Musculoskeletal Physiotherapy (MSK)

Achilles-Tendinopathy-patient-information (1MB docx)

The Achilles tendon is found just behind and above your heel. It joins your heel bone (calcaneum) to your calf muscles. The function of the Achilles tendon is to help you go up on your tiptoes, therefore it is involved in walking, running and jumping.
Achilles tendinopathy occurs when the tendon is unable to adapt to the strain being placed on it. This leads to repeated small amounts of damage within the tendon fibres & results in the tendon trying to heal itself in response to the strain. It can occur at the attachment to the heel and in the middle of the tendon.

How is it caused?

• Not being fit enough to cope with demands placed on the tendon
• Sudden changes in the intensity or amount of exercise e.g. running
• Repetitive activities
• Tight and/or weak calf muscles
• Stiff joints in the foot
• Smoking and some metabolic conditions e.g. diabetes, high cholesterol raise the risk of having tendon problems

What are the symptoms?

• Pain above the back of the heel, as well as stiffness (especially in the morning).
• Pain after running & while running, which worsens a few hours after the run.
• As the pain progresses you find you are unable to run as far before it comes on, and the pain may stick around for an hour or two after exercise.
• It often eases somewhat with activity and exercise.
• Tight and stiff calves.
• Usually there will be localised swelling at the painful site, forming a bump.

How is it diagnosed?

Diagnosis is generally made clinically following a history taking and physical examination.

What can I do?

Reduce the tendon’s use:

Reduce the amount of walking and running that you do. Use heel wedges or shoes with a raised heel, including running shoes.

Medication

Medication such as paracetamol or anti inflammatories such as ibuprofen may also help to reduce your symptoms. If you require further information on pain relief, speak to your GP or pharmacist.

Ice

Ice the painful site for a maximum of 20 minutes following activity.

Exercise

Exercise is an essential towards improving Achilles tendinopathy. Exercises should be done as pain allows, with some discomfort being acceptable as long as it settles within 30 minutes and is not worse the next day. If a sharp shooting pain is provoked then ease off. As your pain reduces and your movement improves consider progressing to the more difficult exercises.
 

Final stage of recovery

Continue swimming and cycling as much as the pain will allow.
If you can do 3 sets of 8 to 15 repetitions of single leg calf raises comfortably, begin short bursts of jumping, skipping or running on the spot.
Restart running, beginning on grass for 5 to 10 minutes, and build up your normal training over the next 2 to 3 months.

Factors influencing pain and recovery

During your recovery a number of other factors can influence your pain levels. Keep the following factors in mind to help move the healing process along.

Sleep

Sleep is very important for your wellbeing. Poor sleep quality, and lack of sleep can make managing pain more difficult. Consistently getting 6 to 9 hours is recommended.

Get help and tips on sleep and tiredness on the NHS Website.

Nutrition and weight

Being overweight can increase the physical strain on the body and also contribute to inflammation in your body. Make sure you eat a balanced diet. Adult weight management services are available free to Essex residents.

Smoking

Smoking can also impact how quickly tissues can heal and affect pain levels. For help with stopping smoking help can be found on the Essex lifestyle website or the NHS Quit smoking website.

Physical Activity

Maintain your leg, arm and trunk strength whilst also working on specific Achilles exercises. E.g. cycling, body weight exercises or weight training like squats and lunges.

Work

You may be worried about continuing with work, or other responsibilities. It is important to discuss these fears with your practitioner. Remaining at work usually leads to a quicker recovery even if you have to work with modified activities.
Your relationship with your boss and colleagues, job enjoyment, feeling supported at work and returning to work are all very important in helping your recovery. Speak to your employer if you need support at work.

Look after yourself

Pain is not usually simply a physical problem. Your general well-being can make you vulnerable to pain and your wellbeing can also be made worse by pain. Looking after your general health and well-being will help recovery.  There is helpful advice on the NHS website.

Reduce stress and anxiety

It is normal for people with pain to have stress, anxiety and change in mood. This may affect your ability to cope with the pain and may influence your pain levels. Help is available if you are being affected by stress, anxiety or low mood – see the links below or discuss with your practitioner.

It is important that your whole nervous system is in a healthy state to aid recovery. If your brain is stressed or overworked this may slow recovery. Relaxation is an important part of your recovery. Simple relaxation techniques may help manage pain and stress. Try to set aside some time each day to relax – you can use relaxation techniques as linked below, or simply an activity you enjoy – reading, deep breathing, sitting in the garden, singing – whatever relaxes you.

Find help and support on the NHS website & the North Essex NHS Website.

How long will it last?

• For most people Achilles tendinopathy can take from 3 to 6 months to settle down.
• It is important to modify activity until the symptoms settle down while carrying out the exercises.
• If there is no improvement in symptoms after following the above advice for 3 months seek help from a Physiotherapist/GP.

What other options are there?

Physiotherapy

Physiotherapists can provide specialist education and advice regarding exercise. If you wish to receive 1:1 physiotherapy treatment please fill out a self-referral form and send to [email protected].

Extracorporeal Shockwave therapy

ESWT is a procedure where audible, low energy sound waves are passed through the skin to the injured area. It is a safe minimally invasive treatment but can give some discomfort/pain. It is still uncertain how effective this treatment is for Achilles tendinopathy.

Surgery

This is not routinely recommended and is only considered if symptoms remain disruptive despite the treatments discussed in this leaflet. Surgery generally involves removing the diseased areas of tendon.
Steroid injections are not recommended in or around the Achilles tendon due to the risk of rupture.

Useful websites:

NHS Tendonitis

Achilles tendinopathy

Note: This information is intended as general information only.

acromioclavicular-joint-pain-patient-information-leaflet_branded (1MB docx)

Non traumatic acromioclavicular joint pain is associated with the small joint on the top of the shoulder where the collar bone (clavicle) joins the front of the shoulder blade (acromion). It is a joint which moves mostly when reaching up high or across the chest.

How is it caused?

The joint often can become painful following repetitive activities. Eventually, the cartilage thins and the surrounding bone grows thicker. You may be more likely to develop acromioclavicular joint pain if you participate in activities involving throwing or repeated overhead motion.

What are the symptoms?

Pain and tenderness at the top of the shoulder over the joint which may radiate along the collarbone.
Pain when reaching the arm across the body and reaching up high.

How is it diagnosed?

Acromioclavicular joint pain is generally diagnosed by a clinical examination. X-Rays and MRI scans may reveal degenerative changes however this can be a common finding (between 76 to 82%) in patients without pain. Imaging is not recommended in the first instance unless another cause is suspected or more invasive treatment is being planned. Your Physiotherapist or GP is able to determine if imaging is required following your examination.

What can I do?

Activity Modification

In the majority of cases acromioclavicular joint pain will improve if you temporarily reduce the pressure through the affected shoulder to a level which does not aggravate your pain (such as reducing repeated overhead activity). This will allow your symptoms to settle.

Exercise

Keep active to keep muscle strength from diminishing. By building up exercise slowly and gradually you can keep or even improve joint flexibility.
Exercises should be done as pain allows, with some discomfort being acceptable. If a sharp shooting pain is provoked then ease off. As your pain reduces and your movement improves consider progressing to the more difficult exercises.

Medication

Over-the-counter analgesia, such as paracetamol or anti inflammatories such as ibuprofen may also help to reduce your symptoms. If you require further information on pain relief, speak to your GP or pharmacist.

Factors influencing pain and recovery

Whilst you are experiencing acromioclavicular joint pain a number of other factors can influence your pain levels. Keep the following factors in mind to help move the healing process along.

Look after yourself

Pain is not usually simply a physical problem. Your general well-being can make you vulnerable to pain and your wellbeing can also be made worse by pain. Looking after your general health and well-being will help recovery.  There is helpful advice on the NHS website.

Reduce stress and anxiety

It is normal for people with pain to have stress, anxiety and change in mood. This may affect your ability to cope with the pain and may influence your pain levels. Help is available if you are being affected by stress, anxiety or low mood – see the links below or discuss with your practitioner.
It is important that your whole nervous system is in a healthy state to aid recovery. If your brain is stressed or overworked this may slow recovery. Relaxation is an important part of your recovery. Simple relaxation techniques may help manage pain and stress. Try to set aside some time each day to relax – you can use relaxation techniques as linked below, or simply an activity you enjoy – reading, deep breathing, sitting in the garden, singing – whatever relaxes you.

Find help and support here:

NHS Website
North Essex IAPT

Physical Activity

Exercise improves fitness, confidence with movement and strength. It can also help reduce your stress and tension and improve your mood and quality of sleep, helping support you to return to normal activities. Perhaps you could simply start by trying to walk for 10 minutes per day.

Alcohol

Avoid alcohol in the early stages of healing (first three days). Evidence has shown this can slow down recovery and increase the chances of re-injury. Find more information on the Drinkaware website.

Sleep

Sleep is very important for your wellbeing. Poor sleep quality, and lack of sleep can make managing pain more difficult. Consistently getting 6 to 9 hours is recommended. Get help and tips on the NHS Wesbite.

Smoking

Smoking can also impact how quickly tissues can heal and affect pain levels. For help with stopping smoking Essex lifestyle service or the NHS Better health website.

How long will it last?

You can expect a flare up in your symptoms to last anywhere between a few weeks to a couple of months. If your acromioclavicular joint has significant degenerative changes you may experience some ongoing symptoms.
If your symptoms have persisted or worsen despite following the advice and exercise provided in this leaflet you will need to visit your GP surgery again.

Is there anything I should avoid?

Keep repetitive overhead activity to a minimum.
Avoid complete rest where possible. Rest only when joints are very painful.

What other options are there?

Physiotherapy

Physiotherapists can provide expert guidance with exercise to help you return to normal activity.
If you require 1:1 physiotherapy treatment please fill out a self-referral form and send to [email protected].

Steroid injections

Steroid injections may provide pain relief. These are used if your pain is severe and preventing you from enjoying your normal activities. Some research suggests these benefits could last for up to 6 months.

Surgery

Referral for an orthopaedic opinion would be considered for patients whose symptoms remain unacceptable despite an appropriate period of relative rest, pain relief, an exercise programme and a corticosteroid injection over a period of 4 to 6 months.

Surgery involves removing the damaged part of the acromioclavicular joint. This can be done through either open or keyhole procedures. Possible side effects include ongoing weakness, instability and pain.

ankle-osteoarthritis-patient-information-leaflet_branded (578kB docx)

Osteoarthritis is a condition that affects the joints, causing pain and stiffness. It is made up of two joints which allows your foot to move up and down and from side to side. When the ankle develops osteoarthritis, some of the cartilage roughens and becomes thin and the joint doesn’t move as smoothly as it should. In severe cases the cartilage can become so thin that it no longer covers the bone resulting in reduced joint space which can be a cause of pain.

How is it caused?

Osteoarthritis of the ankle can be caused by a combination of factors:

• Previous joint injury such as repeated sprains or ankle fractures
• Age: occurs mostly in those aged over 40.
• Gender: it is twice as common in women.
• Obesity: Being overweight increases the strain on your joints.
• Genetic factors: if a close family member has osteoarthritis, you are more likely to develop the condition.

What are the symptoms?

Ankle osteoarthritis can present differently in everyone. The most common symptoms include:

• Pain and difficulty weight bearing                                                  
• Early morning joint stiffness less than 30 minutes
• Reduced movement
• Crepitus (grating/grinding)
• Giving way
• Locking

How is it diagnosed?

Ankle osteoarthritis is normally diagnosed based on the signs and symptoms identified during a physical examination. X-rays taken in standing can be useful but are not always required. There are no blood tests for osteoarthritis but they can be used to rule out other conditions.

What can I do?

Stay Active

When you have osteoarthritis it is important to keep active. Exercise has been shown to ease pain and improved function for people with ankle osteoarthritis. Gentle exercise in the form of specific exercises for your joint (see below), or more generalised activity such as swimming or walking, can help you can strengthen the muscles and protect the joint.
These exercises should be done 2 to 3 times daily up to 10 times each. They may make your muscles ache initially. Stop if the exercises severely aggravate your symptoms.

Medication

Over-the-counter analgesia, such as paracetamol or anti inflammatories such as ibuprofen may also help to reduce your symptoms. If you require further information on pain relief, speak to your GP or pharmacist.

Warmth

Can help reduce symptoms, use for 10 minutes twice daily.

Weight management

Some studies have shown that losing weight can help to reduce the frequency of ankle pain from 34% to 2% in previously obese patients.

Aids

Walking aids can help to reduce some of the load through your joint. Ankle supports and braces can be used to reduce instability in severe cases.

Pacing your activities

Try to find the right balance between activity and rest to avoid overstraining your joints.

Footwear

Getting the right footwear is important to support your ankle and prevent further injury. High heels and unsupportive shoes such as flip flops can increase your risk of further injury.

Factors influencing pain and recovery

During your recovery a number of other factors can influence your pain levels. Keep the following factors in mind to help move the healing process along.

Look after yourself

Pain is not usually simply a physical problem. Your general well-being can make you vulnerable to pain and your wellbeing can also be made worse by pain. Looking after your general health and well-being will help recovery.  There is helpful advice on the NHS website.

Reduce stress and anxiety

It is normal for people with pain to have stress, anxiety and change in mood. This may affect your ability to cope with the pain and may influence your pain levels. Help is available if you are being affected by stress, anxiety or low mood – see the links below or discuss with your practitioner.
It is important that your whole nervous system is in a healthy state to aid recovery. If your brain is stressed or overworked this may slow recovery. Relaxation is an important part of your recovery. Simple relaxation techniques may help manage pain and stress. Try to set aside some time each day to relax – you can use relaxation techniques as linked below, or simply an activity you enjoy – reading, deep breathing, sitting in the garden, singing – whatever relaxes you.

Find help and support here:

NHS Website
North Essex IAPT

Physical Activity

Exercise improves fitness, confidence with movement and strength. It can also help reduce your stress and tension and improve your mood and quality of sleep, helping support you to return to normal activities. Perhaps you could simply start by trying to walk for 10 minutes per day.

Alcohol

Avoid alcohol in the early stages of healing (first three days). Evidence has shown this can slow down recovery and increase the chances of re-injury. Drink aware.

Sleep

Sleep is very important for your wellbeing. Poor sleep quality, and lack of sleep can make managing pain more difficult. Consistently getting 6-9 hours is recommended. Get help and tips on the NHS website.

Smoking

Smoking can also impact how quickly tissues can heal and affect pain levels.
For help with stopping smoking there is help and advice on the NHS website.

How long will it last?

You can expect a flare up in your symptoms to last anywhere between a few weeks to a couple of months. If your ankle joint has significant degenerative changes you may experience some ongoing symptoms. If your symptoms have persisted despite following the advice and exercise provided in this leaflet you may need the guidance of a physiotherapist to help you return to normal activity.

