TAKE FLIGHT, WEBSITE OR SIT TIGHT?
ABOUT THE AUTHOR
Karen Finnin Musculoskeletal Physiotherapist BAppSc(Physio), MMuscPhys, Karen graduated as a Physiotherapist from LaTrobe University in Melbourne, Australia in 1998, and subsequently completed a Masters in Musculoskeletal Physiotherapy. With over a decade working in Private Practice and with Defence populations, Karen has extensive experience in managing spinal injuries, general sporting injuries and work related conditions. She has travelled interstate and overseas with sporting teams, and has developed a number of education programs in fields such as core stability retraining, fit ball use, and injury management. Karen is the Director of Physios Online, an online Physiotherapy Practice that specializes in providing long distance consultations for injured people working in remote areas. You can contact Karen at karen@physios-online.com, or visit the Physios Online website at www.physios-online.com. 1
TAKE FLIGHT, WEBSITE OR SIT TIGHT?
ACKNOWLEDGEMENTS The author wishes to acknowledge the following sources: Dan Uden Sports Physiotherapist BExSc, BPhysio, MSportsPhys Greg Dea APA Sports Physiotherapist MPhysio(Sports), BPhysio(Hons), BSc Clinical Sports Medicine By Peter Brukner and Karim Khan Published 2007 by McGraw Hill Australia Pty Ltd in North Ryde, NSW Referenced Journal Articles: 1. Starman, J.S., Gettys, K., Capo, J.A., Fleischli, J.E., Norton, H.J., Karunakar, M.A. , Quality and Content of Internet-Based Information for Ten Common Orthopaedic Sports Medicine Diagnoses. J Bone Joint Surg Am, 2010. 92: p. 1612-8. 2. Russell, T.G., Buttrum, P., Wootton, R., Jull, G.A., Internet-based outpatient telerehabilitation for patients following total knee arthroplasty: a randomized controlled trial. J Bone Joint Surg Am, 2011. 93-A(2): p. 113-20. 3. Russell, T.G., Blumke, R., Richardson, B., Truter, P., Telerehabilitation mediated physiotherapy assessment of ankle disorders. Physiother. Res. Int., 2010. 15: p. 167-175. 4. Kairy, D., Lehoux, P., Vincent, C., Visintin, M., A systematic review of clinical outcomes, clinical process, healthcare utilization and costs associated with telerehabilitation. Disability and Rehabilitation, 2009. 31(6): p. 427-447. 5. Russell, T.G., Buttrum, P., Wootton, R., Jull, G.A., Rehabilitation after total knee replacement via low-bandwidth telemedicine:The patient and therapist experience. J Telemed Telecare, 2004. 10(Suppl 1): p. 85-87.
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TAKE FLIGHT, WEBSITE OR SIT TIGHT?
CONTENTS
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Introduction
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Common Injury One: Neck Pain
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Common Injury Two: Shoulder Pain Insidious Onset
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Common Injury Three: Shoulder Pain Acute Onset
Common Injury Six: Knee Pain Insidious Onset
Common Injury Nine: Ankle Injury
Common Injury Four: Elbow Pain
Common Injury Seven: Knee Pain Acute Onset
Common Injury Five: Low Back Pain
Common Injury Eight: Shin Pain
Common Injury Ten: Foot Arch Pain
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TAKE FLIGHT, WEBSITE OR SIT TIGHT?
Knowing What Steps to Take… If you live or work in a remote location, and sustain a musculoskeletal injury, it is important to know when the injury requires more than your own basic management, and where to go to for help. Injury management can be more difficult in remote locations, where the desire to act fast often competes with the upheaval and cost of increased travel for specialized services. Accessing health services, particularly in remote areas, is becoming easier and more efficient than ever before. This is largely due to the development of ‘eHealth’ initiatives. ‘eHealth’ refers to the progression of healthcare into the use of digital and online technologies. It is a broad term, and can include the digitizing of patient records, transmission of test results, and performance of health related consultations online. 4
TAKE FLIGHT, WEBSITE OR SIT TIGHT?
