Your questions….our mission
N.B. These frequently asked questions (FAQ) are based on situations I have encountered in my practice. They are meant to provide part of the answers to questions I am often asked in consultation. Although they are not a complete and exhaustive review of the various conditions nor a medical text, the answers are based on scientific evidence and good practices in physiotherapy. They are intended as guidelines, founded on my clinical experience and practice.
The objective is to help better understand pain, the body, the joints and the muscles, the effects of inflammation on these elements, and the connections between them. Understanding is part of the solution.
Right information leads to right decisions
1 - Do I have to consult a doctor before consulting a physiotherapist?
It depends…on the type of pain, its intensity, the time elapsed since the injury, insurance coverage*, etc.
As an example, if pain is intense enough to impede sleep, walking or function, a doctor should be consulted.
If pain is more chronic, well known, a doctor's consultation before a physiotherapy consultation isn't always necessary. Physiotherapists have been able to receive clients through direct access since 1994. They make an evaluation, and if a medical consultation is necessary to clarify a clinical situation, they direct the client to a doctor.
*Group insurance companies often ask for a medical consultation before a physiotherapy consultation; verification with insurance providers will answer this question.
2 - Why does it hurt?
In general, pain occurs when a tissue is injured (stretch, contusion, strain, inflammation).
The term commonly used in physiotherapy for a damaged tissue is an "injury": muscle injury, ligament injury, joint injury. The orthopedic problems treated in clinics are mainly muscle problems or joint problems, or both at the same time. Chronic problems necessarily involve both, with joint problems exacerbating muscle tensions and vice versa. Treatment aims to break the vicious circle of pain. In acute problems, tissue injury and inflammation are the cause of pain.
3- What type of pain does a physiotherapist deal with?
Here are some of the terms in a physiotherapist's vocabulary:
- Acute pain: Recent pain, often accompanied by inflammation.
- Chronic pain: Pain that is present permanently or repeated over time. Chronicity is used to describe a situation in which pain is present for over three months.
- Orthopeadic: All that concerns the muscle and joint systems and the skeleton.
- Neuromuscular: All that concerns the muscles and the communication system between the nervous system and the muscles.
- Musculoskeletal: All that concerns the muscle and joint systems and the skeleton.
- Pain threshold: Intensity of the stimulus or stimuli, which are interpreted by the brain as being a pain. Below the pain threshold, stimuli are often interpreted as being pressure or discomfort. Above the threshold, they are interpreted as pain. The higher the pain threshold, the less pain there is for the same stimulus.
- Interpretation of pain: This is the sum of the different stimuli received by the brain and analyzed according to personal and cultural factors, personal experiences, etc.
The most frequent problems treated in the clinic include knee and back pain, such as sprains or knee dislocations, patellar tendinitis, lumbar sprains, disk herniation and sciatica.
The most underestimated problems—because they're often more complex than they seem—include shoulder and neck problems, such as rotator cuff tendinitis, biceps tendinitis, cervical sprain, torticollis, cervicobrachialgia (neck and arm pain) and whiplash.
The more neglected problems are head and foot aches. It is little-known that mechanical causes of these pains can be treated in physiotherapy. Plantar fasciitis and migraines are good examples.
4- Back Pain, disk herniation, sciatica, piriformis syndrome, pelvis imbalance, etc.
Each of these conditions can be treated in physiotherapy. Here is what the physiotherapist will look at for back, pelvis and hip problems:
- The mobility of the segments involved in the pain, but also of the segments that aren't painful. Non-painful segments tend to restrain movement with their rigidity (stiffness)
- The protection of vertebral levels showing signs of degeneration
- The strength and coordination of the transverse abdominal muscles
- The quality (stiffness-length-strength) of lumbar, pelvic and leg muscles and the muscles that hold the various segments together
- The coordination of vertebral and dorsolumbar muscles (multifidus, iliolumbar, quadratus lumborum, latissimus dorsi, etc.) and the legs muscles (the gluteus, quadriceps, hamstrings, etc)
- The relation between the shoulder and pelvic girdles
The physiotherapist will choose the appropriate treatment according to the dysfunctions identified in the evaluation. Many options are available for a given problem. As the condition progresses, the physiotherapist will choose the best option at each session.
5 - Knee Pain (tendinitis, patello-femoral syndrome, strain ligament, etc)
Pain in the knee necessarily conceals an imbalance in the tensions between the front and back areas of the knee or between the inner and outer sides. A physiotherapy evaluation will highlight strengths and weaknesses of the knee, and a treatment plan will be established according to individual needs. If the structures (ligaments, muscles, menisci) are not damaged, recovery should be complete, regardless of age or physical condition. What is important to know about the knee is that it handles heavy loads. Complete rehabilitation will therefore include—on top of the mobilizations, stretching, strengthening and muscle control exercises—proprioception exercises and treatments that put a load on the joint to avoid recurrence of the injury.