If you require 1:1 physiotherapy treatment please fill out a self-referral form and send to [email protected]
If your symptoms have worsened despite the advice given we would recommended you see a healthcare professional for review.

Is there anything I should avoid?

Over rest

Your symptoms are more likely to get worse if you sit and do nothing; too much rest is likely to increase stiffness and can result in muscle weakness.

High impact activities

Jumping, hopping, skipping and running may aggravate your symptoms if done too much too quickly.

What other options are there?

Injections

Studies have shown a steroid injection into the ankle joint can provide short (6 weeks) to medium term (3 months) pain relief.

Surgery

Depending on the severity of your symptoms, XR findings and medical history, you may be referred to an orthopaedic consultant for an opinion regarding surgery.

Different types of surgery include:

• Arthroscopy: is a keyhole surgery where the ankle is washed out and any bony spurs and damaged cartilage can be removed.
• Arthrodesis: (also known as fusion) aims to fuse the ankle bones together, using screws, to eliminate motion in the joint thus reducing pain and improving function. This will affect the way you walk so should be discussed fully with your surgeon.
• Total Ankle Replacement: aims to improve pain while maintaining some of the motion in the joint. The joint is replaced with a prosthetic joint.

ankle-sprain-patient-information-leaflet_branded (1MB docx)

A sprained ankle occurs when the ligaments of the ankle are injured. Ligaments are strong bands of tissue that connect one bone to another and help hold joints together.

How is it caused?

A sprained ankle occurs when a ligament is forced into an abnormal position, causing it to overstretch.
The most common type of ankle sprain is when the sole of your foot turns inwards, overstretching the ligaments on the outside of your ankle and squeezing those on the inside.

Ankle sprains are more likely to occur:

• If you are female.
• If you are under or over weight.
• If you have limited ankle range of motion.
• If you have poor balance/coordination.
• During activities involving jumping.
• Wearing high heeled shoes.

Ankle sprains occur in different severities. The 3 grades of ankle sprain are:

• Grade 1 – a mild strain (typically involving less than 10% the fibres).
• Grade 2 – a partial ligament tear (typically involving between 11 to 49% of the fibres)
• Grade 3 – a complete ligament tear (typically involving more than 50% of the fibres)

Diagnosis is generally made clinically following a history taking and physical examination.
You may be referred for an X-Ray if an ankle fracture is suspected. If your ankle is not recovering as expected with rehabilitation you may be referred for further investigations such as an Ultrasound or MRI scan.

What are the symptoms?

Signs and symptoms of a sprained ankle vary depending on the severity of the injury.

They may include:

• Pain, especially when you bear weight on the affected foot
• Tenderness when you touch the ankle
• Swelling
• Bruising
• Restricted range of motion
• Instability in the ankle
• Popping sensation or sound at the time of injury

What can I do?

In the early stages (48 to 72 hours)

Over-the-counter analgesia, such as paracetamol or anti inflammatories such as ibuprofen may also help to reduce your symptoms. If you require further information on pain relief, speak to your GP or pharmacist.

Progressive Exercise

Exercise is an essential part of your recovery following an ankle sprain. Coordination and balance training have been shown to prevent recurrent ankle sprains. They should be done as pain allows, with some discomfort being acceptable. If a sharp shooting pain is provoked then ease off. As your pain reduces and your movement improves consider progressing to the more difficult exercises.

Factors influencing pain and recovery

During your recovery a number of other factors can influence your pain levels. Keep the following factors in mind to help move the healing process along:

Look after yourself

Pain is not usually simply a physical problem. Your general well-being can make you vulnerable to pain and your wellbeing can also be made worse by pain. Looking after your general health and well-being will help recovery.  There is helpful advice on this website: https://www.nhs.uk/oneyou

Reduce stress and anxiety

It is normal for people with pain to have stress, anxiety and change in mood. This may affect your ability to cope with the pain and may influence your pain levels. Help is available if you are being affected by stress, anxiety or low mood – see the links below or discuss with your practitioner.
It is important that your whole nervous system is in a healthy state to aid recovery. If your brain is stressed or overworked this may slow recovery. Relaxation is an important part of your recovery. Simple relaxation techniques may help manage pain and stress. Try to set aside some time each day to relax – you can use relaxation techniques as linked below, or simply an activity you enjoy – reading, deep breathing, sitting in the garden, singing – whatever relaxes you.

Find help and support here:

NHS mind matters Website
North Essex IAPT

Physical Activity

Exercise improves fitness, confidence with movement and strength. It can also help reduce your stress and tension and improve your mood and quality of sleep, helping support you to return to normal activities. Perhaps you could simply start by trying to walk for 10 minutes per day.

Alcohol

Avoid alcohol in the early stages of healing (first three days). Evidence has shown this can slow down recovery and increase the chances of re-injury. Drink aware website.

Sleep

Sleep is very important for your wellbeing. Poor sleep quality, and lack of sleep can make managing pain more difficult. Consistently getting 6 to 9 hours is recommended. Get help and tips here on the NHS wesbite.

Smoking

Smoking can also impact how quickly tissues can heal and affect pain levels.
For help with stopping smoking there is help and advice on the NHS website.

How long will it last?

In the first few weeks you will weight bear as pain allows using the support from elbow crutches and an ankle support if necessary.
Mild sprains would be expected to recover within 3 to 4 weeks.
Moderate or severe sprains treated conservatively would be expected to recover within 6 to 8 weeks.

You may need the guidance of a physiotherapist to help you return to normal activity:

• If your injury is more severe;
• If you wish to return to sports involving jumping activities or high speed movement; or
• If your symptoms have persisted despite following the advice and exercise provided in this leaflet.
• If you require 1:1 physiotherapy treatment please fill out a self-referral form and send to [email protected]

Is there anything I should avoid?

Overstretching within the first few weeks can put too much strain on the healing tissue.
Returning too quickly to activity involving high speed movement within the first 30 to 50 days has the potential to cause further injury. A gradual re-introduction to running is advised.

What other options are there?

Bracing

In more severe cases an ankle brace may be worn for 4 to 6 weeks after your injury to help with your recovery.

Physiotherapy

Manual mobilisation of joints combined with exercise therapy has been shown to result in short term increases in ankle range of motion and reductions in pain.

Surgery

Surgery is mainly reserved for patients who have chronic instability after an ankle sprain and who have not responded to a comprehensive exercise-based physiotherapy programme.

base-of-thumb-osteoarthritis-patient-information-leaflet_branded (360kB docx)

It is a common form of arthritis which can affect the joint at the base of the thumb. This joint is known as the Carpometacarpal joint.

How is it caused?

It can develop gradually overtime or after using the thumb for activities that are more demanding more than normal in a short space of time.

There are a number of risk factors that increase the risk of developing osteoarthritis including:

• Being female over the age of 40.
• Previous trauma or surgery to the affected joint.

What are the symptoms?

Pain at the base of the thumb made worse with movement and eased with rest.

• Difficulty gripping
• Stiffness after long periods of rest
• Swelling at the base of the thumb
• In more severe cases deformity of the joint with bony spurs

How is it diagnosed?

Diagnosis is generally made clinically following a history taking and physical examination. An X-ray may be requested to assess the joint prior to further treatment.

What can I do?

Exercise

Exercise can help to ease pain and improve function. Gentle exercises (see below) can be trialled whilst keeping pain at an acceptable level. If pain builds up to much, try less repetitions and check your technique.

Medication

Over-the-counter analgesia, such as paracetamol or anti inflammatories such as ibuprofen may also help to reduce your symptoms. If you require further information on pain relief, speak to your GP or pharmacist.

Joint protection

Consider adjusting the way you use your thumb during painful activities to reduce stress on the joint. For example, spreading load over several joints and using stronger joints rather than just putting strain through the thumb.

Assistive devices

Devices such as jar twisters, wide grip cutlery, pen grips and key/tap turners can help to reduce the strain on the thumb joint making daily activities more manageable. Visit the Independent Living wesbite for further information.

Splints

Can help to reduce the strain on the thumb joint during daily activities which you find painful. Ask your therapist for more information about splints that may be appropriate for you.

Factors influencing pain and recovery

During your recovery a number of other factors can influence your pain levels. Keep the following factors in mind to help move the healing process along.

Look after yourself

Pain is not usually simply a physical problem. Your general well-being can make you vulnerable to pain and your wellbeing can also be made worse by pain. Looking after your general health and well-being will help recovery.  There is helpful advice on the NHS website.

Reduce stress and anxiety

It is normal for people with pain to have stress, anxiety and change in mood. This may affect your ability to cope with the pain and may influence your pain levels. Help is available if you are being affected by stress, anxiety or low mood – see the links below or discuss with your practitioner.
It is important that your whole nervous system is in a healthy state to aid recovery. If your brain is stressed or overworked this may slow recovery.

Relaxation is an important part of your recovery. Simple relaxation techniques may help manage pain and stress. Try to set aside some time each day to relax – you can use relaxation techniques as linked below, or simply an activity you enjoy – reading, deep breathing, sitting in the garden, singing – whatever relaxes you.

Find help and support here:

NHS Website
North Essex IAPT

Physical Activity

Exercise improves fitness, confidence with movement and strength. It can also help reduce your stress and tension and improve your mood and quality of sleep, helping support you to return to normal activities. Perhaps you could simply start by trying to walk for 10 minutes per day.

Alcohol

Avoid alcohol in the early stages of healing (first three days). Evidence has shown this can slow down recovery and increase the chances of re-injury. Find more information on the Drinkaware website.

Sleep

Sleep is very important for your wellbeing. Poor sleep quality, and lack of sleep can make managing pain more difficult. Consistently getting 6 to 9 hours is recommended. Get help and tips Live well, sleep and tiredness website.

Smoking

Smoking can also impact how quickly tissues can heal and affect pain levels. For help with stopping smoking Essex lifestyle service or the NHS Better health website.

How long will it last?

If you require 1:1 physiotherapy treatment please fill out a self-referral form and send to [email protected]
If your symptoms have worsened despite the advice given we would recommended you see a healthcare professional for review.

What other options are there?

Surgery

If you symptoms cannot be managed Common surgical procedures include include removal of arthritic bone, replacement of the joint (arthroplasty), or fusion of the bone. Common surgical procedures include include removal of arthritic bone, replacement of the joint (arthroplasty), or fusion of the bone.

calf-strain-patient-information-leaflet_branded (2MB docx)

A calf injury is a strain or tear to the muscles at the back of the lower leg. They most often occur at the middle of the calf where the muscle joins its tendon. The muscles of the calf include the gastrocnemius (upper calf) and soleus (lower calf).

How is it caused?

A calf injury can occur if any of the tendons or muscles that are stretched beyond their limit.
The upper calf is more commonly injured during sudden, explosive movements, such as sprinting, lunging or jumping. The lower calf is generally injured following slower repetitive activities such as steady running.

Calf injuries are more likely to occur:

• with increasing age
• if you have previously injured your calf muscles

How is it diagnosed?

Calf injuries occur in different severities. The 3 grades of calf injury are:

• Grade 1 – a mild muscle pull or strain (typically involving less than 10% of calf muscle fibres).
• Grade 2 – a partial muscle tear (typically involving between 11-49% of the fibres)
• Grade 3 – a complete muscle tear (typically involving more than 50% of the fibres)

Diagnosis is generally made clinically following a history taking and physical examination. If a more severe injury is suspected or your symptoms are not improving as expected then further investigations such as an Ultrasound Scan or MRI may be required.

What are the symptoms?

Mild calf strains (grade 1) may not be painful until after the activity is over. There may be a sensation of cramp or tightness and a slight feeling of pain when the muscle is stretched or contracted. A feeling of pain may be reported while walking, using stairs or standing on your toes.
Partial calf tears (grade 2) will usually cause sudden pain and tenderness at the back of your calf and are usually more painful and tender. There may also be some swelling and bruising at the back of your calf and you may have lost some strength in your leg.
Limping is likely during walking and occasional sudden twinges of pain during activity may occur.
Severe calf tears (grade 3) will usually be very painful, tender, swollen and bruised. There may have been a “popping” sensation at the time of the injury. On the rare occasion that the muscle has come away from its attachment to the tendon, the muscle may have a bunched appearance. Walking unaided is likely to be very difficult.
With more severe injuries, if there are symptoms of tingling, loss of feeling or coldness in the lower leg or foot then this could indicate the swelling associated with the injury is putting pressure on the nerves and blood vessels in the leg. This requires an assessment by the Emergency Department at your local hospital.

What can I do?

In the early stages (48 to 72 hours)

Over-the-counter analgesia, such as paracetamol, may also help to reduce your symptoms. If you require further information on pain relief, speak to your GP or pharmacist.

Progressive Exercise

Exercise is an essential part of your recovery following a calf injury. Exercises should be done as pain allows, with some discomfort being acceptable. If a sharp shooting pain is provoked then ease off. As your pain reduces and your movement improves consider progressing to the more difficult exercises.

Final stage of recovery

Continue swimming and cycling as much as the pain will allow.
If you can do 3 sets of 8 to 15 repetitions of single leg calf raises comfortably, begin short bursts of jumping, skipping or running on the spot.
Restart running, beginning on grass for 5 to 10 minutes, and build up your normal training over the next 2 to 3 months.

Factors influencing pain and recovery

During your recovery a number of other factors can influence your pain levels. Keep the following factors in mind to help move the healing process along.

Look after yourself

Pain is not usually simply a physical problem. Your general well-being can make you vulnerable to pain and your wellbeing can also be made worse by pain. Looking after your general health and well-being will help recovery.  There is helpful advice on the NHS website.

Reduce stress and anxiety

It is normal for people with pain to have stress, anxiety and change in mood. This may affect your ability to cope with the pain and may influence your pain levels. Help is available if you are being affected by stress, anxiety or low mood – see the links below or discuss with your practitioner.
It is important that your whole nervous system is in a healthy state to aid recovery. If your brain is stressed or overworked this may slow recovery.

Relaxation is an important part of your recovery. Simple relaxation techniques may help manage pain and stress. Try to set aside some time each day to relax – you can use relaxation techniques as linked below, or simply an activity you enjoy – reading, deep breathing, sitting in the garden, singing – whatever relaxes you.

Find help and support here:

NHS Website
North Essex IAPT

Physical Activity

Exercise improves fitness, confidence with movement and strength. It can also help reduce your stress and tension and improve your mood and quality of sleep, helping support you to return to normal activities. Perhaps you could simply start by trying to walk for 10 minutes per day.

Alcohol

Avoid alcohol in the early stages of healing (first three days). Evidence has shown this can slow down recovery and increase the chances of re-injury. Find more information on the Drinkaware website.

Sleep

Sleep is very important for your wellbeing. Poor sleep quality, and lack of sleep can make managing pain more difficult. Consistently getting 6 to 9 hours is recommended. Get help and tips Live well, sleep and tiredness website.

Smoking

Smoking can also impact how quickly tissues can heal and affect pain levels. For help with stopping smoking Essex lifestyle service or the NHS Better health website.

