Ankle injuries: Do I need an x-ray?

Ankle injuries, particularly ankle sprains are among the most common injuries seen by sports physiotherapists. Especially on the Northern Beaches where people are out and about playing sports, running and generally doing things that put them at more risk of doing themselves a mischief.

So, you’ve just rolled your ankle down at the beach playing volleyball and it hurts like heck! What do you do?

Hundreds of thousands of people attend emergency rooms around the world with ankle injuries, usually sustained recreationally or in a simple fall. Most of the time, these people end up having a simple soft tissue injury or a small fracture of no clinical significance. With most people just going straight for the emergency room, they’re exposing themselves not just to the germs of the emergency ward, but also to x-ray radiation for possibly no benefit.

Ankle injuries make up around 5% of all patients who visit emergency rooms. Fewer than 15% of them will have a clinically significant fracture.[1] Some will have more serious fractures, requiring immobilisation or internal fixation, but there are more ways than one to determine whether you have a more serious injury of the ankle.

Are x-rays needed? Turn to the Ottawa rules

Ankle sprains cause pain, oedema, ecchymosis, and often make it impossible to bear weight without pain. Even though uncomplicated sprains usually heal with physio treatment, other ankle injuries may require a more surgical approach.

Differentiating between a simple and complicated injury is not always easy, particularly for relatively inexperienced physiotherapists. This is why a series of tests and rules have been developed to serve as guidelines for sports physios to diagnose ankle injuries and to determine the indications for radiography.[2]

The Ottawa foot and ankle rules are an evidence-based guide that helps determine the use of initial x-rays after acute ankle injury. The rules state:

An ankle X-Ray series is required if there is any pain in the malleolar zone and:

  • Bone tenderness at the posterior edge or tip of the lateral malleolus


  • Bone tenderness at the posterior edge or tip of the medial malleolus


  • An inability to bear weight both immediately and in the emergency department for four steps

A foot X-Ray series is required if there is any pain the midfoot zone and:

  • Bone tenderness at the base of the fifth metatarsal


  • Bone tenderness at the navicular


  • An inability to bear weight both immediately and in the emergency department for four steps

In a recent review of 27 studies evaluating the implementation of the Ottawa ankle rules, a hit rate of almost 100% was found for the rules, with a possibility of reducing the number of unneeded x-rays by between 30–40%.[3] With a reliability of nearly 100%, the rules have also shown to diagnose and exclude ankle and foot fractures in children and young adults.[4]

Of course, the value of a normal x ray in providing reassurance and diagnosis of more serious injuries is still relevant. However, the Ottawa ankle rules provide a high level of diagnostic confidence in the absence of x-rays when considering treatment options and recommendations for return to activity.

If you have hurt your ankle, don’t waste any time in getting to your local sports or musculoskeletal physio ASAP. They will be able to take you through an in-depth physical assessment and likely determine the severity of your injury without clogging up emergency rooms and exposing yourself to radiation in the process.


[1] Heyworth, J. (2003). Ottawa ankle rules for the injured ankle. British Journal of Sports Medicine, 37(>3), 194–194.

[2] Stiell IG, Greenberg GH, McKnight RD, et al. Decision rules for the use of radiography in acute ankle injuries: refinement and prospective validation. JAMA 1993;269:1127–32.

[3] Bachmann LM, Kolb E, Koller MT, et al. Accuracy of Ottawa ankle rules to exclude fractures of the ankle and mid-foot: systematic review. BMJ 2003:326:417–9.

[4] Plint AC, Bulloch B, Osmond MH, et al. Validation of the Ottawa ankle rules in children with ankle injuries. Acad Emerg Med 1999;6:1005–9.

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