Research has proven that people ‘googling’ generic health information online can be inaccurate and unsafe[1]. Online consultation, however, where the assessment and advice is by a qualified professional, and tailored to the patient, is as effective as ‘on site’ consultation in many areas of health. This certainly is true for online Physiotherapy consultation [2-5], meaning that quality diagnosis and management of musculoskeletal injuries is now increasingly accessible to people living and working in remote locations. When you sustain a musculoskeletal injury, you have to decide between three main action steps: Do I need to make the effort to travel to a health service, such as a Doctor or Physiotherapist? Is my injury suitable for online consultation with a Physiotherapist, saving the time and cost of travel? or Do I administer basic medical management, and simply self-monitor the injury, to be followed up only if symptoms do not progress as expected. In this book, we have simplified these three options with the following terms:
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TAKE FLIGHT, WEBSITE OR SIT TIGHT?
Take Flight?
ie, when do I need to make the effort to travel for review by Doctor or Physiotherapist? Certain symptoms or conditions require assessment by a Doctor or Physiotherapist in a ‘face to face’ consultation. This is generally recommended when there is: - Severe pain or dysfunction - A possibility of permanent disability from delaying intervention - Requirement of referral for investigations (eg xray, MRI), or to a specialist for surgical opinion Referral to a Medical Doctor, is always required if ‘red flags’ are present, eg - night sweats - waking in the night due to pain - unexplained weight loss - change in bladder or bowel function - severe and escalating pain - history of tumor
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Website?
Ie, when is it appropriate and effective to seek consultation online, such as Physiotherapy? Visiting a Physiotherapist ‘face to face’ is a simple action when one is available locally. In more remote situations, however, a Physiotherapist may not be easy to access. In many cases, however, musculoskeletal injury can be very effectively managed through an online consultation process. 6
TAKE FLIGHT, WEBSITE OR SIT TIGHT?
Ensure that your online Physiotherapist has a recognized degree (minimum of Bachelor), and is registered with a National Registration body, such a AHPRA in Australia. www.physios-online.com, for example, uses only Australian qualified Physiotherapists who are AHPRA registered, and are specifically trained in the use of the online consultation format.
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Sit Tight?
ie, when is it OK to perform some basic medical management and just ‘see how you go’? Sometimes injuries simply require basic management, such as RICE (Rest, Ice, Elevation, Compression), or basic medications, such as those available at the supermarket (ensure you follow the directions and warnings on the pack). If the injury does not settle as expected, follow the ‘Take Flight’ or ‘Website’ guidelines. It is not the intention of this book to cover first aid training, but there are many books and courses that do so adequately. Take Flight, Website or Sit Tight? outlines the action steps you should take, for the ten most common musculoskeletal injuries. It is designed to assist your decision making process, but you should always consult your doctor if you are unsure or very concerned about your injury. To ask questions, give feedback or obtain further copies of this book, please contact enquiries@physios-online.com. 7
TAKE FLIGHT, WEBSITE OR SIT TIGHT?
COMMON INJURY ONE:
Neck Pain Summary
Neck pain may sneak up on you gradually, or hit you all of a sudden. Pain can be simply due to muscle tension, or from damage to joints, discs or nerves. The longer the neck pain lasts, the more factors tend to contribute, such as stress, posture, muscle weakness and chronic soft tissue changes. Neck pain that includes persisting pins and needles, numbness and/or weakness in the arm must be investigated, and may require surgery in severe circumstances.
Take Flight Travel to see a Medical Doctor if any of these factors are present: • A history of trauma to the neck eg fall onto head/neck • A history of acceleration/deceleration injury eg car accident 8
TAKE FLIGHT, WEBSITE OR SIT TIGHT?
• General neck pain lasting more than 3 months • Arm pins and needles and/or numbness and/ or weakness lasting more than 2 weeks • Severe Sharp shooting pain lasting more than 2 weeks (bad enough to interrupt sleep)
Website Seek Physiotherapy consultation online if there is: • Neck pain, that is not improving, lasting more than 3 days
Sit Tight
If you experience a sudden onset of neck pain (eg waking with it in the morning) and there is no arm pins and needles and/or numbness and/ or weakness, it is possible that it may settle in 2 to 3 days with relative rest, heat and gentle movement. If it does not resolve, consult the ‘Take Flight’ and ‘Website’ guidelines above.
