Cycling – Why does my knee hurt?

Living and working in the Mole Valley area, means cycling and knee pain is one of the most common issues we get contacted about.

The patella is the kneecap and the Patellofemoral joint is where the kneecap articulates with the femur. Pains from the Patellofemoral joint are called Anterior Knee Pain (AKP) or Patellofemoral joint pain.

Cyclists are commonly troubled by pain at the front of the knee and at Head2Toe Physio we see a mix of road cyclists and mountain bikers with this problem.

Essentially the cause of the pain in cyclists can either be due to bike issues or body issues.

Body Issues

In a race cyclist, there are 3 main issues which can increase force through the kneecap.

The knee rests at about 30 degrees flexion with the pedal in the lowest position and about 110 degrees at the top of the pedal stroke. The forces going through the kneecap are enormous as the quadriceps contract to push the pedal down.

As the knee is extended and the moves towards the floor, the knee tends to move ever so slightly in a valgus or knock-kneed direction, towards the crossbar.

If the tibia (shin bone) rotates out when the knee extends, the femur (thigh bone) rotates in. This inward or medial rotation has also been shown to increase force through the kneecap.

Bike Issues

The three points of contact on a bike and the three bits of the bike most commonly adjusted, are the saddle, handlebars and pedals. Lots of studies have been done on the possible consequences of having a seat which is too high or too low.

Common injury risks with a high saddle position seem to be Iliotibial Band (ITB) pain, hamstring tendon pain and Anterior Cruciate Ligament (ACL) strain.

Low saddle position seems to be more likely to lead to AKP in particular patellofemoral joint pain.

Fitting

Most bike shops will now include fitting sessions before selling you a bike. It seems sensible to ensure you spend the time and maybe a bit more money seeing someone with good bike fitting qualifications and experience.

Alterations can be made to saddle height, saddle position (forward and backward), pedal and handlebar position.

Saddle height can have an effect on patellofemoral joint loading.

Saddle position can have the effect of moving the knee in front or behind the line of the pedal spindle. This alters the amount of knee bend and could have an effect on loading.

Pedal position, foot shape, shoes worn and cleats used should all be checked. Cleat systems almost always allow adjustment of forward/backward, side to side and rotation movements. All these can have an effect on loading through the kneecap.

Handlebar position is less important for the knee and in clinic the main problems we see with handlebar position are ones involving the neck. That’s another story for another blog post!

Treatment for Knee pain in cycling.

Consideration of bike issues is important to us at Head2Toe Physio. However, it’s our knowledge and experience dealing with the relevant body issues of cyclists that is where we really add value.

Assessment by our Physiotherapists at Head2Toe will highlight where there are tight structures, weak areas or unhelpful postures. Treatment focuses on improving these areas and ultimately helping you have a more comfortable ride!

If you or anyone you know is suffering from knee pain and would like to have a physiotherapy assessment with the team at Dorking , Leatherhead or Crawley , contact us here.

Asplund C, St Pierre P, Knee pain and bicycling. Fitting concepts for clinicians, The Physician and Sports Medicine, 2004, 32 (4).

Callaghan M, PAtellofemoral pain: A vicious cycle? In Touch, 2016, 154.

Pelvic Pain in Pregnancy

Ah the wonders of pregnancy! The full-bodied luscious hair, the glowing skin, the swollen ankles….

Not everyone glides through pregnancy with ease. Among the common ailments of pregnancy, is pelvic pain. It is estimated that 1 in 5 pregnant women will experience some pelvic or back pain through their pregnancy, most commonly in the second and third trimester.

Most people with pelvic girdle pain have pain in the buttock, back, groin, thigh or pubic bone. The pain tends to be aggravated by standing and walking and some can start to have a ‘waddling gait’. Other mums-to-be have pain when turning in bed or getting out of a car. 

For some lucky ladies, this can resolve by itself. For others, the pain can become quite disabling. This can be especially difficult as the chances of getting pelvic pain increases with pregnancies. Having a reduction in mobility and a three-year-old to run around after is quite testing to put it mildly.

Although pain in the pelvis and low back is relatively common, around 50 to 70% of pregnant women will experience symptoms in their pregnancy. This does not have to be normal.

Despite all of this I would like to let you know that physiotherapy can help!

Why do we think women get pelvic pain in pregnancy?

Well the evidence we have, suggests that there are multiple factors. Previously it was thought that the hormone relaxin was responsible. This helpful hormone is released to loosen the pelvic ligaments ready for pelvis to widen for the birth of the baby.

It has been found that these hormones peak at around 12-14 weeks, this does not correlate to when we normally see symptoms developing so there must be another reason!

Research has suggested that the pelvic joints moving asymmetrically and altered activity of the muscles around the back and pelvis are having an impact. Essentially the altered biomechanics that occur in the body to accommodate the growing baby seem to be responsible.

