Waves Sports Massage

03/10/2025

02/10/2025

Shoulder, back & chest muscle movement

01/10/2025

After 3 years I've finally received my Level 5 Certification in Sports Massage

26/09/2025

📘 A Clinician's Guide to Sciatica: Assessment and Evidence-Based Management

▪️ Sciatica overview
🔹 Also known as lumbar radiculopathy or lumbosacral radicular syndrome
🔹 Annual incidence: 1%-5%
🔹 Accounts for 5%-10% of low back pain cases
🔹 Most prevalent in individuals aged 30-50
🔹 Prognosis generally favorable, but thorough assessment is crucial

🧠 Understanding the Etiology

▪️ Sciatica is a symptom, not a diagnosis
🔹 Characterized by pain radiating along the sciatic nerve’s path
🔹 Most often caused by compression of lumbosacral nerve roots (L4-L5 or L5-S1)
🔹 Most common cause: lumbar disk herniation
🔹 Must consider spinal and non-spinal etiologies

▪️ Spinal Causes
🔹 Herniated disk
🔹 Degenerative spine disease
🔹 Spondylolisthesis
🔹 Synovial cysts
🔹 Rare: tumors or fractures

▪️ Non-Spinal Causes
🔹 Piriformis syndrome
🔹 Pelvic conditions (e.g., endometriosis)
🔹 Pregnancy-related changes
🔹 Gluteal injection trauma
🔹 Hip fractures or dislocations

🩺 The Physiotherapy Assessment

1️⃣ Subjective Examination (History Taking)

▪️ Pain Characteristics
🔹 Unilateral radiating leg pain, worse than low back pain
🔹 Sharp or aching, dermatomal pattern in posterior leg

▪️ Aggravating Factors
🔹 Pain worsens with movement, lumbar spine flexion
🔹 Coughing, sneezing, or straining → suggests disk rupture

▪️ Neurological Symptoms
🔹 Paresthesia (numbness or tingling)
🔹 Subjective weakness
🔹 “Foot slapping” when walking → footdrop (L5 involvement)

▪️ Screening for Red Flags
🔹 Essential part of assessment
🔹 Urgent referral if serious pathology suspected

⚠️ Cauda Equina Syndrome

Bowel/bladder dysfunction

Saddle anesthesia

Progressive or severe bilateral leg weakness

Reduced a**l sphincter tone

⚠️ Fracture/Malignancy

History of trauma

Age >50

Unexplained weight loss

History of cancer

Fever or IV drug use

2️⃣ Objective Examination (Physical Assessment)

▪️ Neurological Examination
🔹 L4 involvement: Pain anterior thigh/medial leg; weakness knee extension & hip flexion; patellar reflex abnormality
🔹 L5 involvement: Pain posterolateral thigh/lateral leg; weakness foot dorsiflexion & hip abduction; footdrop; Trendelenburg gait
🔹 S1 involvement: Pain posterior thigh/leg & lateral foot; weakness plantar flexion; inability to walk on toes; Achilles reflex abnormality

▪️ Provocative Testing
🔹 Straight Leg Raise (SLR) / Lasègue Test: Pain between 30–70° → L5 or S1 compression; high sensitivity, low specificity
🔹 Crossed Straight Leg Raise / Fajersztajn’s Test: Raising unaffected leg reproduces pain; low sensitivity, high specificity for disk herniation
🔹 Slump Test: Seated with cervical flexion, knee extension, ankle dorsiflexion
🔹 Femoral Stretch Test: Prone knee flexion → anterior thigh pain; L2-L4 root compression

🛠️ Evidence-Based Management Strategies

▪️ Prognosis
🔹 About 75% resolve without specific treatment

▪️ Patient Education & Staying Active
🔹 Reassure good outcome possible
🔹 Encourage return to normal activities as tolerated
🔹 Bed rest not recommended
🔹 Advise light exercise (walking, swimming)

▪️ Exercise Therapy
🔹 Stabilization exercises (transversus abdominis, multifidus)
🔹 Directional preference exercises
🔹 Mobilization
🔹 Early referral to physiotherapy (within 3 days) improves outcomes

▪️ Manual Therapy
🔹 Spinal manipulation may help short-term pain relief
🔹 Chiropractic spinal manipulation reduces acute back & leg pain up to 180 days
🔹 When combined with home exercise: improved pain & disability at 12 weeks (not sustained at 52 weeks)