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TAKE FLIGHT, WEBSITE OR SIT TIGHT?
COMMON INJURY TWO:
Shoulder PainGradual Onset Summary
A gradual onset of shoulder pain is often caused by issues with the ‘rotator cuff’ tendons. Severe pain or marked functional limitation can require an Ultrasound investigation, to examine the tendons for tears. Unless a tear is full thickness, conservative (non-surgical) management is often adequate.
Take Flight Travel to see a Medical Doctor if any of these factors are present: • Unsatisfactory improvement following a 6 week rehabilitation program (ie continued impairment of daily activities or sport) • Marked weakness with arm elevation past shoulder height, lasting more than 6 weeks 10
TAKE FLIGHT, WEBSITE OR SIT TIGHT?
• Pain interrupting sleep for more than 2 weeks
Website Seek Physiotherapy consultation online if there is: • Shoulder pain lasting more than 1 week
Sit Tight If a shoulder develops pain due to overload with a particular activity, and the duration has been less than a week, avoid the aggravating activity/ies, and see if it settles. If pain persists, use the ‘Take Flight’ and ‘Website’ guidelines.
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TAKE FLIGHT, WEBSITE OR SIT TIGHT?
COMMON INJURY THREE:
Shoulder PainAcute Onset Summary
Shoulder trauma can range from reaching quickly to grab a falling object, to forceful dislocation from body contact. Dislocation can sometimes cause damage that requires review by a surgeon. Despite this, dislocations can often be managed conservatively, unless they keep happening. Forcefully resisted muscle contraction around the shoulder can also cause cartilage damage, or a rotator cuff tendon tear. A fall onto the shoulder can cause acromio-clavicular joint separation, or clavicle fracture.
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TAKE FLIGHT, WEBSITE OR SIT TIGHT?
Take Flight Travel to see a Medical Doctor if any of these factors are present: • History of a full dislocation • Marked weakness with arm elevation persisting past 5 days • Unsatisfactory improvement with 6 weeks of a rehabilitation program • Traumatic injury, with obvious deformity, pain and swelling
Website Seek a Physiotherapy consultation online if there is: • Shoulder pain lasting more than 1 week
Sit Tight A fall or ‘yank’ on the shoulder can cause some tendon inflammation that feels painful the day after, but settles over the course of a week. If symptoms persist, it is important to refer as recommended above, to get the shoulder structures assessed. Mild injuries to the ac joint require minimal management, except for avoiding painful activities.
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TAKE FLIGHT, WEBSITE OR SIT TIGHT?
COMMON INJURY FOUR:
Elbow Pain Summary Elbow pain is most commonly a gradual onset of pain through overuse, but a direct blow, forced movement, or fall onto the arm can also cause issues. Lateral epicondylalgia (‘tennis elbow’) is the most common cause of pain in the elbow, with irritation of the tendon/bone junction caused by repeated use. Trauma related bony tenderness generally requires investigation.
Take Flight Travel to see a Medical Doctor if any of these factors are present: • Significant trauma, particularly in the presence of bony tenderness and swelling
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TAKE FLIGHT, WEBSITE OR SIT TIGHT?
• Unresolving pain lasting 3 to 6 months
Website Seek a Physiotherapy consultation online if there is: • Elbow pain lasting more than 2 weeks
Sit Tight If elbow pain flares up due to a specific overload incident (like a weekend of pruning, first squash game in a while, or intensive use of a hammer), then rest from the painful activity until pain settles. If the activity has to be returned to, do it with frequent breaks at first, and gradual progression of load. If pain persists, follow the ‘Take Flight’ and ‘Website’ guidelines.
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TAKE FLIGHT, WEBSITE OR SIT TIGHT?