How long will it last?

The length of time it takes to recover from a calf strain or tear will depend on how severe the injury is. Less severe injuries (grade 1) may take a few days to heal, whereas it could take weeks or several months to recover from a more severe injury (grade 2 or 3). Return to sporting activity has been shown to take between 21 to 79 days depending on how severe the injury is.

You may need the guidance of a physiotherapist to help you return to normal activity:

• If your injury is more severe;
• If you wish to return to sports involving high speed movements; or
• If your symptoms have persisted despite following the advice and exercise provided in this leaflet.
• If you require 1:1 physiotherapy treatment please fill out a self-referral form and send to [email protected]

Is there anything I should avoid?

Overstretching within the first few weeks can put too much strain on the healing tissue.
Returning too quickly to activity involving high speed movement within the first 30 to 50 days has the potential to cause further injury. A gradual re introduction to running is advised.

What other options are there?

The vast majority of calf injuries recover without the need for more invasive treatment. However, in more severe cases where there has been a complete rupture of the calf muscle where it attaches to the achilles tendon, you may be referred to an orthopaedic surgeon to discuss the possibility of surgery.

carpal-tunnel-syndrome-patient-information-leaflet_branded (636kB docx)

Carpal tunnel syndrome (CTS) is a condition in which the median nerve is compressed where it passes under the transverse carpal ligament at the wrist. CTS affects more women than men and is most common in those aged between 40 and 65. In more than 50% of patients it can affect both wrists.

How is it caused?

Any condition that reduces the amount of space within the carpal tunnel can cause CTS. Examples of these can include (but are not limited to): inflammation, wrist arthritis, wrist fractures, fluid retention, diabetes, obesity or rheumatoid arthritis.

What are the symptoms?

• Pain, pins and needles or numbness in the thumb, forefinger, middle finger and half of the ring finger nearest the thumb.
• Clumsiness of the hand or a weakened grip – some people find they drop things.
• Symptoms are often worse at night but can also be experienced during the day.

How is it diagnosed?

CTS is can be diagnosed clinically following an assessment by a healthcare professional. Further investigations such as nerve conduction studies may be considered when the diagnosis is unclear.

What can I do?

There are a few strategies that can help you reduce or prevent the symptoms of CTS. Recent research shows that it can reduce the need for surgery by up to 21% in mild to moderate cases.

Exercises

These exercises help relieve CTS symptoms by gently gliding the median nerve and tendons through the carpal tunnel.

If you feel an increase in your pain or symptoms you should stop that exercise until you can talk to your therapist. Your exercises are an important part of getting better. They will only help if you do them as often as instructed.

Splinting

Wearing a resting splint at night may help to reduce the severity of your symptoms. Splinting can reduce the pressure in the carpal tunnel (pressure is the least when the wrist is straight) and allow inflamed areas in the wrist to rest. Splinting has been shown to provide symptom relief for up to 6 months in less severe cases. Please be aware it may take several weeks for the before you see an improvement in your symptoms.

Activity and environment modification

Take regular breaks when lifting heavy objects and consider alternating heavy tasks with lighter tasks.
Consider using cutlery with thicker handles.

How long will it last?

Symptoms of CTS recover without any treatment in 30% of people within 6 months of diagnosis. In some people symptoms of CTS may fluctuate for many years and worsen during periods of increased hand use.

Is there anything I avoid?

Avoid positioning the wrist in extremes of movement as this can increase the pressure in the carpal tunnel.
Avoid prolonged or repetitive pinching or gripping.
Consider using padded gloves during activities to reduce vibration such as riding a bike or mowing the lawn.

What other options are there?

If there’s a particular cause, like an underactive thyroid or arthritis, treating that condition may help.

Other treatment will depend on the severity of your symptoms.
In less severe cases, steroid injections can help to reduce swelling and pressure on the nerve in your wrist. Steroid injections have been shown to provide symptom relief for up to six months. Steroid injections are not always a cure. CTS can come back and you may need another injection or consider other options. Side effects are rare but include a possible temporary flare in pain and symptoms.

In more severe cases, surgery may be needed release pressure from the nerve in the carpal tunnel. This would be considered where:
symptoms of numbness are constant
there is evidence of muscle wasting
when symptoms are not relieved by nonsurgical measures.

Surgery has been shown to produce successful outcomes in 75-90% of patients.  

The goal of carpal tunnel surgery is to relieve pressure by cutting the ligament pressing on the median nerve. The operation takes around 20 minutes and you do not have to stay in hospital overnight. It can take a month after the operation to get back to normal activities. Possible side effects include scar sensitivity, injury to the nerves or blood vessels, wound infections and a lack of effect in around 10 to 25% of patients particularly in those with longer term symptoms. Recurrence rates following carpal tunnel decompression surgery vary between 0.3 and 12%.

cervical-spondylosis-patient-information-leaflet_branded (712kB docx)

Cervical Spondylosis is a term used to describe age related changes to the vertebral bones and discs within our neck. It is a naturally occurring condition as we become older, this could be likened to having a grey hair or wrinkle.

Stockport physiotherapy

How is it caused?

These changes are caused by normal aging of the spine. Following daily activity and over time, the discs gradually become thinner and bones can develop spurs which can cause pain and irritation. The joints within the neck can also become stiff, which results in a loss of range of movement in the neck.

What are the symptoms?

The symptoms of cervical spondylosis can come and go, or in some cases may be persistent. Symptoms include:

• Neck pain which can be provoked by movement
• Referred pain within the upper limbs, base of the skull, between the shoulder blades.
• Neck stiffness, especially on waking in the morning
• Headaches and migraines

How is it diagnosed?  

A diagnosis can be made based on your symptoms alone and/or including a physical examination from your Physiotherapist or GP.
Imaging is not normally needed to confirm a diagnosis of cervical spondylosis. An X-ray may be considered if your diagnosis is unclear or if you have failed to respond to recommended treatment. An XR may reveal a loss of height between the joints within the neck however these findings are very common and have not been shown to predict pain levels.

What can I do?

Exercise

One of the most important things you can do to relieve your symptoms, is to keep moving your neck.
Try completing neck movements every few hours as this will enable you to get back to normal activity as soon as possible. Movement will help to reduce muscle tension, reduce pain and increase range of movement. Avoiding movement could lead to higher levels of pain and poorer recovery resulting in longer periods off work.
These exercises should be carried out often, throughout the day. These exercises may cause discomfort but should not increase your pain or symptoms. Perform the exercises in a slow and controlled manner.

Medication

If you require medication to relieve your pain, you can liase with your GP or pharmacist to determine the most appropriate medication. It can be difficult to move your neck if you are in too much pain, therefore it is useful to take pain medication, to relieve the pain, enable you to carry out exercise effectively and allow a faster recovery.

Heat therapy

The application of heat such as a hot water bottle wrapped in a towel or a wheat bag, to relax the muscles in your neck.

How long will it last?

The length of time symptoms are experienced will depend on the individual. Some individuals experience no pain with the condition, or pain could be episodic; lasting for a few weeks at a time, or pain could be more persistent. It is important to note that the spine is a very strong structure within the body and it is likely the pain will improve over time and following completion of exercises.

If your symptoms have not improved or worsen despite following the advice and exercise provided in this leaflet you will need to visit your GP surgery again.

Other factors which may influence pain

Look after yourself

Pain is not usually simply a physical problem. Your general well-being can make you vulnerable to pain and your wellbeing can also be made worse by pain. Looking after your general health and well-being will help recovery.  There is helpful advice on the NHS website.

Reduce stress and anxiety

It is normal for people with pain to have stress, anxiety and change in mood. This may affect your ability to cope with the pain and may influence your pain levels. Help is available if you are being affected by stress, anxiety or low mood – see the links below or discuss with your practitioner.
It is important that your whole nervous system is in a healthy state to aid recovery. If your brain is stressed or overworked this may slow recovery.

Relaxation is an important part of your recovery. Simple relaxation techniques may help manage pain and stress. Try to set aside some time each day to relax – you can use relaxation techniques as linked below, or simply an activity you enjoy – reading, deep breathing, sitting in the garden, singing – whatever relaxes you.

Find help and support here:

NHS Website
North Essex IAPT

Physical Activity

Exercise improves fitness, confidence with movement and strength. It can also help reduce your stress and tension and improve your mood and quality of sleep, helping support you to return to normal activities. Perhaps you could simply start by trying to walk for 10 minutes per day.

Alcohol

Avoid alcohol in the early stages of healing (first three days). Evidence has shown this can slow down recovery and increase the chances of re-injury. Find more information on the Drinkaware website.

Sleep

Sleep is very important for your wellbeing. Poor sleep quality, and lack of sleep can make managing pain more difficult. Consistently getting 6 to 9 hours is recommended. Get help and tips on the Live well, sleep and tiredness website.

Nutrition and weight

Being overweight can increase the physical strain on the body and also contribute to inflammation in your body. Make sure you eat a balanced diet. Adult weight management services are available free to Essex residents here.

Smoking

Smoking can also impact how quickly tissues can heal and affect pain levels. For help with stopping smoking Essex lifestyle service or the NHS Better health website.

Is there anything I avoid?

Do not wear a neck brace or collar as this will slow down your recovery.

What other options are there?

Physiotherapy

Physiotherapists can provide expert guidance with exercise and other supportive treatments to help you return to normal activity.
If you require 1:1 physiotherapy treatment please fill out a self-referral form and send to [email protected].

Surgery is not a recommended treatment for cervical spondylosis.

de-quervains-tenosynovitis-patient-information-leaflet_branded (614kB docx)

De Quervain’s tenosynovitis is a common painful condition that causes swelling of the tendon sheath (which covers the tendons as they run through a tunnel on the thumb side of the wrist) or of the tendons themselves. Due to the swelling, the tendons’ ability to glide smoothly back and forth to move the thumb is restricted. This is not harmful, but it can be painful.

BSSH – de_quervains_syndrome.

How is it caused?

De Quervain’s tenosynovitis can be caused by repetitive activities such as gripping or typing. It is also common in new mothers, as they perform repetitive movements of the hand by lifting their babies, and during pregnancy, possibly due to hormonal changes or fluid retention. In some cases, the condition develops for no known reason.

What are the symptoms?

You may experience:

• pain on the thumb side of the wrist, which is made worse by lifting the thumb upwards (‘thumbs up’ position), turning a key, wringing out clothes or twisting the wrist towards the little finger.
• mild swelling around the site of pain.
• difficulty gripping objects.

How is it diagnosed?

A diagnosis can be made based on your symptoms alone and/or including a physical examination from your Physiotherapist or GP.

What can I do?

Rest

It is important to limit the aggravating movements to reduce pain and allow the symptoms to settle. Try to maintain neutral wrist posture when lifting things and avoid wrist postures where wrist deviates towards little finger direction.

Splinting

Using a splint for 4 to 6 weeks (a device used for support or immobilisation) may allow the condition to settle as it will limit the movement of thumb and wrist and helps them to rest.

Medication

Over-the-counter analgesia, such as paracetamol or anti inflammatories such as ibuprofen may also help to reduce your symptoms. If you require further information on pain relief, speak to your GP or pharmacist.

Exercise

Exercises such as those below can help to strengthen your tendon, improve hand function and minimise pain. They should be done as pain allows, with some discomfort being acceptable. If a sharp shooting pain is provoked then ease off. As your pain reduces and your movement improves consider progressing to the more difficult exercises.

What other options are there?

Corticosteroid injections

In persistent cases steroid injections may be considered to help with reducing swelling and pain. Steroid injections are not always a cure but some studies have reported up a 75% success rate within 2 injections. Side effects are rare but include a possible temporary flare in pain and symptoms.

Surgery

Surgery should be considered for stubborn cases where trial of above non-surgical treatments for 3 to 6 months have failed to bring any improvement.

dupuytren-contracture-patient-information-leaflet_branded (59kB docx)

Dupuytren’s contracture is a condition where firm painless lumps or nodules fixed to skin and deep fascia appear in the palm of hand. In some cases these nodules group to form cords. When the cord gradually contracts, it can prevent the finger straightening completely.

Webmd – What Is Dupuytren’s Contracture?

How is it caused?

There is no single cause for Dupuytren’s contracture.
You are more likely to develop a Dupuytren’s contracture if you are male, have a family history of the condition, if you have diabetes, if you smoke, if you drink alcohol or have high cholesterol.
It occasionally appear after injuries to wrist or hand and sometimes after surgeries to these areas.

What are the symptoms?

In the early stages:

• Pitting and thickening of the palm skin
• A lump or nodule in the palm most commonly in line with the ring or little finger. The nodule may feel tender and sore at first, but this discomfort eventually goes away.

In the later stages:

• The nodule contracts and extends to form cords. These inflexible cords cause the fingers to bend, or “curl,” forward toward the palm and prevent them from straightening fully.
• Difficulty with tasks such as face washing, hair combing, and putting the hand in your pockets.

How is it diagnosed?

A Dupuytren’s contracture is normally diagnosed based on you tell us and a physical examination. Being unable to lay your palm flat on a tabletop raises the suspicion of a Dupuytren’s contracture.

What Can I do?

Unfortunately, there is no way to prevent the disease or stop it from coming back. However, you can minimise your risk by addressing lifestyle factors such as reducing smoking and alcohol intake and controlling diabetes.

What other options are there?

Surgery

This is the main treatment offered for a Dupuytren’s contracture and is generally considered for patients when there is shortening and contracture of the hand and function becomes more affected. Restoring movement at the knuckle joint can be achieved more easily than that at the smaller finger joints.
Patients must be aware that Dupuytren’s contracture can return to the same place on the hand or may reappear somewhere else with up to 40% of people have a recurrence following surgery. Recurrence is more likely (up to 70%) in younger male patients, if the original contracture was severe or affected both hands, or if there is a strong family history of the condition.
Recovery after surgery varies depending on amount of contracture. It can take a long time to recover full or partial function of the hand. After surgery you may be referred to Hand Therapy for ongoing advice.

femoral-acetabular-impingement-patient-information-leaflet_branded (549kB docx)

FAI is a condition where there is a variation in the hip joint structure. It can affect the head of the thigh bone (femur), the socket (acetabulum) or both. Variations are considered to be normal, but unfortunately it can be painful to some people.

AAOS- femoroacetabular impingement

How is it caused?

Having very deep hip sockets or a hip that is angled a little further back than normal.
Childhood conditions called Perthes disease (where the blood supply to this hip is affected, and can affect the ball part of the joint), and slipped capital femoral epiphysis (where the growth plate moves during childhood).
Trauma or fracture which fails to heal or after a fracture where it heals with the hip facing backwards.
 
In general FAI is more commonly caused by a developmental cause rather than trauma.

What are the symptoms?

Pain and discomfort in the groin or outer aspect of the hip/thigh or buttock.
Clicking or catching sensations
Difficulty with certain movements or are position-related eg- when the knee is brought towards the chest such as squatting or during long car journeys.