Conditions such as arthritis and arthrosis can cause joint degeneration. In these cases, changing certain habits and maintaining a regular exercise program are advised.
6 – Can tendinitis (tendinopathy) be treated? Is there any residual fragility?
- What is a tendinitis?
As the suffix itis suggests, tendinitis is an inflammation of the tendon. Inflammation in the tendon increases its size (diameter) and blocks movement or causes friction on the surrounding bony structures. This maintains the tendon irritation and can even lead to certain degeneration. The longer the tendinitis lasts, the more the tendon's structure is altered and the more fragile it becomes. In case of chronicity, tendinosis sets in. The density of the fibres diminishes and the orientation changes. The force that the tendon is able to absorb diminishes.
Tendinitis occurs most frequently in the joints of the knee (patellar tendinitis), the shoulder (rotator cuff tendinitis, biceps tendinitis) and the ankle (Achilles tendinitis).
Epicondylitis—tennis elbow—is also a tendinitis, as is plantar fasciitis. (ref. #7)
- Treatment of tendinitis
Any tendinitis can be treated with physiotherapy. An evaluation is made to identify the problems specific to each tendinitis, and an adapted treatment plan is devised. The course of the condition depends, among other things, on joint mobility, muscle flexibility and the number of joints involved in the movement mechanics. A number of factors act to make the problem more complex: inflammation, how much the tendons are used, the mechanical stress applied to the structures every day, the time elapsed since the injury, anatomy, and personal factors such as genetics.
If the integrity of the various structures (joint, muscle, nerve) is maintained, there should be no residual fragility. But if the integrity of the structures (structures damaged through arthrosis, tear, degeneration, etc.) is compromised, certain fragility may remain.
7 – Plantar fasciitis, is it treatable?
Plantar fasciitis is a complex condition because the foot contains a number of rigid structures that make it stable. The foot is also the segment of the body that absorbs most of the load when walking, running and even in a static standing posture.
Physiotherapy evaluation involves checking the foot mobility and the strength of the various muscles connected to the foot and making an assessment of that mobility while weight-bearing (standing) and resting (sitting or lying down).
What is crucial to remember is that the foot is extremely important for the body's entire equilibrium. When a foot is injured, it should be treated immediately.
8- Should I stop sports during rehabilitation?
Ceasing every activity is not always necessary. Many factors will influence decision making, such as the nature of the injury, the tissue injured, whether the problem is acute or not, the pain intensity, the use of medication, the type of sport, etc. A good guideline is to heed pain and respect one's limits. Stopping all athletic activity can sometimes delay rehabilitation, just as continuing activities without adapting them to the temporary condition. Reactivating the inflammatory process again and again after each practice delays healing unnecessarily. Finding the limit, without exceeding it, is key to progress.
If it is an acute injury, it is better to take a break. Another important element is the stability of the joint. An unstable joint due to a stretched or torn ligament must first be stabilized before training can resume.
9- Can I exercise the same day as a treatment?
When an injury is acute, a joint is more fragile. Exercise after a treatment is not therefore recommended. For chronic pain, treatment results will determine if it is possible to exercise after a physiotherapy session or not. The degree of irritation or inflammation reproduced in the session can dictate condition's behaviour in the evening. Muscle fatigue is another factor in making the decision to add on exercise or not. Other factors like the quality of the muscle control gained, proprioception, the quantity of exercises performed at the clinic and the number of hours of rest between the end of the physiotherapy session and the following training also impact the final decision.
Two key questions can help make a decision:
- 1) "How do you feel?"
- 2) "Do you have to take medication to ease the pain when resting?"
In these circumstances, logic and common sense are good guidelines.
And when making such a decision, it is often a good idea to resist pressure by teammates and/or coaches who may be ill-informed about the injury.
10 –Hopes for the treatment outcome
The body has multiple resources for healing and compensation. A muscle, joint, or tissue injury will heal through the innate action of the body, just as the skin will repair itself when scratched or cut. If treatments are added at the same time, the chances that the tissues will recover optimally are maximized. An ankle or knee ligament, for instance, will knit more tightly if the joint alignment is optimized with physiotherapy treatments. If the joint remains loose on one side, the ligament will knit less tightly and allow more movement when there is a major mechanical stress (e.g. jump, sudden stop, movement in the snow), even if it is only by a few millimetres.
In cases of residual pain due to old injuries, it is always a good time to treat these areas because the body is in a perpetual state of change and its cells are constantly regenerating. A poorly healed ligament or one with poorly aligned cells can always be improved, provided that the problem is identified and corrected. The same goes for any injury involving the spine. As mentioned above (see #2 and #3), a major part of musculoskeletal disorders is simply joint and muscle imbalance. To correct such problems, good manual therapy is part of the solution as well as an adapted and personalized exercise program.