📌 When to Refer

▪️ Urgent Referral
🔹 Any red flag symptoms → emergency or spine specialist

▪️ Non-Urgent Referral
🔹 No improvement after 4-6 weeks conservative therapy
🔹 Severe, unresponsive pain/disability after 12 weeks
🔹 Surgery considered after ≥6 weeks failed conservative care (except urgent cases)

18/09/2025

🦵 Leg Length Discrepancy (LLD)

📖 Definition

▪️ Leg length discrepancy (LLD) or anisomelia = condition where paired lower extremities have unequal length

🗂️ Classification of LLD

🔹 Anatomical

▪️ Structural limb length inequality (osseous shortening between trochanter femoral major → ankle mortise)
▪️ Congenital: developmental abnormalities (birth/childhood)
▪️ Acquired: trauma, fractures, orthopedic degenerative diseases, surgical disorders (e.g., joint replacement)
▪️ Radiographic study:
➡️ 90% of normal population = some variance in bony leg length
➡️ 20% = difference >9 mm

🔹 Functional

▪️ Non-structural shortening (unilateral asymmetry without osseous shortening)
▪️ Causes:
➡️ Joint contracture
➡️ Static/dynamic mechanical axis malalignment
➡️ Muscle weakness/shortening
▪️ Cannot be detected with radiography
▪️ Develops from abnormal motion at hip, knee, ankle, or foot in any plane

⚠️ Etiological Factors

True LLD

▪️ Idiopathic developmental abnormalities
▪️ Fracture
▪️ Trauma to epiphyseal endplate before skeletal maturity
▪️ Degenerative disorders
▪️ Legg-Calvé-Perthes Disease
▪️ Cancer / neoplastic changes
▪️ Infections

Functional LLD

▪️ Soft tissue shortening
▪️ Joint contractures
▪️ Ligamentous laxity
▪️ Axial malalignments
▪️ Foot biomechanics (e.g., excessive ankle pronation)

🧍 Role of LLD on Posture and Gait

📌Standing

▪️ Patient compensates to level difference in height
▪️ Longer leg vs Short leg compensation:
➡️ Foot: pronation vs supination
➡️ Ankle: dorsiflexion vs plantarflexion
➡️ Knee: flexion vs extension
➡️ Hip: flexion & internal rotation vs extension & external rotation
➡️ Innominate bone: posterior rotation vs anterior rotation
▪️ If uncompensated → anterior & posterior iliac spine on short leg lower → sacral base unleveling, scoliosis, ↑ muscle activity

📌Walking

▪️ Gait asymmetries throughout kinetic chain
▪️ ↑ vertical displacement of center of mass → ↑ energy consumption
➡️ Compensations: calcaneal eversion, knee extension, toe walking, circumduction, hip/knee flexion (steppage gait)
▪️ ↓ stance time & stride length on shorter leg
▪️ ↓ walking velocity, ↑ cadence

📌Running

▪️ Running biomechanics differ from walking
➡️ Greater vertical oscillation
➡️ No double support → weight not shared
➡️ Stance phase 30% in running vs 60% in walking
➡️ Stress on lower extremity = 3× walking
▪️ Effect of LLD may be amplified threefold

🦴 Associated Musculoskeletal Disorders

▪️ Low Back Pain
➡️ LLD affects lumbar spine via scoliosis & pelvic obliquity
➡️ Lumbosacral facet joint angles smaller on short side → possible OA risk
➡️ Literature inconclusive on causal link

▪️ Hip Pain
➡️ Longer leg predisposes to osteoarthritis
➡️ Femoral head contact area decreases with ↑ length
➡️ (+10 mm = 5% loss, +50 mm = 25% loss)
➡️ Increased hip abductor tone + GRF burden on longer leg

▪️ Stress Fractures
➡️ Tibia, metatarsals, femur of longer leg → higher incidence

▪️ Other Associations
➡️ Trochanteric bursitis
➡️ Patellar capacity/joint incongruences
➡️ Myofascial pain syndrome of peroneus longus

🔍 Differential Diagnosis

▪️ Pelvis shift
▪️ Low back pain (LBP)
▪️ Idiopathic scoliosis
▪️ Iliotibial band syndrome
▪️ Foot pronation
▪️ Stress fractures (lower extremity)

🩻 Examination & Outcome Measures

▪️ Radiography = most accurate method
➡️ Best for differentiating anatomical vs functional
➡️ Limitations: contractures, magnification error, time/cost

▪️ CT scan
➡️ No greater accuracy vs radiography
➡️ Higher cost, not routinely justified