How is it diagnosed?

Diagnosis is generally made clinically following a history taking and physical examination. If FAI is suspected further imaging in the form of an X ray or MRI scan may be requested.

What can I do?

Stay Active

Exercise is recommended as a first line of treatment for FAI. It is important to patient and consistent as it may take up 3 months for symptoms to improve.   
These exercises may make your muscles ache initially. Stop if the exercises severely aggravate your symptoms.

Medication

Over-the-counter analgesia, such as paracetamol or anti inflammatories such as ibuprofen may also help to reduce your symptoms. If you require further information on pain relief, speak to your GP or pharmacist.

Pacing your activities

Try to find the right balance between activity and rest to avoid overstraining your joint.

Factors influencing pain and recovery

During your recovery a number of other factors can influence your pain levels. Keep the following factors in mind to help move the healing process along.

Look after yourself

Pain is not usually simply a physical problem. Your general well-being can make you vulnerable to pain and your wellbeing can also be made worse by pain. Looking after your general health and well-being will help recovery.  There is helpful advice on the NHS website.

Reduce stress and anxiety

It is normal for people with pain to have stress, anxiety and change in mood. This may affect your ability to cope with the pain and may influence your pain levels. Help is available if you are being affected by stress, anxiety or low mood – see the links below or discuss with your practitioner.
It is important that your whole nervous system is in a healthy state to aid recovery. If your brain is stressed or overworked this may slow recovery. Relaxation is an important part of your recovery. Simple relaxation techniques may help manage pain and stress. Try to set aside some time each day to relax – you can use relaxation techniques as linked below, or simply an activity you enjoy – reading, deep breathing, sitting in the garden, singing – whatever relaxes you.

Find help and support here:

NHS Website
North Essex IAPT

Exercise

Exercise improves fitness, confidence with movement and strength. It can also help reduce your stress and tension and improve your mood and quality of sleep, helping support you to return to normal activities. Perhaps you could simply start by trying to walk for 10 minutes per day.

Alcohol

Avoid alcohol in the early stages of healing (first three days). Evidence has shown this can slow down recovery and increase the chances of re-injury. Find more information on the Drinkaware website.

Sleep

Sleep is very important for your wellbeing. Poor sleep quality, and lack of sleep can make managing pain more difficult. Consistently getting 6 to 9 hours is recommended. Get help and tips Live well, sleep and tiredness website.

Smoking

Smoking can also impact how quickly tissues can heal and affect pain levels. For help with stopping smoking Essex lifestyle service or the NHS Better health website.

Nutrition and weight

Being overweight can increase the physical strain on the body and also contribute to inflammation in your body. Some studies have shown that reducing bodyweight by 5% resulted in a 32.6% improvement in physical function after 8 months. Make sure you eat a balanced diet. Adult weight management services are available free to Essex residents.

How long will it last?

It is important to patient and consistent as it may take up 3 months for symptoms to improve.  
If your symptoms have worsened despite the advice given we would recommended you see a healthcare professional for review as you may require more guidance specific to your individual needs.

Is there anything I should avoid?

Take care with activities which may have a greater chance of aggravating your symptoms such as prolonged sitting, deep squatting or rowing.

What other options are there?

Physiotherapy

A physiotherapist can help provide advice and guidance on exercise which is specific to your individual needs.
If you require 1:1 physiotherapy treatment please fill out a self-referral form which can found at https://eput.nhs.uk/our-services/essex/west-essex-community-health-services/adults/rehabilitation/musculo-skeletal-physiotherapy and send to [email protected]

Surgery

If a patient’s symptoms persist after a course of treatment, a referral to an orthopaedic surgeon may be recommended for a surgical opinion. Surgery would aim to reshape either the ball or socket of the hip joint. This can be done either through keyhole (arthroscopy) or open surgery. This would be followed by a course of physiotherapy rehabilitation. For further information on surgery visit AASOS – Orth info,hip arthroscopy.

golfers-elbow-patient-information-leaflet_branded (566kB docx)

Golfer’s elbow is a common musculoskeletal condition that affects as much as 1 in 3 people in their lifetime, usually affecting those between 40 and 60 years of age. It is a condition that causes pain pain where the tendons of your forearm muscles attach to the bony bump on the inside of your elbow. It is also known as medial elbow tendinopathy, and previously as medial epicondylitis.

How is it caused?

It mostly occurs due to overuse of the muscles and tendons of the forearm, which attach to bony bump on the inside of your elbow, which are responsible for flexing the wrist, turning and gripping objects.
It is not limited to golf and can occur in sports involving repeated wrist movements, or everyday activities, which involve a lot of gripping. If the muscles and tendons are strained, tiny tears and inflammation can develop, causing pain. It is not commonly caused by a specific injury or event.

What are the symptoms?

Pain around the bony bump on the inside of your elbow that can spread into the forearm and wrist.
Pain during activities involving gripping or twisting your forearm, such as turning a door handle or opening a jar and typing.

How is it diagnosed?

Golfer’s elbow is generally diagnosed based on you tell us and a physical examination of your elbow and wrist. You will only be referred for tests such as ultrasound scan or other imaging if nerve damage or other problems are suspected.

What can I do?

Activity modification

You should still be able to continue most activities but you may need to make some changes. Avoid heavy activities or positions that aggravate your symptoms such as holding heavy shopping in the one hand, use your other arm whenever possible and take regular breaks from activities such as typing.

Exercise

This has been shown to be an essential part of helping improve symptoms in the medium to long term. Exercise can help to gradually build up the load that the tendon can tolerate over time. It can take several months before benefit from exercise is noted so you need to stick with it.
A small increase in pain while exercising is ok as long as it goes away within 30 minutes and is not worse the next day. If this happens, do less repetitions or reduce the weight/tension next times and gradually build up again.

Ice

Apply ice wrapped in a tea towel to the area a few times a day for approx. 8-10 minutes. This can help to reduce swelling and pain.

Support strap/clasp

These may assist in reducing load through the tendons helping to reduce symptoms. Ask your health professional for further information.

Medication

Over-the-counter analgesia, such as paracetamol or anti inflammatories such as ibuprofen may also help to reduce your symptoms. If you require further information on pain relief, speak to your GP or pharmacist. Take any medication as prescribed at regular intervals to reduce symptoms, not just when it is particularly bad.

Factors influencing pain and recovery

During your recovery a number of other factors can influence your pain levels. Keep the following factors in mind to help move the healing process along.

Look after yourself

Pain is not usually simply a physical problem. Your general well-being can make you vulnerable to pain and your wellbeing can also be made worse by pain. Looking after your general health and well-being will help recovery.  There is helpful advice on the NHS Website.

Reduce stress and anxiety

It is normal for people with pain to have stress, anxiety and change in mood. This may affect your ability to cope with the pain and may influence your pain levels. Help is available if you are being affected by stress, anxiety or low mood – see the links below or discuss with your practitioner.
It is important that your whole nervous system is in a healthy state to aid recovery. If your brain is stressed or overworked this may slow recovery. Relaxation is an important part of your recovery. Simple relaxation techniques may help manage pain and stress. Try to set aside some time each day to relax – you can use relaxation techniques as linked below, or simply an activity you enjoy – reading, deep breathing, sitting in the garden, singing – whatever relaxes you.

Find help and support here:

NHS Website
North Essex IAPT

Physical Activity

Exercise improves fitness, confidence with movement and strength. It can also help reduce your stress and tension and improve your mood and quality of sleep, helping support you to return to normal activities. Perhaps you could simply start by trying to walk for 10 minutes per day.

Alcohol

Avoid alcohol in the early stages of healing (first three days). Evidence has shown this can slow down recovery and increase the chances of re-injury. Find more information on the Drinkaware website.

Sleep

Sleep is very important for your wellbeing. Poor sleep quality, and lack of sleep can make managing pain more difficult. Consistently getting 6 to 9 hours is recommended. Get help and tips Live well, sleep and tiredness website.

Smoking

Smoking can also impact how quickly tissues can heal and affect pain levels. For help with stopping smoking Essex lifestyle service or the NHS Better health website.

How long will it last?

Golfer’s elbow can last on average between 6 months to 2 years.
It is important to remain patient during your rehabilitation as it can take up to 12 weeks for elbow symptoms to respond to treatment.
If your symptoms have persisted or worsen despite following the advice and exercise provided in this leaflet you will need to visit your GP surgery again.

What other options are there?

If you haven’t responded to self-management strategies over a course of a few months you may be referred for:

Physiotherapy

They can advise you further about exercises to complete, and may consider other management strategies to help reduce your symptoms.

Shockwave therapy

Shockwave therapy is a non-invasive treatment, where high-energy shockwaves are passed through the skin to help relieve pain and promote movement in the affected area. However, these treatments may not be available on the NHS in your local area.

Steroid injection

This is considered when all other measures have been unsuccessful. The injection is completed directly into the painful area and provides short term benefit. There is growing evidence that the tendon itself can be damaged further by completing this procedure, and therefore should only be considered as a last resort.

Surgery

This is also reserved for particularly stubborn, severe cases, and is completed rarely. It involves removing part of the damaged tendon.

greater-trochanteric-pain-syndrome-patient-information-leaflet_branded (498kB docx)

Greater trochanteric pain syndrome (or outer hip pain) is a painful condition caused by irritation to the soft tissues of the outer thigh and hip area. These can include tendons, muscles or bursae (fluid-filled sacs that help smooth movement between muscles, tendons and the hip bone).
It is most common in women between the ages of 40 to 60.

Boston hip center- greater trochanteric pain syndrome

How is it caused?

Many factors may contribute to pain development of outer hip pain. These include:

• a change in activity load, frequency or duration of compared to what you are used to.
• weakness of the hip and thigh muscles that support the knee function.
• a direct fall on outside edge of hip.
• prolonged or excessive pressure to your hip area such as sitting on a soft sofa or sleeping on your affected side.

How is it diagnosed?

Diagnosis is generally made clinically following a history taking and physical examination. If diagnosis is unclear or if your symptoms are not improving as expected then further investigations such as an Ultrasound Scan or MRI scan may be required.

What are the symptoms?

Pain on the outside of your hip sometimes spreading down the outside of the thigh towards the knee.
Worse when going up and/or down stairs.
Worse lying on the painful side (and sometimes on the other side).
Worse when crossing legs.

What can I do?

Progressive Exercise

Exercise is an essential part of your recovery. Research tells us that exercise combined with advice provides better long term outcomes when compared to having a steroid injection or doing nothing.
This should be done as pain allows, with some discomfort being acceptable. If a sharp shooting pain is provoked then ease off. As your pain reduces consider progressing to the more difficult exercises.

Nutrition and weight

Being overweight can increase the physical strain on the body and also contribute to inflammation in your body. Make sure you eat a balanced diet. Adult weight management services are available free to Essex residents.

Medication

Sometimes patients may trial non steroidal anti inflammatories such as ibuprofen which can be obtained without prescription. Follow recommended doses and always discuss with your GP or Pharmacist if you unsure.

Factors influencing pain and recovery

During your recovery a number of other factors can influence your pain levels. Keep the following factors in mind to help move the healing process along.

Look after yourself

Pain is not usually simply a physical problem. Your general well-being can make you vulnerable to pain and your wellbeing can also be made worse by pain. Looking after your general health and well-being will help recovery.  There is helpful advice on the NHS website.

Reduce stress and anxiety

It is normal for people with pain to have stress, anxiety and change in mood. This may affect your ability to cope with the pain and may influence your pain levels. Help is available if you are being affected by stress, anxiety or low mood – see the links below or discuss with your practitioner.
It is important that your whole nervous system is in a healthy state to aid recovery. If your brain is stressed or overworked this may slow recovery.

Relaxation is an important part of your recovery. Simple relaxation techniques may help manage pain and stress. Try to set aside some time each day to relax – you can use relaxation techniques as linked below, or simply an activity you enjoy – reading, deep breathing, sitting in the garden, singing – whatever relaxes you.

Find help and support here:

NHS Website
North Essex IAPT

Physical Activity

Exercise improves fitness, confidence with movement and strength. It can also help reduce your stress and tension and improve your mood and quality of sleep, helping support you to return to normal activities. Perhaps you could simply start by trying to walk for 10 minutes per day.

Alcohol

Avoid alcohol in the early stages of healing (first three days). Evidence has shown this can slow down recovery and increase the chances of re-injury. Find more information on the Drinkaware website.

Sleep

Sleep is very important for your wellbeing. Poor sleep quality, and lack of sleep can make managing pain more difficult. Consistently getting 6 to 9 hours is recommended. Get help and tips Live well, sleep and tiredness website.

Smoking

Smoking can also impact how quickly tissues can heal and affect pain levels. For help with stopping smoking Essex lifestyle service or the NHS Better health website.

How long will it last?

In most cases symptoms should show signs of improvement following this advice over a period of 6 to 12 weeks, however full recovery can sometimes take between 6 to 9 months.

It is also common to experience flare ups during your recovery as you start to build up your activity levels. If you do experience a flare up, consider reducing the intensity of your exercise until your pain settles and then try building up again as you can tolerate.

You may need the guidance of a physiotherapist to help you return to normal activity if your symptoms have shown some improvement but have still persisted despite following the advice and exercise provided in this leaflet.

If you require 1:1 physiotherapy treatment please fill out a self-referral form and send to [email protected]

Is there anything I should avoid?

• Avoid sleeping on the aggravated side. If sleeping on the opposite hip, try placing a pillow between your knees to stop your painful leg crossing over.
• Avoid sitting with your legs crossed.
• Avoid leaning on one hip when standing up and keep your weight evenly through both feet.

What other options are there?

In some instances where there hasn’t been an improvement with initial treatments, a steroid injection may be considered. In general, steroid injections have a short acting effect with some research showing this may last between 3 to 6 months. However, their effectiveness can be influenced by other factors such as whether you also have existing problems with your lower back or knee.

hamstring-muscle-injuries-patient-information-leaflet_branded (622kB docx)

A hamstring injury is a strain or tear to the group of tendons or large muscles at the back of the thigh. They most often occur at the middle of the back of the thigh where the muscle joins its tendon or at the base of the buttocks.

AAOS – Hamstring Muscle Injuries

How is it caused?

A hamstring injury can occur if any of the tendons or muscles are stretched beyond their limit.
They often occur during sudden, explosive movements, such as sprinting, lunging or jumping. But they can also occur more gradually, or during slower movements that overstretch your hamstring.

Hamstring injuries are more likely to occur:

• with increasing age
• if you have weak hamstring muscles, especially in comparison to your quadriceps (muscles on the front of the thigh)
• if you have previously injured your hamstring muscles
• during the later stages of competition
• if you have had a previous major knee injury

How is it diagnosed?