There are many risk factors that predispose some women to this more than others. What we do know is that early intervention is thought to give the best chance of avoiding more severe problems further on in pregnancy. 

What treatment can you have when you are pregnant?

Seeing a physiotherapist who is experienced in this area is important as they can give appropriate advice and treatment for the problem.

Treatment includes muscle training around the pelvis, spine and abdominals, manual therapy for the spine, pelvis and hip and pain relief such as acupuncture.

Acupuncture has been well researched and is shown to be safe in, as long as the practitioner is specifically trained in pregnancy acupuncture.

Read about Anna Watson and Ante/Post natal Physio at Head2Toe Physio Dorking here

Assessment and treatment can be administered in the clinic or in the comfort of your own home.

If you or anyone you know is suffering from Womens Health issues and would like to have a physiotherapy assessment with Anna Watson for suitability of Womens Health physiotherapy treatment, contact us here.

Mogren IM, Pohjanen AI. Low back pain and pelvic pain during pregnancy: prevalence and risk factors. Spine 2005; 30(8):983-991.

 Wu WH, Meijer OG, Uegaki K, Mens JM, Van Dieen JH, Wuisman PI et al. Pregnancy related pelvic girdle pain (PPP), I: Terminology, clinical presentation, and prevalence. Eur Spine J 2004.

Elden H, Ostgaard HC, Fagevik-Olsen M, Ladfors L Hagberg H (2008) Treatments of pelvic girdle pain in pregnant women: adverse effects of standard treatment, acupuncture and stabilising exercises on the pregnancy, mother, delivery and the fetus/neonate. BMC Complement Altern Med. 26, 8, 34). (49) 

Shoulder Pain

Summer is here (although it feels ironic to say that given the deluge yesterday and the week of rain we have forecast). Summer motivates many of us to get out playing cricket, tennis, stool ball (a Sussex speciality), athletics and golf. For those less athletically minded, many get more active with DIY and gardening throughout.

As is often the case with increased activity we can start to get more aches and pains. All the sports and activities mentioned earlier put us at increased risk of aches and pains, in particular shoulders can begin to suffer if not looked after properly.

The complex nature of the shoulder makes it vulnerable to various different pains and instabilities. Many of us have been diagnosed with a condition called sub- acromial impingement syndrome or shoulder impingement. It tends to cause pain down on the top and the side of your arm, pain lifting your arm overhead, pain at night and sometimes a feeling of weakness. This is specifically what a new review has looked at.

Research

A recent systematic review (a review of relevant studies) looking at shoulder surgery versus physiotherapy rehabilitation in patients with subacromial impingement, has shown that the long-term outcomes of physiotherapy rehab can be as beneficial as surgery if not slightly better! The key findings were:

• some patients will continue to experience minor pain regardless of whether they have surgery or physiotherapy.
• placebo surgery studies show us that there is no important benefit of having surgery, on pain or function.

Whilst nothing is clear cut and there are thoughts that if we better divide patients into different groups we may get different results, at the moment we have to work with what we do know. When our patients come in to see us, we do everything we can to successfully rehabilitate them without referring them onto a surgeon.

 The key to success of any rehabilitation is a thorough and accurate assessment and diagnosis by an experienced physiotherapist. A good explanation is needed at the start of the process that it may take a good 4-6 months to see definitive benefits. Physiotherapy should involve manual techniques and most importantly a graded exercise regime which needs to be adapted and increased at appropriate times under the guidance of a skilled physiotherapist.

This should allow you to continue doing your activities whilst being rehabbed although we may need to modify techniques or teach appropriate strapping techniques.

The benefits of an appropriate physiotherapy regime for shoulder pain particularly impingement is no longer in question. This does not depend on your age or how active you are. Some people can have shoulder pain in simple tasks such as putting jumpers on or trying to wash their hair. Don’t continue to suffer the pain in silence.

Subacromial decompression surgery for adults with shoulder pain: a systematic review with meta analysis; Lahdeoja, T et al; British Journal of Sports Medicine, 15/1/19.

If you or anyone you know is suffering from shoulder pain and would like to have a physiotherapy assessment with the team at Dorking , Leatherhead or Crawley , contact us here.

Dorking and Mole Valley Athletics Club 10’s

Well, a week has gone by and I’ve just about recovered from all the post race sports massage I helped give after the DMVAC Dorking 10K and 10 miler.

As a hands on physiotherapist I think I work pretty hard most days and the site of a 20 stone front row rugby player with a bad back doesn’t scare me. However I have a new found respect for how hard the massage therapists at Head2Toe Physio work on a daily basis!

DMVAC ran both the 10K and the 10 miler again this year. We were happy to help last year and this year only got bigger and busier!

The weather was lovely and the backdrop clearly spectacular. It made for an interesting mix of runners, some local and some from a lot further afield.

