Diagnosing and treating Quadriceps strains and injuries

If I had a dollar for every time I saw a new patient who had been self treating a “quad strain” for months when the pain is actually from something completely different, I could be retired right now.

Your thigh and quadriceps might seem like a straightforward area to self diagnose when you’re feeling pain, but it’s actually a rather complicated musculoskeletal zone.

Without treatment from a sports physio or musculoskeletal specialist, thigh pain can linger and deteriorate into a more serious ailment. Thankfully, with the right diagnosis and treatment, your thigh pain is unlikely to become chronic.

Are my thighs and quadriceps the same thing?

No. Your thigh includes the quadriceps femoris, but the quads alone are not the entire thigh. Your thigh is actually a region made up of 3 main groups of muscles:

  • The quadriceps (located at the front of your leg)
  • The adductors (on the inside area of your leg)
  • The hamstrings (at the rear of your leg towards your glutes)

The quadriceps is comprised of four muscles that connect just above your knee:

  • The Vastus Lateralis (located to the outside of your thigh)
  • The Vastus Intermedius (located in the centre of your thigh)
  • The Rectus Femoris (smaller and located at the front of the thigh covering the Vastus Intermedius)
  • The Vastus Medialis (to the inside of your thigh)

What are the signs of a quadriceps strain and how is it treated?

As with most muscular and tendon tears, thigh strains are divided into three grades:

  • Grade one – the symptoms of a grade 1 tear may not be present until after the activity is over. It can commonly feel like a thigh cramp with associated tightness and mild pain when the muscles are stretched or contracted.
  • Grade two – you will feel immediate pain during stretch and muscle contraction worse than a grade 1 injury and is usually sore to touch.
  • Grade three – is a serious injury where the muscle is completely torn. You will feel an immediate burning or stabbing pain in your thigh that will stop you being able to walk without pain and there may even be a large lump of muscle tissue above a depression accompanied by bruising.

Your thigh is a prime area for referred pain

What is referred pain? Pain is a continually evolving science that we don’t know everything about yet. Referred pain is any pain felt at a location in your body that is not the direct source of the pain.

Have you ever visited a physio for a sore shoulder and the first place they started looking at was your neck? That’s referred pain.

Due to your thigh’s proximity to the groin, pelvis and role in ITB function, it is a prime candidate to feel referred pain from any number of local regions.

Thigh pain can also be the manifestation of:

  • Sciatica type symptoms – your femoral nerve can refer pain to the front of your thigh
  • Hip joint conditions such as arthritis
  • Meralgia Paresthetica – when the lateral femoral cutaneous nerve becomes impinged
  • Lower back pain
  • Vascular problems such as a deep venous thrombosis
  • And rarely; a fracture to the femur bone

As a musculoskeletal physio we have years of clinical experience diagnosing and treating thigh injuries of all kinds along with diagnosing causes of referred pain to the thigh. After a detailed clinical assessment of your injury, biomechanics, sporting technique and muscle coordination, we will devise a rehabilitation program tailored to your needs.

Give us a call on (02) 8964 4086 or book an appointment and info@fixio.com.au


Throwing biomechanics and common throwing injuries

Summer is nearly here and that means Northern Beaches cricketers will be dusting off the whites and getting ready for a spit free Summer of cricket. It also means your local Dee Why physio is getting prepared for the annual increase in throwing injuries and other shoulder, elbow and wrist injuries.

While throwing injuries usually occur in throwing sports such as cricket, softball, javelin and water polo, they can also pop up in sports that simply use a lot of overhead rotation and movement like serving in volleyball and tennis.

The biomechanics of throwing

Throwing is the co-ordinated effort of a number of muscle groups and is one of the fastest actions human beings can perform. Major league pitchers’ maximum humeral internal rotation velocity has been measured at over 7500°/second.[1]

An overhead throw has 6 phases:

  • wind up,
  • stride,
  • cocking,
  • acceleration,
  • deceleration and
  • follow through


Escamilla RF, Andrews JR. Shoulder muscle recruitment patterns and related biomechanics during upper extremity sports[2]

Throwing injuries tend to occur due to overuse, poor throwing technique and can come on gradually, sneaking up on you before you realise you’ve done yourself a painful injury.

Throwing injuries most commonly occur in the shoulder of the throwing arm, but can also appear as elbow and wrist complaints too.

Shoulder injuries

The shoulder is the most common location for injuries from throwing and overhead movements and different phases of throwing gives us the possibility of all kinds of different injuries.[3]

  • Windup – No injuries are common
  • Cocking – Anterior subluxation, internal impingement, glenoid labrum lesions, subacromial impingement.
  • Acceleration – Shoulder instability, labral tears, overuse tendinitis, tendon ruptures.
  • Deceleration – Labral tears at the attachment of long head of biceps, subluxation of long head of biceps by tearing of transverse ligament, lesions of rotator cuff
  • Follow Through – Tear of superior aspect of glenoid labrum at the origin of biceps tendon, subacromial impingement.

Elbow injuries

During the throwing motion, your arm is acting like a whip just before it cracks. This leaves your elbow under a lot of stress and at risk of injury as well.

That repetitive sideways force to the elbow combined with a poor throwing technique is the recipe for a Medial Collateral Ligament Sprain and swelling and pain.

How do physiotherapists treat throwing injuries?