Hamstring injuries occur in different severities. The 3 grades of hamstring injury are:

• Grade 1 – a mild muscle pull or strain (typically involving less than 10% of hamstring muscle fibres).
• Grade 2 – a partial muscle tear (typically involving between 11-49% of the fibres)
• Grade 3 – a complete muscle tear (typically involving more than 50% of the fibres)

Diagnosis is generally made clinically following a history taking and physical examination. If a more severe injury is suspected or your symptoms are not improving as expected then further investigations such as an Ultrasound Scan or MRI may be required.

What are the symptoms?

Mild hamstring strains (grade 1) may not be painful until after the activity is over. There may be a sensation of cramp or tightness and a slight feeling of pain when the muscle is stretched or
contracted. A feeling of pain may be reported with sitting or while walking uphill or ascending stairs.

Partial hamstring tears (grade 2) will usually cause sudden pain and tenderness at the back of your thigh and are usually more painful and tender.

There may also be some swelling and bruising at the back of your thigh and you may have lost some strength in your leg. Limping is likely during walking and occasional sudden twinges of pain during activity may occur. Bending the knee against resistance will cause pain and there may be some difficulty in fully straightening the knee.

Severe hamstring tears (grade 3) will usually be very painful, tender, swollen and bruised. There may have been a “popping” sensation at the time of the injury. Walking is likely to be very difficult.

What can I do?

In the early stages (48 to 72 hours)

Over-the-counter analgesia, such as paracetamol, may also help to reduce your symptoms. If you require further information on pain relief, speak to your GP or pharmacist.

Progressive Exercise

Exercise is an essential part of your recovery following a hamstring injury. Specific exercise regimes have been shown to help prevent injuries re-occur.

They should be done as pain allows, with some discomfort being acceptable. If a sharp shooting pain is provoked then ease off. As your pain reduces and your movement improves consider progressing to the more difficult exercises.

Factors influencing pain and recovery

During your recovery a number of other factors can influence your pain levels. Keep the following factors in mind to help move the healing process along:

Work

You may be worried about continuing with work, or other responsibilities. It is important to discuss these fears with your practitioner. Remaining at work usually leads to a quicker recovery even if you have to work with modified activities.
Having poor posture does not cause back pain. There is no perfect posture. Staying in one position for long periods can be a factor in your pain. It is important to plan regular breaks and change posture regularly.
Your relationship with your boss and colleagues, job enjoyment, feeling supported at work and returning to work are all very important in helping your recovery. Speak to your employer if you need support at work.

Painkillers

Painkillers may help to manage your pain but should only be taken for a short period. Paracetamol is not usually effective for sciatica. Painkillers do not speed up your recovery. They should always be used with other options such as exercise or other improvements to your well-being.

Look after yourself

Pain is not usually simply a physical problem. Your general well-being can make you vulnerable to pain and your wellbeing can also be made worse by pain. Looking after your general health and well-being will help recovery.  There is helpful advice on the NHS website.

Reduce stress and anxiety

It is normal for people with pain to have stress, anxiety and change in mood. This may affect your ability to cope with the pain and may influence your pain levels. Help is available if you are being affected by stress, anxiety or low mood – see the links below or discuss with your practitioner.
It is important that your whole nervous system is in a healthy state to aid recovery. If your brain is stressed or overworked this may slow recovery.

Relaxation is an important part of your recovery. Simple relaxation techniques may help manage pain and stress. Try to set aside some time each day to relax – you can use relaxation techniques as linked below, or simply an activity you enjoy – reading, deep breathing, sitting in the garden, singing – whatever relaxes you.

Find help and support here:

NHS Website
North Essex IAPT

Physical Activity

Exercise improves fitness, confidence with movement and strength. It can also help reduce your stress and tension and improve your mood and quality of sleep, helping support you to return to normal activities. Perhaps you could simply start by trying to walk for 10 minutes per day.

Alcohol

Avoid alcohol in the early stages of healing (first three days). Evidence has shown this can slow down recovery and increase the chances of re-injury. Find more information on the Drinkaware website.

Sleep

Sleep is very important for your wellbeing. Poor sleep quality, and lack of sleep can make managing pain more difficult. Consistently getting 6 to 9 hours is recommended. Get help and tips Live well, sleep and tiredness website.

Nutrition and weight

Being overweight can increase the physical strain on the body and also contribute to inflammation in your body. Make sure you eat a balanced diet. Adult weight management services are available free to Essex residents.

Smoking

Smoking can also impact how quickly tissues can heal and affect pain levels. For help with stopping smoking Essex lifestyle service or the NHS Better health website.

How long will it last?

The length of time it takes to recover from a hamstring strain or tear will depend on how severe the injury is. Less severe injuries (grade 1) may take a few days to heal, whereas it could take weeks or several months to recover from a more severe injury (grade 2 or 3).

You may need the guidance of a physiotherapist to help you return to normal activity:

• If your injury is more severe;
• If you wish to return to sports involving high speed movements; or
• If your symptoms have persisted despite following the advice and exercise provided in this leaflet.

If you require 1:1 physiotherapy treatment please fill out a self-referral form and send to [email protected]

Is there anything I should avoid?

Overstretching within the first few weeks can put too much strain on the healing tissue.
Returning too quickly to activity involving high speed movement has the potential to cause further injury.

What other options are there?

The vast majority of hamstring injuries recover without the need for more invasive treatment. However, in more severe cases where there has been a complete rupture of the hamstrings where they attach at the base of buttock, you are likely to be referred to an orthopaedic surgeon to discuss the possibility of surgery to repair the tendons.

hip-osteoarthritis-patient-information-leaflet_branded (608kB docx)

Osteoarthritis is a condition that affects the joints, causing pain and stiffness. The hip is a “ball and socket joint” which is covered in a layer of cartilage. When the hip develops osteoarthritis, some of the cartilage roughens and becomes thin and the joint doesn’t move as smoothly as it should. In severe cases the cartilage can become so thin that it no longer covers the bone resulting reduced joint space.

AAOS – Hip osteoarthritis

How is it caused?

Hip osteoarthritis can be caused by a combination of factors:

• Age: osteoarthritis occurs mostly in those aged over 40
• Gender: osteoarthritis is twice as common in women
• Previous joint injury: normal activity and exercise does not cause osteoarthritis, but previous injuries/surgery can increase the risk
• Obesity: Being overweight increases the strain on your joints which can contribute to osteoarthritis
• Genetic factors: if a close family member has osteoarthritis, you are more likely to develop the condition

What are the symptoms?

Hip osteoarthritis can present differently in everyone. The most common symptoms include:

• Pain                                                            
• Early morning joint stiffness less than 30 minutes
• Reduced movement
• Crepitus (grating/grinding)
• Giving way
• Locking
• Difficulty climbing stairs or crouching down
• Muscle wasting

How is it diagnosed?

Hip osteoarthritis is normally diagnosed based on the signs and symptoms identified during a physical examination. X-rays can be useful but are not always required. There are no blood test for osteoarthritis but can be used to rule out other conditions.

What can I do?

Stay Active

Exercise has proven to ease pain and improve function. Gentle exercise in the form of specific exercises for your joint (see below), or more generalised activity such as swimming or walking, can help you can strengthen the muscles and protect the joint.

These exercises may make your muscles ache initially. Stop if the exercises severely aggravate your symptoms.

Medication

Over-the-counter analgesia, such as paracetamol or anti inflammatories such as ibuprofen may also help to reduce your symptoms. If you require further information on pain relief, speak to your GP or pharmacist.

Warmth

May help reduce symptoms, use for 10 minutes twice daily.

Nutrition and weight

Being overweight can increase the physical strain on the body and also contribute to inflammation in your body. Some studies have shown that reducing body weight by 5% resulted in a 32.6% improvement in physical function after 8 months. Make sure you eat a balanced diet. Adult weight management services are available free to Essex residents.

Aids

Walking aids can help to reduce some of the load through your joint.
Pacing your activities: Try to find the right balance between activity and rest to avoid overstraining your joints.
A range of excellent resources for helping manage osteoarthritis.

Factors influencing pain and recovery

During your recovery a number of other factors can influence your pain levels. Keep the following factors in mind to help move the healing process along.

Look after yourself

Pain is not usually simply a physical problem. Your general well-being can make you vulnerable to pain and your wellbeing can also be made worse by pain. Looking after your general health and well-being will help recovery.  There is helpful advice on the NHS website.

Reduce stress and anxiety

It is normal for people with pain to have stress, anxiety and change in mood. This may affect your ability to cope with the pain and may influence your pain levels. Help is available if you are being affected by stress, anxiety or low mood – see the links below or discuss with your practitioner.
It is important that your whole nervous system is in a healthy state to aid recovery. If your brain is stressed or overworked this may slow recovery. Relaxation is an important part of your recovery. Simple relaxation techniques may help manage pain and stress. Try to set aside some time each day to relax – you can use relaxation techniques as linked below, or simply an activity you enjoy – reading, deep breathing, sitting in the garden, singing – whatever relaxes you.

Find help and support here:

NHS Website
North Essex IAPT

Physical Activity

Exercise improves fitness, confidence with movement and strength. It can also help reduce your stress and tension and improve your mood and quality of sleep, helping support you to return to normal activities. Perhaps you could simply start by trying to walk for 10 minutes per day.

Alcohol

Avoid alcohol in the early stages of healing (first three days). Evidence has shown this can slow down recovery and increase the chances of re-injury. Find more information on the Drinkaware website.

Sleep

Sleep is very important for your wellbeing. Poor sleep quality, and lack of sleep can make managing pain more difficult. Consistently getting 6 to 9 hours is recommended. Get help and tips Live well, sleep and tiredness website.

Smoking

Smoking can also impact how quickly tissues can heal and affect pain levels. For help with stopping smoking Essex lifestyle service or the NHS Better health website.

How long will it last?

You can expect a flare up in your symptoms to last anywhere between a few weeks to a couple of months. If your hip joint has significant degenerative changes you may experience some ongoing symptoms. If your symptoms have persisted despite following the advice and exercise provided in this leaflet you may need the guidance of a physiotherapist to help you return to normal activity.

If you require 1:1 physiotherapy treatment please fill out a self-referral form and send to [email protected].

If your symptoms have worsened despite the advice given we would recommended you see a healthcare professional for review.

Is there anything I should avoid?

Over rest: your symptoms are more likely to get worse if you sit and do nothing; too much rest is likely to increase stiffness and can result in muscle weakness.

What other options are there?

In severe cases, hip replacement surgery may be recommended. Suitability for surgery depends on several factors including general health and fitness and severity of OA. Surgery is not an effective treatment for everyone.
If you are considering a joint replacement and would like more information to help you discuss your situation with your health professional please visit Joint calc website for further information.

knee-cap-pain-patient-information-leaflet_branded (618kB docx)

Knee cap pain is described as pain around or behind the knee cap that starts without any traumatic injury. It can occur during or shortly after performing an exercise or activity. It is sometimes called anterior knee pain, runner’s knee or patella mal-tracking. It is the most common condition effecting the knee.
The kneecap sits in a groove on the end of the thigh bone. This joint is known as the patellofemoral joint. The knee cap acts as a lever for muscles controlling movement of the knee. These movements are controlled by a number of muscles that connect to the knee cap. Together, these muscles help to stabilise the knee cap and keep it running smoothly within the groove.

Physio pedia

How is it caused?

There is no specific cause for knee cap pain but many possible factors that might contribute to it:

• A change in activity load, frequency or duration eg- Running more often, on more challenging terrain or for longer periods than you are used to.
• Weakness of the hip and thigh muscles that support the knee function
• Tightness of the thigh and calf muscles reducing the loading efficiency of the joint
• Movement biomechanics (How well your muscles control your movement)
• Foot biomechanics (flat feet or over pronation changing the loading force through the joint)
• Natural body shape (the position of your hip, knees and feet)
• Very rarely is the structure of your knee joint the problem.

What are the symptoms?

Pain around or behind the knee cap during or following activities such as running, squatting, jumping, going downstairs or sitting for long periods of time.
A ‘noisy’ knee that produces a crackling sound is often the result of healthy fluid within the joint moving around. It does not necessarily mean the knee cap is damaged or even going to be painful.

How is it diagnosed?

A physiotherapist is well placed to diagnose this condition by listening to your symptoms and asking specific questions to rule out other causes for the knee pain. 
Imaging is not normally needed to confirm a diagnosis of knee cap pain. Wear and tear changes to the cartilage on scans are very common and have not been shown to predict pain levels. These changes should not prove to limit recovery and return to full function.

What can I do?

Activity adjustment

Finding the right level of activity within level a pain that is tolerable for you is an essential part of making a good recovery.
Consider adjusting the activity that triggers the pain in the first instance, this may mean completely stopping or just a reduction in frequency and intensity to let the pain settle. You can take painkillers if you need to.

Exercise

Start regular and specific exercises to help strengthen the hip and thigh muscles that support the knee. Exercises need to be progressed so that these muscles can withstand increased loads and demands.
You should focus on exercise that is not too painful. Challenging your muscles to a tolerable discomfort is ok, as is lower impact exercise such as swimming, cycling and walking.

Gradually build up to a return to your sport or activity in combination with your strengthening exercises. This is especially important if too much training was highlighted as contributing to the onset of your symptoms.
The exercises below build up in difficulty, progress gradually through them as you feel able.

A comprehensive exercise programme and guidance for returning to running.

Medication

Over-the-counter analgesia, such as paracetamol or anti inflammatories such as ibuprofen may also help to reduce your symptoms. If you require further information on pain relief, speak to your GP or pharmacist.

Factors influencing pain and recovery

During your recovery a number of other factors can influence your pain levels. Keep the following factors in mind to help move the healing process along:

Look after yourself

Pain is not usually simply a physical problem. Your general well-being can make you vulnerable to pain and your wellbeing can also be made worse by pain. Looking after your general health and well-being will help recovery.  There is helpful advice on the NHS website.

Reduce stress and anxiety

It is normal for people with pain to have stress, anxiety and change in mood. This may affect your ability to cope with the pain and may influence your pain levels. Help is available if you are being affected by stress, anxiety or low mood – see the links below or discuss with your practitioner.
It is important that your whole nervous system is in a healthy state to aid recovery. If your brain is stressed or overworked this may slow recovery.

Relaxation is an important part of your recovery. Simple relaxation techniques may help manage pain and stress. Try to set aside some time each day to relax – you can use relaxation techniques as linked below, or simply an activity you enjoy – reading, deep breathing, sitting in the garden, singing – whatever relaxes you.

Find help and support here:

NHS Website
North Essex IAPT

Physical Activity

Exercise improves fitness, confidence with movement and strength. It can also help reduce your stress and tension and improve your mood and quality of sleep, helping support you to return to normal activities. Perhaps you could simply start by trying to walk for 10 minutes per day.

Alcohol

Avoid alcohol in the early stages of healing (first three days). Evidence has shown this can slow down recovery and increase the chances of re-injury. Find more information on the Drinkaware website.