📌Direct Methods

▪️ Tape measure between fixed landmarks (ASIS → medial/lateral malleolus)
▪️ Errors possible due to iliac asymmetries, joint contractures, long-axis deviations, umbilicus asymmetry
▪️ Tips:
➡️ Take mean of 2–3 measures
➡️ Compare measures across clinicians

📌Indirect Methods

▪️ Palpation of iliac crests or ASIS in standing
▪️ Use of blocks/book pages under shorter limb until pelvis is level
▪️ Best clinical method = palpation + block correction
▪️ Consider pelvic rotations outside frontal plane

📌PALM (Palpation Meter)

▪️ Valid, reliable, cost-effective alternative to radiography
▪️ Measures pelvic height difference with inclinometer

📌Block Method

▪️ Patient stands with equal weight, knees extended
▪️ Wooden boards placed under short leg until pelvis level
▪️ Reliability depends on clinician skill

🦵 LLD After Total Hip Arthroplasty

📌Clinical Signs

▪️ Pain from imbalance in hip/knee/spine muscles
▪️ Pain & fatigue in longer leg quadriceps/hamstrings (flexed knee syndrome)
▪️ Instability/dislocation due to component orientation

📌Post-op Apparent LLD

▪️ Causes: periarticular muscle spasm, lumbosacral scoliosis, pelvic obliquity
▪️ Leads to tilted pelvis despite equal measured lengths
▪️ Treatment: reassurance, physical therapy, temporary shoe lift
▪️ Most cases resolve within 6 months

🛠️ Medical Management

▪️ Decision depends on magnitude & symptoms
▪️ Categories:
➡️ Mild (0–30 mm): usually no surgery unless symptomatic
➡️ Moderate (30–60 mm): case-by-case, possibly surgical
➡️ Severe (>60 mm): surgical correction indicated

🩺 Surgical Intervention

▪️ Epiphyseal growth blockade (in adolescents/children – stops growth in longer leg)
▪️ Bone resection shortening (in skeletally mature patients)
▪️ Limb lengthening (LLD >40–50 mm)
➡️ Cortical osteotomy + external fixation for gradual distraction

🏋️ Physical Therapy Management

📌Non-Surgical Interventions

▪️ Muscle stretching (TFL, adductors, hamstrings, piriformis, iliopsoas, others as needed)
▪️ Shoe lifts:
➡️ Inserts (10–20 mm correction)
➡️ Sole build-up (30–60 mm correction)
➡️ Gradual implementation in small increments

📌LLD, Shoe Lifts & Low Back Pain

▪️ Shoe lifts reduce LBP when correlated with LLD
▪️ Correction should be gradual
▪️ Shoe inserts effective in ≤10 mm LLD
▪️ Combine with back exercises
▪️ Quadratus lumborum endurance reduced on side of short leg (small study – more research needed)

12/09/2025

Schematic drawing stages Frozen Shoulder

11/09/2025

Considering its role in bearing the entire weight of the body, it is not surprising that the ankle joint has quite a few ligaments that stabilise it during movement.
The ligaments are divided into two groups: the medial (tibial) and lateral (fibular) collateral ligaments.
The medial collateral ligament, also known as the deltoid ligament, is a strong band that reinforces the medial aspect of the joint and prevents dislocations of the ankle joint. The ligament has a proximal attachment on the medial malleolus of the tibia, and fans out from there to insert onto the navicular bone, calcaneus, and talus.

27/08/2025

Overuse (Repetitive Trauma) Syndromes: Nonoperative Management

Definition: An overuse syndrome is a local inflammatory response to stresses from repetitive microtrauma.
Causes include
Faulty alignment in the lower extremity
Muscle imbalances or fatigue
Changes in exercise or functional routines
Training errors
Improper footwear
Combination of factors
Syndrome occurs when tissue is stressed before adequate healing.
Abnormal pronation of the subtalar joint is a common cause.
Related causes: excessive joint mobility, leg-length discrepancy, femoral anteversion, external tibial torsion, genu valgum, or muscle flexibility and strength imbalances.

22/08/2025

Crazy bone or crazy nerve contusion

21/08/2025

📌Intrinsic Muscles of the Foot

👉The muscles along the dorsal side of the foot (a) generally extend the toes while the muscles of the plantar side of the foot (b, c, d) generally flex the toes. The plantar muscles exist in four layers, providing the foot the strength to counterbalance the weight of the body. In this diagram, three of the layers are shown from a plantar view beginning with the bottom-most layer just under the plantar skin of the foot (b) and ending with the top-most layer (d) located just inferior to the foot and toe bones.

18/08/2025

Typical causes of Rotator Cuff Pain