COMMON INJURY FIVE:
Low Back Pain Summary Low back pain may sneak up on you gradually, or hit you all of a sudden. Pain can be simply due to muscle tension, or from damage to joints, discs or nerves. The longer the back pain lasts, the more factors tend to contribute, such as stress, posture, muscle weakness and chronic soft tissue changes. Bcck pain that includes persisting pins and needles, numbness and/or weakness in the leg/s must be investigated, and may require surgery in severe circumstances.
Take Flight Travel to see a Medical Doctor if any of these factors are present: • History of trauma to the back, eg a fall • Noted change in bladder or bowel function • General back pain lasting more than 3 months 16
TAKE FLIGHT, WEBSITE OR SIT TIGHT?
• Pain with spinal extension and/or rotation, linked with a history of repeated extension/rotation load eg gymnastics, fast bowling • Lower limb pins and needles and/or numbness and/or weakness lasting more than 2 weeks • Severe, or sharp, shooting pain lasting more than 2 weeks (bad enough to interrupt sleep)
Website Seek a Physiotherapy consultation online if there is: • Back pain, that is not improving, lasting more than 3 days
Sit Tight It is generally important to seek consultation for all episodes of back pain, lasting more then 3 days, from a Physiotherapist or Doctor. The main time when it is OK to leave it to settle on its own, is if back soreness simply results from muscle soreness following a weights/gym workout, or a new activity. If pain persists, follow the ‘Take Flight’ and ‘Website’ guidelines.
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TAKE FLIGHT, WEBSITE OR SIT TIGHT?
COMMON INJURY SIX:
Knee Pain Insidious Onset Summary Knee pain that develops gradually can often be due to issues with the kneecap (patello-femoral joint), but can also be due to degenerative changes like arthritis, cartilage damage or tendon issues. Persistent locking, catching or giving way can be indicators of structural damage requiring medical review, as can persisting swelling.
Take Flight Travel to see a Medical Doctor if any of these factors are present: • Can’t bend the knee past 90 degrees • Can’t weight bear for more than 4 steps • Locking, catching or giving way persisting despite rehabilitation 18
TAKE FLIGHT, WEBSITE OR SIT TIGHT?
• Experience significant swelling • Experience pain which is unresolved/ unchanging after 12 weeks
Website Seek Physiotherapy consultation online if there is: • Knee pain lasting more than 2 weeks
Sit Tight If you develop knee pain, but can walk around OK and have no swelling, it can often be good to leave it for a week or two to see if it settles down. Avoid impact activity (or aggravating activity). If pain persists, follow the ‘Take Flight’ and ‘Website’ guidelines.
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TAKE FLIGHT, WEBSITE OR SIT TIGHT?
COMMON INJURY SEVEN:
Knee Pain Acute Onset Summary
Acute knee trauma often occurs on the sports field, but can also occur through motor vehicle accidents, slips and falls. A knee with a history of twisting mechanism, click or pop at that time, and instant swelling, must be reviewed by a doctor, and potentially undergo MRI scan. Most other knee ligament injuries are managed conservatively, particularly if no other accompanying damage is found. Persisting mechanical failure must be investigated.
Take Flight Travel to see a Medical Doctor if any of these factors are present: • History of a traumatic incident, particularly in the presence of bony tenderness 20
TAKE FLIGHT, WEBSITE OR SIT TIGHT?
• Twisting episode with an audible snap and swelling • Inability to flex knee past 90 degrees • Inability to weight bear for more than 4 steps • Locking, catching or giving way persisting despite rehabilitation • Significant swelling • Pain unresolved/ unchanging after 6 week rehabilitation program
Website Seek a Physiotherapy consultation online if there is: • Knee pain lasting more than 1 week
Let It Go If you develop knee pain, but can walk around OK and have no swelling, it can often be good to leave it for a week or two to see if it settles down. Avoid impact activity (or aggravating activity). If pain persists, follow the ‘Take Flight’ and ‘Website’ guidelines.
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TAKE FLIGHT, WEBSITE OR SIT TIGHT?