Sleep

Sleep is very important for your wellbeing. Poor sleep quality, and lack of sleep can make managing pain more difficult. Consistently getting 6 to 9 hours is recommended. Get help and tips Live well, sleep and tiredness website.

Smoking

Smoking can also impact how quickly tissues can heal and affect pain levels. For help with stopping smoking Essex lifestyle service or the NHS Better health website.

How long will it last?

There is no quick fix for knee cap pain and it requires consistency to maintain your rehabilitation. Improvements should be seen over a 3-6 month period.
If your symptoms have persisted despite following the advice and exercise provided in this leaflet you may need the guidance of a physiotherapist to help you return to normal activity.

If you require 1:1 physiotherapy treatment please fill out a self-referral form and send to [email protected].

Is there anything I avoid?

Increasing your activity levels too quickly may make it more difficult to control your symptoms and lead to symptom flare up. If you do experience a flare up try to manage it early by reducing your activity levels and regressing your exercises back to a manageable level. Then gradually build back up your progressions and activity levels.

Ice, Heat or pain killers may be helpful to reduce the pain and allow you to build back up sooner.

What other options are there?

Occasionally shoe inserts (guided by a podiatrist), taping techniques (guided by a physiotherapist) or an injection are required to help settle the pain and allow you to start the rehabilitation process. These may be required in the short term over approximately 4 to 6 weeks. 
A referral for surgery is rarely required as nearly all knee cap pain can be managed through education and exercise.

knee-ligament-injuries-patient-information-leaflet_branded (828kB docx)

The knee joint is one of the largest joints of the body and is supported a number of ligaments. A ligament is made of tough fibrous tissue and provides strength to a joint by connecting one bone to another. There are four main ligaments around the knee joint:

Collateral Ligaments (MCL and LCL): which runs on the inside (medial collateral) and outside (lateral collateral) of the knee and helps to protect and stabilise the knee joint against too much side to side movement.
Cruciate Ligaments (ACL and PCL): which are found inside the knee joint and helps to protect the joint against too much forward, backward and rotational movement.

AASOS Combined knee ligament injuries

How is it caused?

A knee ligament injury occurs when a ligament is forced into an abnormal position, causing it to overstretch.
Injury to the collateral ligaments generally occurs following an sideways stress applied to the knee. This can occur in sports injuries such as skiing, football or rugby or even a simpler situation such as slipping on ice.
Anterior cruciate ligament injuries occur commonly in sports or situations which involve pivoting and sudden deceleration such as football, basketball, netball and skiing. Posterior cruciate ligament injuries appear to be less common and are usually as a result of a direct blow to the front of the tibia with the knee in a flexed position; this can be from contact with an opponent, equipment or falling onto the knee.

What are the symptoms?

• Sometimes you may hear an audible pop or crack at the time of injury or the feeling that something is going out and then back.
• Pain and restricted knee range of movement.
• Difficulty weight bearing.
• Widespread tenderness.
• Swelling and discolouration: may be more indicative of a more severe sprain.
• Sometimes feelings of knee instability or giving way.

How is it diagnosed?

Knee ligament injuries occur in different severities. The 3 grades of knee ligament injuries are:

• Grade 1 – a mild strain (typically involving less than 10% the fibres).
• Grade 2 – a partial ligament tear (typically involving between 11 to 49% of the fibres)
• Grade 3 – a complete ligament tear (typically involving more than 50% of the fibres)

If you think you may have a mild knee ligament injury you should seek advice from a health professional such as a GP or First Contact Practitioner. They will start with taking an in-depth history regarding your injury and the situation around which it occurred.

Diagnosis is generally made clinically following a history taking and physical examination.

You may be referred for an X-Ray if an ankle fracture is suspected. If your knee is not recovering as expected with rehabilitation you may be referred for further investigations such as an MRI scan.

What can I do?

The early stages (48 to 72 hours)

Over-the-counter analgesia, such as paracetamol or anti inflammatories such as ibuprofen may also help to reduce your symptoms. If you require further information on pain relief, speak to your GP or pharmacist.

Progressive Exercise

Exercise is an essential part of your recovery following a knee ligament injury. Strength training has been shown to prevent recurrent knee injuries. They should be done as pain allows, with some discomfort being acceptable. If a sharp shooting pain is provoked then ease off. As your pain reduces and your movement improves consider progressing to the more difficult exercises.

Graded return to running: start with walking and jogging intervals. Gradually, increase your distance first and then speed.

Factors influencing pain and recovery

Whilst you are experiencing  pain a number of other factors can influence your pain levels. Keep the following factors in mind to help move the healing process along.

Look after yourself

Pain is not usually simply a physical problem. Your general well-being can make you vulnerable to pain and your wellbeing can also be made worse by pain. Looking after your general health and well-being will help recovery.  There is helpful advice on the NHS website.

Reduce stress and anxiety

It is normal for people with pain to have stress, anxiety and change in mood. This may affect your ability to cope with the pain and may influence your pain levels. Help is available if you are being affected by stress, anxiety or low mood – see the links below or discuss with your practitioner.
It is important that your whole nervous system is in a healthy state to aid recovery. If your brain is stressed or overworked this may slow recovery.

Relaxation is an important part of your recovery. Simple relaxation techniques may help manage pain and stress. Try to set aside some time each day to relax – you can use relaxation techniques as linked below, or simply an activity you enjoy – reading, deep breathing, sitting in the garden, singing – whatever relaxes you.

Find help and support here:

NHS Website
North Essex IAPT

Physical Activity

Exercise improves fitness, confidence with movement and strength. It can also help reduce your stress and tension and improve your mood and quality of sleep, helping support you to return to normal activities. Perhaps you could simply start by trying to walk for 10 minutes per day.

Alcohol

Avoid alcohol in the early stages of healing (first three days). Evidence has shown this can slow down recovery and increase the chances of re-injury. Find more information on the Drinkaware website.

Sleep

Sleep is very important for your wellbeing. Poor sleep quality, and lack of sleep can make managing pain more difficult. Consistently getting 6 to 9 hours is recommended. Get help and tips Live well, sleep and tiredness website.

Smoking

Smoking can also impact how quickly tissues can heal and affect pain levels. For help with stopping smoking Essex lifestyle service or the NHS Better health website.

How long will it last?

In the first few weeks you will weight bear as pain allows using the support from elbow crutches and a knee support if necessary.
Mild sprains would be expected to recover within 3 to 4 weeks.
Moderate or severe sprains treated conservatively would be expected to recover within 6 to 8 weeks.
If your symptoms have persisted or worsen despite following the advice and exercise provided in this leaflet you will need to visit your GP surgery again.

You may need the guidance of a physiotherapist to help you return to normal activity:

• If your injury is more severe; or
• If you wish to return to sports involving jumping activities or high speed movement;
• If you require 1:1 physiotherapy treatment please fill out a self-referral form and send to [email protected]

Is there anything I should avoid?

Overstretching within the first few weeks can put too much strain on the healing tissue.
You should avoid pushing through pain and work within your pain limits. As your injury starts to heal your pain will reduce and you will be able to do more. You should aim not to increase your pain above a 4 to 5/10. Your exercises may feel challenging and make the muscles feel achy and fatigued but they should not be increasing your pain excessively for a prolonged period of time. If this is the case then discontinue and contact your physiotherapist.
Complete rest or prolonged periods of reduced activity are likely to delay your recovery and return to normal function.

What other options are there?

Bracing

This is sometimes recommended in more severe cases to in the early stages to help protect the injured area. Braces may limit side to side movement or restrict the amount of knee bending. If a brace is required you will be guided by your consultant or therapist about how it should be used.

Physiotherapy

Physiotherapists can provide expert guidance with exercise, gait retraining and where necessary manual therapy to help you return to normal activity.

Surgery

Surgery to reconstruct a ligament is mainly reserved for patients who have chronic instability after a knee ligament injury and who have not responded to a comprehensive exercise-based physiotherapy programme. You will be referred to an orthopaedic surgeon to discuss your options.

knee-osteoarthritis-patient-information-leaflet_branded (617kB docx)

Download leaflet

Osteoarthritis is a condition that affects the joints, causing pain and stiffness. The knee is a ‘hinge joint’ which is covered in a layer of cartilage. When the knee develops osteoarthritis, some of the cartilage roughens and becomes thin and the joint doesn’t move as smoothly as it should. In severe cases the cartilage can become so thin that it no longer covers the bone resulting reduced joint space.

How is it caused?

• Knee osteoarthritis can be caused by a combination of factors:
• Age: osteoarthritis occurs mostly in those aged over 40
• Gender: osteoarthritis is twice as common in women
• Previous joint injury: normal activity and exercise does not cause osteoarthritis, but previous injuries/surgery can increase the risk
• Obesity: Being overweight increases the strain on your joints which can contribute to osteoarthritis
• Genetic factors: if a close family member has osteoarthritis, you are more likely to develop the condition

What are the symptoms?

Knee osteoarthritis can present differently in everyone. The most common symptoms include:

• Pain                                                            
• Early morning stiffness less than 30 minutes
• Reduced movement
• Hard or soft swellings
• Crepitus (grating/grinding)
• Giving way
• Locking
• Difficulty climbing stairs
• Knees can become bowed
• Muscle wasting

How is it diagnosed?

Knee osteoarthritis is normally diagnosed based on the signs and symptoms identified during a physical examination. X-rays can be useful but are not always required. There are no blood test for osteoarthritis but can be used to rule out other conditions.

What can I do?

Stay Active: Exercise has proven to ease pain and improve function. Gentle exercise in the form of specific exercises for your joint (see below), or more generalised activity such as swimming or walking, can help you can strengthen the muscles and protect the joint.

Warmth

Can help reduce symptoms, use for 10 minutes twice daily.

Medication

Over-the-counter analgesia, such as paracetamol or anti inflammatories such as ibuprofen may also help to reduce your symptoms. If you require further information on pain relief, speak to your GP or pharmacist.

Weight management

Studies tell us that losing 10 to 19.9% of your baseline body weight can significantly improve pain and function.

Aids

Walking aids can help to reduce some of the load through your joint. Knee supports and braces can be used to reduce instability in severe cases.

Pacing your activities

Try to find the right balance between activity and rest to avoid overstraining your joints, a range of excellent resources for helping manage osteoarthritis.

Factors influencing pain and recovery

During your recovery a number of other factors can influence your pain levels. Keep the following factors in mind to help move the healing process along.

Look after yourself

Pain is not usually simply a physical problem. Your general well-being can make you vulnerable to pain and your wellbeing can also be made worse by pain. Looking after your general health and well-being will help recovery.  There is helpful advice on the NHS website.

Reduce stress and anxiety

It is normal for people with pain to have stress, anxiety and change in mood. This may affect your ability to cope with the pain and may influence your pain levels. Help is available if you are being affected by stress, anxiety or low mood – see the links below or discuss with your practitioner.
It is important that your whole nervous system is in a healthy state to aid recovery. If your brain is stressed or overworked this may slow recovery.

Relaxation is an important part of your recovery. Simple relaxation techniques may help manage pain and stress. Try to set aside some time each day to relax – you can use relaxation techniques as linked below, or simply an activity you enjoy – reading, deep breathing, sitting in the garden, singing – whatever relaxes you.

Find help and support here:

NHS Website
North Essex IAPT

Physical Activity

Exercise improves fitness, confidence with movement and strength. It can also help reduce your stress and tension and improve your mood and quality of sleep, helping support you to return to normal activities. Perhaps you could simply start by trying to walk for 10 minutes per day.

Alcohol

Avoid alcohol in the early stages of healing (first three days). Evidence has shown this can slow down recovery and increase the chances of re-injury. Find more information on the Drinkaware website.

Sleep

Sleep is very important for your wellbeing. Poor sleep quality, and lack of sleep can make managing pain more difficult. Consistently getting 6 to 9 hours is recommended. Get help and tips Live well, sleep and tiredness website.

Smoking

Smoking can also impact how quickly tissues can heal and affect pain levels. For help with stopping smoking Essex lifestyle service or the NHS Better health website.

How long will it last?

You can expect a flare up in your symptoms to last anywhere between a few weeks to a couple of months. If your knee joint has significant degenerative changes you may experience some ongoing symptoms. If your symptoms have persisted despite following the advice and exercise provided in this leaflet you may need the guidance of a physiotherapist to help you return to normal activity.

If you require 1:1 physiotherapy treatment please fill out a self-referral form and send to [email protected]

If your symptoms have worsened despite the advice given we would recommended you see a healthcare professional for review.

Is there anything I should avoid?

Over rest: your symptoms are more likely to get worse if you sit and do nothing; too much rest is likely to increase stiffness and can result in muscle weakness.

What other options are there?

Injections  

Research has shown a steroid injection into the knee joint can provide short (6 weeks) to medium term (3 months) pain relief. However, studies have also shown that when patients who have had a steroid injection are compared to patients who underwent physiotherapy, pain levels and disability were lower in those who had received physiotherapy at 1 year follow up. Recent research has also shown that steroid injections may speed up the process of osteoarthritis over a 2 to 4 year period.

Surgery

In severe cases, keyhole or a knee replacement surgery may be recommended. Suitability for surgery depends on several factors including general health and fitness and severity of OA.
If you are considering a joint replacement and would like more information to help you discuss your situation with your health professional please visit the National Joint Registry website.

large-rotator-cuff-rehabilitation-patient-information-leaflet_branded (726kB docx)

A large rotator cuff injury involves the group of muscles known as the rotator cuff which arise from the shoulder blade and attach to the top of your humerus (arm bone).

Rotator cuff tears.

How is it caused?

Prolonged overuse or injury.

What are the symptoms?

• Limited active shoulder range of motion (often unable to lift the arm above shoulder height).
• Muscle weakness causing difficulty with lifting.
• Pain during activity and possibly at night when lying on your side.

How is it diagnosed?

A large rotator cuff injury is generally diagnosed from your clinical history and physical examination.
If you have had a trauma to the shoulder and a bony or muscle injury is suspected, you may also be referred for investigations such as an X-ray or Ultrasound scan.

What can I do?

Exercise therapy

There is a powerful muscle on the outside of your arm – the deltoid muscle – that may be re-educated to compensate for the torn rotator cuff muscle.
The following exercises help to train the deltoid muscle gradually so that your shoulder should be done 10 times each or until tired, 2 to 3 times a day over a period of 12 weeks to strengthen your deltoid muscle. It will aim to reduce your pain and improve both the range of movement and your arm function.
When an exercise becomes too easy, progress to the next stage.

Factors influencing pain and recovery

During your recovery a number of other factors can influence your pain levels. Keep the following factors in mind to help move the healing process along.

Look after yourself

Pain is not usually simply a physical problem. Your general well-being can make you vulnerable to pain and your wellbeing can also be made worse by pain. Looking after your general health and well-being will help recovery.  There is helpful advice on the NHS website.