It was great to be part of such a well run event and of course we will be back next year…..with some more massage therapists! We will of course look out for any of the ‘spot prize’ winners in the next few weeks.

Congratulations to John, Martin, Louise and all the others who make the DMVAC Dorking 10 event such a success.

If you or anyone you know is suffering from injuries and would like to have a physiotherapy assessment or sports massage with the team at Dorking or Leatherhead , contact us here.

Womens Health Physio Dorking

Specialist Womens Health Physio in Dorking

Womens health is a specialist area of physiotherapy encompassing the needs of women with obstetric or gynaecological issues.

Womens Health issues include continence problems, post gynaecological surgery rehab and back pain. They also includes pregnancy related issues such as back pain in pregnancy, pelvic pain, SPD (Symphysis Pubis Dysfunction) and post natal conditions such as Diastasis Recti.

Pregnancy Related Musculoskeletal Problems

In an ideal world, all new mothers would be seen by a pelvic health Physio in order to optimise their rehabilitation and ensure a safe and effective return to life and sport!

The changes in a woman’s body when they are pregnant are enormous and can cause challenges for the musculoskeletal system. These challenges coupled with the normal stresses of daily life can cause many women to be in pain during their pregnancy.

Women are often working later into their pregnancy or are combining looking after a young family whilst working. This can cause challenges both during the pregnancy and post-natally.

Anna Watson

Anna Watson is a member of Pelvic Obstetric and Gynaecological Physiotherapy and has over 15 years experience in women’s health physiotherapy. She has been trained to use acupuncture specifically for women’s health problems and musculoskeletal pain in pregnancy. She is passionate about issues within women’s health and promoting best care for women. As a mum of 2 and a trained Doula, she can empathise with her patients and can contribute enhanced skills to fully understand and implement the best management for her pregnant patients.

We offer assessment and treatment of the following:

• Pelvic Girdle Pain in Pregnancy (PGP) and post-natally
• Back pain in pregnancy and post-natally
• Diastasis Recti – split abdominals
• Post-Gynaecological surgery

Treatment includes:

• Acupuncture
• Manual therapy
• Specific Muscle training

Assessment and treatment can be administered in the clinic or in the comfort of your own home.

If you or anyone you know is suffering from Womens Health issues and would like to have a physiotherapy assessment for suitability of Womens Health physiotherapy treatment, contact us here.

Get Walking

One of our roles as Physiotherapists is trying to encourage patients to engage in healthy, appropriate activities, in order to improve or maintain fitness levels. For some this might be running marathons, ironman competitions or climbing Ben Nevis; for others walking is a more suitable activity.

Whilst we do our best to recommend local walking groups or routes, occasionally you get to hear about something a little bit different. When I bumped into Peter Sturge at the Sports Centre, I was intrigued to hear about Dorking Museums’s guided history walking tour around Deepdene. Of particular interest to me was the local historical reference to what appears to be an early Physiotherapy service for injured WW1 soldiers!

A less well-known resident of the Deepdene founded the intriguingly named “Almeric Paget Military Massage Corps” in 1914.  The uniformed staff serving in the Corps provided rehabilitative support for the wounded of First World War.  These early physiotherapy treatments included massage, hydro and electric therapy to assist servicemen to recover.

Peter went on to explain that the Deepdene may be visited at anytime in daylight hours but, for those keen to explore the Grade II listed estate and learn more of its fascinating history, the tours led by Dorking Museum’s knowledgeable volunteer guides are recommended.

The 90 minute stroll through the gardens and and along woodland paths will introduce many of the colourful characters who lived in the now lost mansion. These include the “drunken Duke”, a Lord wrong-footed by his “giddy and unfaithful wife”, the wealth that bought the ‘cursed’ Hope Diamond into the family and the squandering of an inheritance.

The tour includes the Grotto, the Embattled Tower and WWII fortifications, combined with a visit inside the Hope Mausoleum.

Tour Dates

For anyone interested in the tour:

The next tour dates:            Sunday 14^th July at 2 p.m.

                                                Sunday 11^th August at 2 p.m.

Tours must be pre-booked and cost £4 per adult (children under 12 free). Booking and further information available at www.dorkingmuseum.org.uk/the-deepdene-trail  

Private tours for groups of 10 or more may be arranged by contacting admin@dorkingmuseum.org.uk.  For visitors with a disability, the Museum’s guides are willing to discuss and plan visits to suit individual needs, enabling access wherever possible.

As part of the fantastic Rusper Village May Day celebrations, Friends of Rusper Primary School have organised a one kilometre family fun run. Number are being limited to 100 runners & walkers of all ages, so please do join us & tell all your friends!

The race will start at 12:30 on Bank Holiday Monday 6th May. There will be a one lap all off-road course that the whole family can enjoy. 