A number of factors contribute to the development of throwing injuries and your physio will do an in-depth biomechanical and injury assessment before getting stuck into your new program.

A bespoke program designed by a musculoskeletal physio will aim to:

  • Improve shoulder flexion, abduction, external and internal rotation
  • Utilise manual and massage therapy techniques on muscle tightness in your latissimus dorsi, pectorals, rotator cuff, abdominals & hip flexors
  • Improve thoracic spine flexibility when performing extension and rotation of throwing

Help prevent throwing injuries with help from your physio

Whether you’re a weekend warrior or an elite athlete, a musculoskeletal physio is a goldmine for injury prevention techniques to ensure you can maintain optimal performance while taking care of your body.

A visit to a physio can help decrease your chances of injury in the future.

  • Help to correct your throwing technique

Ensure your throwing technique is safe and efficient, minimising the risk of injury to the shoulder and elbow. Make sure you use the whole body, including the legs and hips rather than confining the throwing motion to the upper body.

  • Improving flexibility

Upper back flexibility is extremely important for athletes that throw or use overhead motions regularly. Not only does upper back flexibility help with injury prevention to the shoulder, but it also acts as a performance enhancer. Having adequate flexibility in your upper and lower body is important to improving your throwing technique, reducing the risk of injury and performing to your full potential Key joints which require adequate range of motion for throwing include:

  • Shoulder
  • Elbow
  • Upper Back
  • Lower Back
  • Hips
  • Core

For more information on throwing injuries, injury prevention techniques and managing sports injuries, give us a call on (02) 8964 4086 and send an email to info@fixio.com.au.

[1] Seroyer ST, Nho SJ, Bach BR, Bush-Joseph CA, Nicholson GP, Romeo AA. The kinetic chain in overhand pitching: its potential role for performance enhancement and injury prevention. Sports Health. 2010 Mar;2(2):135-46. doi: 10.1177/1941738110362656. PMID: 23015931; PMCID: PMC3445080.

[2] Escamilla RF, Andrews JR. Shoulder muscle recruitment patterns and related biomechanics during upper extremity sports. Sports Med. 2009;39(7):569-90. doi: 10.2165/00007256-200939070-00004. PMID: 19530752.

[3] Houglum PA, Bertoti DB. Brunnstrom’s clinical kinesiology. FA Davis; 2012

Stay at home and do your home exercise program

While it’s outside of the scope of my practice as a sports physio to prescribe medication, as rehabilitation and pain specialists, physiotherapists regularly prescribe exercise to maximise recovery for our patients 

But why do physiotherapists do that? Aren’t they supposed to take care of everything during the consultation at the clinic? 

Compliance with home exercises throughout a patient’s rehab is one of the most important indicators of rehab success. Many patients find it hard to stay consistent with a home exercise program because of their work, family, and school commitments. 

But now that we’re all at home, there’s plenty of time to make sure we’re all doing what we need to in order to recover from those injuries. 

Why are home exercises so important? 

Creating a bespoke home exercise program (HEP) to patients is one of the fundamental aspects of great physiotherapy. Research has shown that patients who follow their prescribed exercises are significantly better at achieving their goals and demonstrate a greater increase in physical function.1  

Exercise at home is designed by your physio to continue the progress made at the clinic. Bworking on things like increasing your flexibility and stamina at home, home exercise programs allow you to increase function and improve muscle memory so that progress is actually gained instead of lost between visits. 

To recover from an injury, developing an exercise routine is one of the most important things you can do.  

Here are just a few reasons why sticking to your physio created HEP is important: 

  • Home exercises are specifically designed to improve muscle memory 
  • Research shows that patients who comply with their HEP are more likely to reach their rehab goals like pain reduction and physical movement 
  • Home exercises can be the beginning of a new active lifestyle 
  • Home exercise compliance helps prevent recurring injury and flare-ups  

How often do you do your homework? 

 If you answered rarely, you’re like most Australians.  Research shows that up to 65% of people don’t complete their home exercise programs! Instead of detention though, it could be long term pain or lack of movement you’re risking. 

While our in-clinic treatment is designed to decrease pain and improve mobility, without strengthening or improving flexibility consistently, your condition won’t improve. 

Your Fixio home exercise program is personalised for your needs 

When our Fixio physiotherapists implement a home exercise program for you, the exercises are tailored to each individual. Even when two people have the same injury, the requirements of each person’s body is different and is influenced by their individual history. 

For example, two people with the same rotator cuff injury may not have the same HEP due to a previous injury or muscular impairment. Individual history like this dictates the type of exercises– whether they are stretches, strength training or endurance training. 

With a personalised approach, patients enjoy quicker recovery times and reduced chances of recurrence. As you gradually recover, your Fixio physio will assess your HEP and increase or change your program with your tolerance, so that your pain does not increase. 

At Fixio Physiotherapy, your sports physio or musculoskeletal physio will work closely with you to provide a repeatable, realistic and trackable home exercise program.  Whether you want to spend 10 minutes a day through to hours on end, your physiotherapist will develop a home exercise program that is not only beneficial but realistic to complete. 

If you have any questions about your home exercise program and what it contributes to your recovery talk to your physio. Education and understanding are crucial to making sure your experience throughout recovery is positive and effective. Call us today or book online for a consultation to ensure you are doing the best exercises as part of your rehabilitation. 


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.



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.