Reduce stress and anxiety

It is normal for people with pain to have stress, anxiety and change in mood. This may affect your ability to cope with the pain and may influence your pain levels. Help is available if you are being affected by stress, anxiety or low mood – see the links below or discuss with your practitioner.
It is important that your whole nervous system is in a healthy state to aid recovery. If your brain is stressed or overworked this may slow recovery. Relaxation is an important part of your recovery. Simple relaxation techniques may help manage pain and stress. Try to set aside some time each day to relax – you can use relaxation techniques as linked below, or simply an activity you enjoy – reading, deep breathing, sitting in the garden, singing – whatever relaxes you.

Find help and support here:

NHS Website
North Essex IAPT

Physical Activity

Exercise improves fitness, confidence with movement and strength. It can also help reduce your stress and tension and improve your mood and quality of sleep, helping support you to return to normal activities. Perhaps you could simply start by trying to walk for 10 minutes per day.

Alcohol

Avoid alcohol in the early stages of healing (first three days). Evidence has shown this can slow down recovery and increase the chances of re-injury. Find more information on the Drinkaware website.

Sleep

Sleep is very important for your wellbeing. Poor sleep quality, and lack of sleep can make managing pain more difficult. Consistently getting 6 to 9 hours is recommended. Get help and tips Live well, sleep and tiredness website.

Smoking

Smoking can also impact how quickly tissues can heal and affect pain levels. For help with stopping smoking Essex lifestyle service or the NHS Better health website.

How long will it last?

It may take up to 12 weeks (3 months) for your symptoms to improve with exercise so it is important to be consistent and stick with it.
If your symptoms persist or worsen despite the advice given we would recommended you see a healthcare professional for review.

Is there anything I should avoid?

Progressing before an exercise becomes too easy may aggravate your pain.
Avoid lifting heavy objects especially when they are not held close the body such as lifting shopping bags into the boot of your car or onto a worktop.

What other options are there?

Physiotherapy

Physiotherapists can provide expert guidance with exercise to help you return to normal activity.
If you wish for your progress to be monitored more closely and require 1:1 physiotherapy treatment please fill out a self-referral form and send to [email protected].

Steroid Injection

This may be useful if pain is limiting your ability to exercise or disturbing your sleep.

Surgery

In certain circumstances, it may be possible to repair a large rotator cuff tear. A referral to an orthopaedic surgeon would be recommended to discuss your options.

low-back-pain-patient-information-leaflet_branded (641kB docx)

Musculoskeletal back pain is often referred to as ‘mechanical back pain’ or ‘non-specific mechanical back pain’ and is very common, affecting most of us at some point (or points) during our lives.

Back pain health

How is it caused?

Fortunately, low back pain it is not usually caused by a serious problem.
However in most cases, it remains difficult to identify the exact structure causing pain. Many structures in your back including joints, muscles and other soft tissues can be a source of pain often at the same time. Scans such as X-rays and MRI will commonly reveal structural changes which are poorly linked to pain levels. Whether the structure involved is a muscle, a ligament, or any other soft tissue, the treatment is largely the same.
Pain is often caused by a change in activity that has not been tolerated well, such as using working at a computer for longer than normal or lifting heavier objects more than normal. Sometimes this may cause pain to start suddenly and other times it may develop gradually.

There may also be other factors involved. You may recognise some from this list:

• Avoiding movements and protecting your back
• Fear of damage or not improving
• Feeling down or being stressed
• Smoking, being overweight, poor sleep, inactivity
• Difficult relationships at work or at home
• Being unhappy at work
• Stressful life events such as bereavement or illness
• Sedentary occupations are more at risk than those involving activity. Being very overweight is another risk factor. Heavy manual work and repetitive lifting do not seem to be risk factors

What are the symptoms?

• Dull ache or a sharp pain usually localised to the lower back region but can be felt into the buttocks, hips or back of the thigh.
• Pain is noticed when performing certain movements
• The pain fluctuates and is not always constantly at one level
• Difficulty getting in a comfortable position at night or when turning over in bed

Should I be worried?

• Only 1% of people with back pain have a rare or serious condition. One rare but serious condition called Cauda Equina Syndrome. This requires emergency treatment. If you experience any of these symptoms you should visit A+E.
• New, significant pain, pins and needles or numbness in both legs
• Loss of feeling or pins and needles between your inner thighs or around genitals
• Numbness around your back passage or buttocks
• Difficulty trying to start, stop or control flow of urine
• Loss of sensation passing urine
• Leaking of urine or not knowing your bladder is empty or full.
• Inability to stop a bowel motion or leaking
• Loss of sensation passing a bowel motion
• Change in ability to achieve an erection or ejaculate
• Loss of sensation in genitals during sexual intercourse

This information can be viewed in another language.

You should also seek advice from your GP if you experience any of the following:

• Severe night pain or night sweats
• Rapid, unexplained weight loss
• Weakness in your legs causing you to trip and fall
• A fever or feeling unwell
• You should tell your practitioner if you have a history of cancer or have had a fall, injury or accident

How is it diagnosed?

Musculoskeletal back pain is normally diagnosed based on you tell us and a physical examination. Scans such as X-ray or MRI are not routinely required unless diagnosis is unclear. This is because they will often show structural change seen with aging which is commonly found in those without pain and is now known not to be a good predictor of pain levels.  

What can I do?

Activity adjustment

In the majority of cases mechanical back pain will settle if you temporarily reduce your activity to a level which does not significantly aggravate your pain. This will allow you to control your symptoms more easily.
For example, it is still completely safe to bend and lift when you have back pain. However, you may have to adjust how often or how heavy you lift for a short time. Try different ways of lifting, like bending your knees. Try to keep the load close to you and do not lift more than you are able to.
Research tells us that avoiding normal activities like lifting will prolong your recovery.  

Exercise

Exercise is an essential towards helping your get back to normal activity as soon as possible as well as promoting healing. It can also be helpful in reducing the likelihood of the problem coming back again in the future. For example, research tells us that regular lifting practice is likely to improve your tolerance to lifting.

Movement will help to reduce muscle tension, reduce pain and increase range of movement. Avoiding movement could lead to higher levels of pain and poorer recovery resulting in longer periods off work.
Exercises may cause discomfort but should not increase your pain or symptoms. If a sharp shooting pain is provoked then ease off. As your pain reduces and your movement improves consider progressing to the more difficult exercises.

Remember, although movement may initially be painful but this does not mean that you are causing more damage or making anything worse.
If your back feels tight and stiff, start with some regular stretches. Stretches increase your flexibility but strengthening will enable you to bend, lift and do daily activities for longer with less pain.

Medication

If you require medication to relieve your pain, you can liaise with your GP or pharmacist to determine the most appropriate medication. It can be difficult to move your neck if you are in too much pain, therefore it is useful to take pain medication, to relieve the pain, enable you to carry out exercise effectively and allow a faster recovery.

Heat therapy

Heat and ice packs can be used for short term relief of pain and to relax muscle tension. In the first
48 to 72 hours you can try a cold pack on the affected area for 5 to 10 minutes – this can be a bag of frozen peas wrapped in a damp tea towel. Others may prefer heat – a hot water bottle, a bath or a shower to relax muscular tension.

Factors influencing pain and recovery

During your recovery a number of other factors can influence your pain levels. Keep the following factors in mind to help move the healing process along.

Work

You may be worried about continuing with work, or other responsibilities. It is important to discuss these fears with your practitioner. Remaining at work usually leads to a quicker recovery even if you have to work with modified activities.

Having poor posture does not cause back pain. There is no perfect posture. Staying in one position for long periods can be a factor in your pain. It is important to plan regular breaks and change posture regularly.
Your relationship with your boss and colleagues, job enjoyment, feeling supported at work and returning to work are all very important in helping your recovery. Speak to your employer if you need support at work.

Look after yourself

Pain is not usually simply a physical problem. Your general well-being can make you vulnerable to pain and your wellbeing can also be made worse by pain. Looking after your general health and well-being will help recovery.  There is helpful advice on the NHS website.

Reduce stress and anxiety

It is normal for people with pain to have stress, anxiety and change in mood. This may affect your ability to cope with the pain and may influence your pain levels. Help is available if you are being affected by stress, anxiety or low mood – see the links below or discuss with your practitioner.
It is important that your whole nervous system is in a healthy state to aid recovery. If your brain is stressed or overworked this may slow recovery. Relaxation is an important part of your recovery. Simple relaxation techniques may help manage pain and stress. Try to set aside some time each day to relax – you can use relaxation techniques as linked below, or simply an activity you enjoy – reading, deep breathing, sitting in the garden, singing – whatever relaxes you.

Find help and support here:

NHS Website
North Essex IAPT

Physical Activity

Exercise improves fitness, confidence with movement and strength. It can also help reduce your stress and tension and improve your mood and quality of sleep, helping support you to return to normal activities. Perhaps you could simply start by trying to walk for 10 minutes per day.

Alcohol

Avoid alcohol in the early stages of healing (first three days). Evidence has shown this can slow down recovery and increase the chances of re-injury. Find more information on the Drinkaware website.

Sleep

Sleep is very important for your wellbeing. Poor sleep quality, and lack of sleep can make managing pain more difficult. Consistently getting 6 to 9 hours is recommended. Get help and tips Live well, sleep and tiredness website.

Nutrition and weight

Being overweight can increase the physical strain on the body and also contribute to inflammation in your body. Make sure you eat a balanced diet. Adult weight management services are available free to Essex residents.

Smoking

Smoking can also impact how quickly tissues can heal and affect pain levels. For help with stopping smoking Essex lifestyle service or the NHS Better health website.

How long will it last?

Most cases of low back pain feel better within 6 weeks although it may take longer for it to resolve. Pain can fluctuate during this time with some days being better than others. Returning to work and progressing your fitness levels will help you led a normal life whilst the pain resolves over time. 
If your symptoms have not improved or worsen despite following the advice and exercise provided in this leaflet you will need to visit your GP surgery again.

Is there anything I should avoid?

Bed Rest Is Bad For Backs
We now know that bed rest for more than a day or two can cause you to feel stiff, lose muscle strength, lose physical fitness, lead to higher pain levels, delay your return to work and affect your psychological health.

What other options are there?

Physiotherapy 

Physiotherapists can provide expert guidance with exercise and other supportive treatments to help you return to normal activity.
If you require 1:1 physiotherapy treatment please fill out a self-referral form and send to [email protected].

Community Pain Management Programme

If you’ve been in pain for a long time, referral to a specialist programme that involves a combination of group therapy, exercises, relaxation, and education about pain and the psychology of pain may be offered. Speak to your health professional for more information.

Surgery and minimally invasive intervention

Surgery including disc replacement is not recommended for managing low back pain. Spinal injections are also not recommended for managing low back pain.

Long term back pain which has failed to respond to specialist advice, exercise, and lifestyle improvements may be considered for minimally invasive treatment. A successful response to a medial branch block (a procedure that temporarily affects the function of the nerves supplying some of the spinal joints) would be followed by radiofrequency denervation (burning of the nerves which supply the facet joints of the spine). These procedures have been shown to work up to 50% of the time with nerve regrowth occurring over 6 to 12 months.

Other useful links – YouTube Videos:

Chartered Society of Physiotherapy advice on managing back pain.

Understanding pain in less than 5 minutes- Live Active

Low back pain – Dr Mike Evans

meniscus-injuries-patient-information-leaflet_branded (831kB docx)

Each knee joint contains an inner and outer meniscus (medial and lateral meniscus). These are thick rubber-like pads of cartilage tissue. They are C-shaped and become thinner towards the middle of the joint. The menisci act like shock absorbers to absorb the impact of the upper leg on the lower leg. They also help to improve smooth movement and stability of the knee.
When people talk about a cartilage injury to a knee, they usually mean an injury to one of the menisci.

AAOS – discoid meniscus

How is it caused?

Traumatic meniscus tear: this is usually caused by forceful knee movement whilst you are weight bearing on the same leg.
Non-traumatic (degenerative) meniscus tear: In some cases a tear develops due to repeated small injuries to the cartilage or due to wear and tear (degeneration) of the meniscal cartilage. This type of tear is commonly found in patients without symptoms and is very common in patients with knee osteoarthritis.

What are the symptoms?

• Pain
• Swelling
• Reduced knee movement, especially when trying to straighten the leg.
• Locking, clicking or giving way (mechanical symptoms)

How is it diagnosed?

Diagnosis is generally made clinically following a history taking and physical examination.
You may be referred for an X-Ray if you have had a trauma and a fracture is suspected or to rule out signs of osteoarthritis. If your knee is not recovering as expected with rehabilitation or diagnosis is unclear you may be referred for further investigations such as an MRI scan.

What can I do?

The early stages (48 to 72 hours)

Over-the-counter analgesia, such as paracetamol or anti inflammatories such as ibuprofen may also help to reduce your symptoms. If you require further information on pain relief, speak to your GP or pharmacist.

Progressive Exercise

Exercise is an essential part of your recovery following a knee meniscus injury. Strength training has been shown to prevent recurrent knee injuries. They should be done as pain allows, with some discomfort being acceptable. If a sharp shooting pain is provoked then ease off. As your pain reduces and your movement improves consider progressing to the more difficult exercises.

Graded return to running: start with walking and jogging intervals. Increase your distance and speed gradually. 

Factors influencing pain and recovery

Whilst you are experiencing pain a number of other factors can influence your pain levels. Keep the following factors in mind to help move the healing process along.

Look after yourself

Pain is not usually simply a physical problem. Your general well-being can make you vulnerable to pain and your wellbeing can also be made worse by pain. Looking after your general health and well-being will help recovery.  There is helpful advice on the NHS website.

Reduce stress and anxiety

It is normal for people with pain to have stress, anxiety and change in mood. This may affect your ability to cope with the pain and may influence your pain levels. Help is available if you are being affected by stress, anxiety or low mood – see the links below or discuss with your practitioner.
It is important that your whole nervous system is in a healthy state to aid recovery. If your brain is stressed or overworked this may slow recovery.

Relaxation is an important part of your recovery. Simple relaxation techniques may help manage pain and stress. Try to set aside some time each day to relax – you can use relaxation techniques as linked below, or simply an activity you enjoy – reading, deep breathing, sitting in the garden, singing – whatever relaxes you.

Find help and support here:

NHS Website
North Essex IAPT

Physical Activity

Exercise improves fitness, confidence with movement and strength. It can also help reduce your stress and tension and improve your mood and quality of sleep, helping support you to return to normal activities. Perhaps you could simply start by trying to walk for 10 minutes per day.

Alcohol

Avoid alcohol in the early stages of healing (first three days). Evidence has shown this can slow down recovery and increase the chances of re-injury. Find more information on the Drinkaware website.

Sleep

Sleep is very important for your wellbeing. Poor sleep quality, and lack of sleep can make managing pain more difficult. Consistently getting 6 to 9 hours is recommended. Get help and tips Live well, sleep and tiredness website.