COMMON INJURY EIGHT:
Shin Pain Summary The most common causes of shin pain are often collectively labelled ‘shin splints’. There is usually a history of commencing or increasing impact activity, which results in overload of the muscles around the tibia bone. In severe situations, this can result in stress fracture, in which the pain is more severe and point specific. In non-responding shin pain, a differential diagnosis of compartment syndrome (nerve or circulatory entrapment) must be considered.
Take Flight Travel to see a Medical Doctor if any of these factors are present: • History of a traumatic incident, particularly in the presence of bony tenderness eg motorbike accident
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TAKE FLIGHT, WEBSITE OR SIT TIGHT?
• Site specific pain with impact and specific tenderness over bone • Escalating pain with activity, failed rehabilitation program
Website Seek a Physiotherapy consultation online if there is: • Shin pain lasting more than 2 weeks
Sit Tight If pain develops quickly with a new impact activity or a dramatic increase in amount of impact activity, rest from the activity until pain settles. On return to the activity, do it on alternate days to begin with, and increase volume by only 10% each week. For persisting, or long duration pain, follow the ‘Take Flight’ and ‘Website’ guidelines.
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TAKE FLIGHT, WEBSITE OR SIT TIGHT?
COMMON INJURY NINE:
Ankle Injury Summary The most common acute ankle injury is the inversion sprain, with damage to the ligaments on the outside of the ankle. The same general mechanism of injury can sometimes cause a fracture, which may or may not require surgery, so any tenderness over bone needs to be investigated. Tenderness on the outside edge of the foot after this type of injury should also be investigated. An ankle sprain that is not recovering should be checked for damage to the cartilage, with an MRI.
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TAKE FLIGHT, WEBSITE OR SIT TIGHT?
Take Flight Travel to see a Medical Doctor if any of these factors are present: • Bony tenderness over the ankle bones or outside edge of the foot • Bony tenderness along the lower leg bones • Inability to weight bear for more than 4 steps • Significant pain and disability persisting 6 weeks post ankle injury, despite rehabilitation • History of recurrent instability (ie ankle ‘rolls’ repeatedly with minimal provocation)
Website Seek Physiotherapy consultation online if there is: • Any acute ankle injury
Sit Tight Once you have had one ankle injury, you are highly likely to re-injure again (and again!), particularly if a rehabilitation program is not completed. All injuries should therefore be referred for rehabilitation with a Physiotherapist. This can be performed via online consultation.
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TAKE FLIGHT, WEBSITE OR SIT TIGHT?
COMMON INJURY TEN:
Foot Arch Pain Summary The predominant cause of a gradual onset of pain in the arch of the foot is Plantar Fasciitis, with peak tenderness at the back of the arch next to the heel. It is often mistakenly referred to as a ‘heel spur’, however the finding of a heel spur on xray has proven to be unrelated to the condition. It can be stubborn to treat, but will usually resolve with time and persistent rehabilitation. Taping of the arch, as guided by a Physiotherapist, can be effective for shorter term pain relief.
Take Flight Travel to see a Medical Doctor if there is: • 3 months of non improving pain, including failed rehabilitation program, for possible injection therapy 26
TAKE FLIGHT, WEBSITE OR SIT TIGHT?
Website Seek Physiotherapy consultation online if there is: • Foot arch pain lasting more than 2 weeks
Sit Tight If foot arch pain, of less than 2 weeks duration, can be attributed to a change in activity or footwear, stop the aggravating activity. Once pain settles, return to the activity gently and progress gradually. For persisting pain, follow the ‘Take Flight’ and ‘Website’ guidelines.
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TAKE FLIGHT, WEBSITE OR SIT TIGHT?
ABOUT PHYSIOS ONLINE www.physios-online.com
Physios Online is an online Physiotherapy Clinic, specializing in distance injury management through the use of digital technologies. Physios Online is great at helping people who are injured, but live or work in a remote location. At Physios Online, Physiotherapists trained in distance injury management, can assess, diagnose and treat musculoskeletal injuries, using a combination of digital media, such as online assessment forms, video and audio communication, and email. For more information:
enquiries@physios-online.com www.physios-online.com
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