For more information and to Book a place click here

Valentines Day massage Vouchers now available from Head2Toe

Looking for a Valentines present idea this year? Why not get a massage voucher for your loved one. Massages can be a relaxing and pampering Swedish massage or a more deep tissue Sports massage.

We can offer massage vouchers for all our clinics – Crawley, Leatherhead and Dorking – just let us know which clinic you want to use your voucher at.

Please contact reception on 01293535884 / 01306876072 or email admin@head2toephysio.co.uk

Knee injuries in skiing are common. The popularity of skiing has exploded over the last 20 years mainly due to increased ski areas, use of snow cannons, cheaper flights and faster ski lifts.

With increased accessibility and increased numbers of recreational skiers, the number of skiing injuries have gone up markedly.

The most common skiing injuries are lower limb injuries including leg fracture , ankle injury and knee injury. The development of the rigid ski boot in the 1970’s is reported to have shifted injuries up the leg from the ankle to the knee, however; since ski boots, ski bindings and the shape of skis have all changed its not easy to pin point why we see so many more knee injuries in clinic but we do!

In a 2015 study¹ comparing injury types and rates between 1996 and 2013, knee injuries were shown to be the most common, head injuries reduced (possibly but not definitely because of the uptake of helmet use) and skiing in the afternoon when tired (and possibly after a drink) increased your chance of getting injured.

Another study² showed that about 75% of skiers/snowboarders injured themselves falling or losing control on a jump whilst only 3-8% of those injured did so due to collision with other skiers or snowboarders.

What both studies seem to suggest is that many injuries are preventable!

What are the most common Knee Injuries in skiing and how do we injure them?

Knee injuries in skiing contribute about 30% of all skiing injuries, with the Medial Collateral ligament (MCL), closely and Anterior Cruciate Ligament (ACL) being the most commonly injured structures in the knee.

The three most common ways of injuring the knee are:

1. Valgus/external rotation mechanism
   1. The skier falls forward and catches their inside edge, which causes the ski to twist out and move away from the skiers body twisting the knee, injuring the MCL and sometimes ACL.
2. Boot induced anterior drawer mechanism
   1. The skier lands a jump with locked knees and lands the back of the ski first. The boot then pushes forward on the calf injuring the ACL.
3. Phantom-foot mechanism
   1. The skier falls backwards between their skis, with all the weight on their downhill ski. The bent knee then twists in hard with all their body weight causing injury to  the MCL and ACL.

Can you get fit for skiing?

Yes you can get fit for skiing…….but…….that’s not the same as saying you can reduce your chance of injury by getting fitter or doing certain types of exercises. It’s complicated.

The evidence that certain exercise programs or certain leg and core conditioning classes reduce your chance of injury just isn’t there. It doesn’t mean doing the right exercises won’t reduce injuries but we just can’t say so for sure. The studies either haven’t been done or the ones that have weren’t good enough to tell us much of use.

I’m certainly not saying that you shouldn’t bother, in fact I’m saying the opposite, you should. It makes a great deal of sense to me that the fitter you are the lower your chances of injuring yourself due to muscle fatigue. I feel from personal experience that my time and performance on the slopes was improved when I’ve been fitter going into the ski holiday. Being well-prepared will help you get in more runs with less fatigue and will probably leave you better prepared for the rare emergency requiring strength or endurance.

How to reduce Ski Knee Injury

I’ll describe in another blog post what I would recommend doing to try and get your body ski ready, but before I deal with that there are some things we do know will reduce your chance of injury:

1. Ski within your limits (get lessons)
2. Be aware of different conditions (this takes some experience)
3. Use the correct gear (your bindings should be set correctly as the majority of knee injuries occur when bindings do not release the ski)
4. Listen to your body (fatigue, light headed etc)
5. Fall correctly (keep knees flexed and don’t stand up in the fall or in a slide)

Before you all roll your eyes and think how obvious these points are, you should consider that ignoring them is still (unsurprisingly) the quickest and most common way to get yourself injured. It doesn’t matter how many ski sits and balance exercises you do, or how good your core is, IGNORE THESE POINTS AT YOUR PERIL!

If you or anyone you know is suffering from knee pain and would like to have a physiotherapy assessment for suitability of physiotherapy treatment, contact us here.

1. Patrick E et al, Changes in Skiing and Snowboarding Injury Epidemiology and Attitudes to Safety in Big Sky, Montana, USA, A Comparison of 2 Cross-sectional Studies in 1996 and 2013, Orthop J Sports Med. 2015 Jun; 3(6): 2325967115588280
2. Stenroos A, Handolin L: Incidence of recreational alpine skiing and snowboarding injuries: Six years experience in the largest ski resort in Finland. Scand J Surg 2014;0:1-5.
3. Koehle, M et al, Alpine ski injuries and their prevention, Sports Medicine 2002, 32, 12, 785-793.