Smoking

Smoking can also impact how quickly tissues can heal and affect pain levels. For help with stopping smoking Essex lifestyle service or the NHS Better health website.

How long will it last?

The majority of meniscus injuries can improve on their own with time and correct management.
If your knee pain is being treated conservatively would be expected to show signs of recovery within 6 to 8 weeks, although full recovery may take as long as 12 to 16 weeks.
 
If your symptoms have persisted or worsen despite following the advice and exercise provided in this leaflet you will need to visit your GP surgery again.

Is there anything I should avoid?

Overstretching within the first few weeks can put too much strain on the healing tissue.
You should avoid pushing through pain and work within your pain limits. As your injury starts to heal your pain will reduce and you will be able to do more. You should aim not to increase your pain above a 4-5/10. Your exercises may feel challenging and make the muscles feel achy and fatigued but they should not be increasing your pain excessively for a prolonged period of time. If this is the case then discontinue and contact your physiotherapist.
Complete rest or prolonged periods of reduced activity are likely to delay your recovery and return to normal function.

What other options are there?

Physiotherapy

Physiotherapists can provide expert guidance with exercise, gait retraining and where necessary manual therapy to help you return to normal activity.
If you require 1:1 physiotherapy treatment please fill out a self-referral form and send to [email protected].

Surgery

A referral to an orthopaedic surgeon may be recommended if your meniscus tear was associated with a specific injury and is causing persistent mechanical symptoms such as locking and giving way.
Most operations are done by arthroscopy (keyhole). The types of operations which may be considered include the following:
The torn meniscus may be able to be repaired and stitched back into place. However, in many cases this is not possible.
In some cases where repair is not possible, a small portion of the meniscus may be trimmed.
Surgery is generally not recommended for non traumatic meniscus tears. Studies have shown no long term difference in outcomes between placebo surgery and meniscectomy (trimming of the meniscus).

Injection therapy

Steroid injections may be considered in situations where pain and/or swelling has persisted. Non traumatic meniscus tears may often not be the cause of ongoing symptoms. They often exist alongside other conditions such as osteoarthritis.

Steroid injections are generally used sparingly as some studies have shown they can cause potential damage to the joint when compared to those who don’t receive injections when monitored over a period of 2 to 4 years. Possible benefits may be seen for 4 to 6 weeks.

mechanical-neck-pain-patient-information-leaflet_branded (720kB docx)

General neck pain is often referred to as ‘mechanical neck pain’ or ‘non-specific mechanical neck pain’ and is very common, affecting most of us at some point (or points) during our lives.

How is it caused?

Pain is often caused by a change in activity that has not been tolerated well, such as using working at a computer for longer than normal or lifting heavier objects more than normal. Sometimes this may cause pain to start suddenly and other times it may develop gradually.

It remains difficult to identify the exact structure causing pain. Many structures in your neck including joints, muscles and other soft tissues can be a source of pain often at the same time. Scans such as X-rays and MRI will commonly reveal structural changes which poorly linked to pain levels. Whether the structure involved is a muscle, a ligament, or any other soft tissue, the treatment is largely the same.

What are the symptoms?

Dull aching pain on one side or both sides of the neck which may radiate to the shoulders or shoulder blades.
Pain which may sometimes be sharp when the neck is moved for example when turning or looking up or down.
Difficulty getting in a comfortable position at night or when turning over in bed.
Sometimes headaches that are most commonly felt at the back or side of the head.

How is it diagnosed?

General neck pain is normally diagnosed based on you tell us and a physical examination. Scans such as X-ray or MRI are not routinely required unless diagnosis is unclear. This is because they will often reveal structural changes commonly found in those without pain and are now known not to be a good predictor of pain levels.

What can I do?

Activity adjustment

In the majority of cases mechanical neck pain will settle if you temporarily reduce your activity to a level which does not significantly aggravate your pain. This will allow you to control your symptoms more easily.

Exercise

Exercise is an essential towards helping your get back to normal activity as soon as possible as well as promoting healing.
Movement will help to reduce muscle tension, reduce pain and increase range of movement. Avoiding movement could lead to higher levels of pain and poorer recovery resulting in longer periods off work.
Exercise should be carried out little and often, throughout the day. Exercises may cause discomfort but should not increase your pain or symptoms. If a sharp shooting pain is provoked then ease off Perform the exercises in a slow and controlled manner. As your pain reduces and your movement improves consider progressing to the more difficult exercises.
Remember, although movement may initially be painful but this does not mean that you are causing more damage or making anything worse.

Medication

If you require medication to relieve your pain, you can liaise with your GP or pharmacist to determine the most appropriate medication. It can be difficult to move your neck if you are in too much pain, therefore it is useful to take pain medication, to relieve the pain, enable you to carry out exercise effectively and allow a faster recovery.

Heat therapy

The application of heat such as a hot water bottle wrapped in a towel or a wheat bag, to relax the muscles in your neck.

Factors influencing pain and recovery

During your recovery a number of other factors can influence your pain levels. Keep the following factors in mind to help move the healing process along.

Work

You may be worried about continuing with work, or other responsibilities. It is important to discuss these fears with your practitioner. Remaining at work usually leads to a quicker recovery even if you have to work with modified activities.
Having poor posture does not cause neck pain. There is no perfect posture. Staying in one position for long periods can be a factor in your pain. It is important to plan regular breaks and change posture regularly.
Your relationship with your boss and colleagues, job enjoyment, feeling supported at work and returning to work are all very important in helping your recovery. Speak to your employer if you need support at work.

Look after yourself

Pain is not usually simply a physical problem. Your general well-being can make you vulnerable to pain and your wellbeing can also be made worse by pain. Looking after your general health and well-being will help recovery.  There is helpful advice on the NHS website.

Reduce stress and anxiety

It is normal for people with pain to have stress, anxiety and change in mood. This may affect your ability to cope with the pain and may influence your pain levels. Help is available if you are being affected by stress, anxiety or low mood – see the links below or discuss with your practitioner.
It is important that your whole nervous system is in a healthy state to aid recovery. If your brain is stressed or overworked this may slow recovery. Relaxation is an important part of your recovery. Simple relaxation techniques may help manage pain and stress. Try to set aside some time each day to relax – you can use relaxation techniques as linked below, or simply an activity you enjoy – reading, deep breathing, sitting in the garden, singing – whatever relaxes you.

Find help and support here:

NHS Website
North Essex IAPT

Alcohol

Avoid alcohol in the early stages of healing (first three days). Evidence has shown this can slow down recovery and increase the chances of re-injury. Find more information on the Drinkaware website.

Sleep

Sleep is very important for your wellbeing. Poor sleep quality, and lack of sleep can make managing pain more difficult. Consistently getting 6 to 9 hours is recommended. Get help and tips Live well, sleep and tiredness website.

Nutrition and weight

Being overweight can increase the physical strain on the body and also contribute to inflammation in your body. Make sure you eat a balanced diet. Adult weight management services are available free to Essex residents.

Smoking

Smoking can also impact how quickly tissues can heal and affect pain levels. For help with stopping smoking Essex lifestyle service or the NHS Better health website.

How long will it last?

Mechanical neck pain is common but most cases aren’t caused by a serious problem. As there is often not one specific cause to mechanical neck pain the amount of time it takes to recover can vary a little. However with the right advice and exercises we would hope you should start to show some improvement within a couple of weeks with symptoms feeling much recovered by 6 to 8 weeks.

If your symptoms have persisted or worsen despite following the advice and exercise provided in this leaflet you will need to visit your GP surgery again.

plantar-fascia-related-pain-patient-information-leaflet_branded (419kB docx)

Plantar fascia related pain (also known as ‘plantar fasciitis, plantar fasciopathy or ‘chronic heel pain’) is one of the most common causes of heel pain affecting 10 to 15% of the population. The Plantar Fascia is a sheet of broadband fibrous tissue that runs along the bottom of the foot. This tissue connects the heel to the base of the toes.
Under normal circumstances the plantar fascia supports the arch of the foot and acts as a shock absorbing ‘bow string’ within the arch of the foot. Sometimes the plantar fascia can become painful if excess stress is placed through it such as through injury/ trauma, an unaccustomed increase in activity levels or through degenerative changes.
 

Plantar fasciitis

How is it caused?

Occasionally plantar fascia related pain may occur suddenly such as following trauma to the foot. However more commonly there is no known cause and the symptoms develop gradually over time. The condition is common in both active people as well as those with a less active lifestyle.

Factors which may predispose you to develop the condition include:

• Being over the age of 40.
• Being overweight (having an increased BMI).
• Altered biomechanics e.g. people with ‘flat feet’ or high arches or those having tight calf muscles may be more at risk.
• Physical activity overload e.g. advancing too quickly in a new sport or activity. Also occupations that require excessive standing and/or walking especially on hard surfaces can contribute.
• Footwear- lack of supportive shoes that provide cushioning/shock absorption can overload the plantar fascia.
• Other factors – A history of inflammatory arthritis and diabetes can also predispose you to develop the condition.

Signs and symptoms

Pain usually starts gradually without any injury to the area. It is often felt on the underside of your heel on the sole of your foot approximately 4cm forward from the back of your heel. It may be very tender to touch. Pain is often a deep, aching sensation but can also feel sharp. Pain is commonly more pronounced first thing in the morning when you put your foot to the floor or standing up after a period of sitting still. Typically pain eases with activity although may become more painful towards the end of the day or after prolonged walking.

How is it diagnosed?

In the vast majority of people, no investigations are necessary and a diagnosis is made by your physiotherapist or health care professional examining you. Occasionally, if your symptoms have persisted or to rule out other causes of heel pain other tests may be performed. These can include x-rays, an ultrasound, MRI scan or blood tests.

How long will it last?

Although a painful aggravating condition the symptoms are often self-limiting and resolve within 6 to 18 months.

What can I do?

Conservative management has been shown to be 90% effective at reducing symptoms but it is important to try and be patient as recovery can take some time. Below are some conservative treatments that have been shown to be effective. Often a combination of treatments is more effective rather than one single approach.

Physiotherapy/Exercises

Specific exercises have been shown to help reduce pain and improve strength of the plantar fascia. This is important in order to build up the tolerance of the tissue to load and to enable you to return to your normal activities more quickly. Exercise is a vital part of the recovery process.

 
Repetitions should feel hard, and there may be some pain. This should improve after 24 hours. If the pain continues reduce the weights used or go back to early stage exercises. Complete the strength exercises every other day.

Pain Management

Over-the-counter analgesia, such as paracetamol or anti inflammatories such as ibuprofen may also help to reduce your symptoms. If you require further information on pain relief, speak to your GP or pharmacist.

Load reduction

Avoid standing and walking for prolonged periods of the day if you can. Depending on your pain you may need to reduce any excessive exercise or sport for a period of time. If you are overweight trying to lose weight is likely to help. If you think you need more help with weight loss, please discuss this with your healthcare professional or GP.

Ice

Apply an icepack (wrapped in a towel) to the sole of the foot for 15 to 20 minutes 2 to 4 times a day. Alternatively fill a 500ml bottle with water and freeze it. Apply the ice by rolling your foot over the bottle with a layer of towel between the bottle and your foot to prevent an ice burn. Do not use ice if you have any circulatory problems or poor skin sensation.

Footwear

Wearing supportive comfortable footwear with cushioned heels such as trainers is advisable. Try to avoid walking barefoot as this can also increase the load on the plantar fascia.

Gel Heel Pads +/- Orthotics

Gel heel pads and off the shelf orthotics that you place in your shoe have been shown to reduce pain in the short term (3). These can be brought from most chemists. Custom made orthotics may be required if the cause of your problem is largely biomechanical. You may be referred to a podiatrist for this by your physiotherapist or healthcare professional.

Factors influencing pain and recovery

During your recovery a number of other factors can influence your pain levels. Keep the following factors in mind to help move the healing process along.

Look after yourself

Pain is not usually simply a physical problem. Your general well-being can make you vulnerable to pain and your wellbeing can also be made worse by pain. Looking after your general health and well-being will help recovery.  There is helpful advice on the NHS website.

Reduce stress and anxiety

It is normal for people with pain to have stress, anxiety and change in mood. This may affect your ability to cope with the pain and may influence your pain levels. Help is available if you are being affected by stress, anxiety or low mood – see the links below or discuss with your practitioner.
It is important that your whole nervous system is in a healthy state to aid recovery. If your brain is stressed or overworked this may slow recovery.

Relaxation is an important part of your recovery. Simple relaxation techniques may help manage pain and stress. Try to set aside some time each day to relax – you can use relaxation techniques as linked below, or simply an activity you enjoy – reading, deep breathing, sitting in the garden, singing – whatever relaxes you.

Find help and support here:

NHS Website
North Essex IAPT

Physical Activity

Exercise improves fitness, confidence with movement and strength. It can also help reduce your stress and tension and improve your mood and quality of sleep, helping support you to return to normal activities. Perhaps you could simply start by trying to walk for 10 minutes per day.

Alcohol

Avoid alcohol in the early stages of healing (first three days). Evidence has shown this can slow down recovery and increase the chances of re-injury. Find more information on the Drinkaware website.

Sleep

Sleep is very important for your wellbeing. Poor sleep quality, and lack of sleep can make managing pain more difficult. Consistently getting 6 to 9 hours is recommended. Get help and tips Live well, sleep and tiredness website.

Smoking

Smoking can also impact how quickly tissues can heal and affect pain levels. For help with stopping smoking Essex lifestyle service or the NHS Better health website.

What other options do I have?
In the first instance you should give these first line treatments 6 to 12 weeks to have an effect. If your symptoms are not improving with conservative measures then other treatment options may be considered:

Night Splints/Strassburg Sock

Traditionally a rigid night splint was occasionally recommended in the management of plantar fascia related pain. However a Strassburg sock is now more commonly used. This is a long sock applied to the lower leg and foot which holds the foot and toes in a stretched position while sleeping.

Immobilisation

If the pain persists, immobilising the heel might be required. This is likely to be a removable boot/moon boot which could be for anything up to 6 weeks.

Steroid injection

Corticosteroid injections have been shown to be effective at reducing plantar fascia pain but unfortunately research suggests the benefits are often short lived. There are also risks associated with the injection including fat pad atrophy and plantar fascia rupture/tear and therefore this is not considered a first line treatment option.

Extracorporeal shockwave therapy (ESWT)

This may be considered in patients with long term plantar fascia pain that have not responded to first line treatments. It has been shown to be 60 to 70% effective at reducing pain in patients with chronic plantar fascia related pain. ESWT is a procedure where audible, low energy sound waves are passed through the skin to the injured area. This has been shown to increase blood flow which helps the healing process. It is a safe minimally invasive treatment but can give some discomfort/pain.

Surgery

This is rarely needed and the results are not very predictable and therefore considered as a last resort.

If considered as an option your consultant will explain your available options to you.