Lost my trust in sports physio. Please Help :(

[ok_cub2008]

Hi there,

I've been struggling with a catalogue injury problems since I was 17 (I'm now 22). I used to be a good athlete and a regional level cricket and tennis player, but that has been taken away from me. I just want to tell my story, I'm sorry if it is a bit long, I'll try to keep it short, but I'm feeling pretty horrific and I would really appreciate any advice/direction. (I'm from the UK by the way).

My intitial problem was a lot of tension and tightness in my left upper trap and left side of my neck.

From the age of 17-19 I was pretty much completely inactive other than doing physio rehab exercises for my shoulder (wall pressups, and external shoulder rotations were the key ones, but many more) and walking. This long duration on the sideline was largely due to an initial misdiagnosis by a chiropractor (surprise, surprise) which, to cut a long story short, complicated things.

During this period I developed tightness in my right hip, a shooting pain down my right leg, tightness in my right calf and fatigue in my right foot. Also, my right trap began to develop this constant dull but significant ache, especially when using a mouse or writing. I managed to overcome the majority of these symptoms somewhat by trying to "switch on" my glutes through exercise, and also stretching helped.

By the time I was 19, the symptoms in my left shoulder/neck had dissipated somewhat, but the range of motion in my left shoulder was and still is inferior to my right shoulder. However, I was fairly confident I could finally resume my sports (cricket, football, weight training).

I went along injury free and pain free until after my 20th birthday. During that year I was exercising a lot: playing cricket 3 times a week, interval running on a treadmill a couple of times a week, weight training (although my strength gains were non-existent). I then started to develop a small prickly feeling in my left knee when running. I thought nothing of it at the time, but a few months later it felt like a shard of glass was penetrating my knee. I went back to my physio who said I had tendinitis (which I now know is either a) code for tendinosis or b) a misdiagnosis). He said it would be a few months of rest and rehabilitation before I should resume playing again. I did the usual eccentric exercise protocol, stretching, ultrasound treatment, and while the symptoms eased, any time I tried to "up the ante", that same pain flared up.

At that point I couldn't really afford private physiotherapy anymore, so sought help from my GP. She referred me to NHS physios, who took an ultrasound scan that showed my left patellar tendon was greatly enlarged. They said I should continue with the exercises I'd already been doing, and come back every 2 months for a check up scan. Each time I returned, the tendon was in the same condition.

It's been two years now, and although I'm still not very confident of recovery, I feel I have made progress in the poorly understood game of trial an error known as tendinosis recovery. In hindsight I feel the physios pushed me too hard, too soon, which caused a relapse. I've been doing double legged squats on a decline platform for 6 months now, 3 sets of 8 reps every day, plus an hour of various leg/back stretches, and my symptoms have improved greatly. Through my igorant view, I don't subscribe to the "you need to generate a bit of pain to encourage tendon regeneration" approach. I now have zero pain when doing anything really, however the tendon itself is still slightly tender to touch and it feels "solid" and enlarged compared to my right patellar tendon.

I've done quite a lot of research into tendinosis on the net, and it shocks me how poorly understood tendiopathy, tendinitis, tendinosis are. At the moment I am due another appointment with an NHS orthopaedic guy (not sure of his exact title). In the first appointment he offered me a cortisone injection, which I refused. Pretty much every academic/anecdotal source on the net, cortisone injections provide only a temporary aid with symptoms relapse occuring nearly 100% of the time and evidence suggesting it actually inhibits tendon regeneration. I said this to him and he just said "that's the ladder of treatments, if this doesn't work we'll consider surgery". I still believe I can recover through non-surgical means, and I am reluctant to go down the surgery route purely because of my growing distrust and the feeling that the histopathology of this condition needs much greater investigation.

Clearly, during the last 2 years I've done no cardiovascular exercise. The only thing I was doing was continuing weight training. Toward the end of 2010 I started to become more irritated and "picky" with the feeling in my left shoulder. Although it felt a lot better than when I was 17, it still didn't feel anywhere near acceptable. I decided to stop lifting weights and focus once again on my old shoulder exercises. When raising my left arm directly forward, upon reaching the end of the range of motion (which is barely vertical) I was getting a large soreness in my lat area, along with other general uncomfort in my neck. Basically, on my left hand side, I struggle to shoulder press thin air. It is like I am fighting against my body when I try to do it.

However, I sort help privately from a different sports physio in April 2011. To be frank I wasn't particularly impressed. With the same type of exercises being prescribed that I already knew (which is understandable) and pretty ineffective neck/shoulder massage, after 8 weeks, I wasn't getting any improvement.

He then suggested maybe I would benefit from sports massage from someone he knew. I was skeptical, but agreed anyway.

This is where the story gets positive. I've been going for these massages every week for just over 2 months now. The improvement in the range of motion in my shoulder has been phenomenol, despite the incredible amounts of pain I've had to endure during these sessions! It is as good, if not better than my right shoulder now. When I went to see my sports masseuse she was shocked that I was being told to do all these rehab exercises, since my muscles were so tight and in spasm. She also critiqued many of my rehab exercises. I'd been told by my physio that my lower back was too curved and I needed to try and straighten it (he gave me pelvic tilts against a wall as an exercise). My masseuse told me the opposite, that I have a tendency to tuck my buttocks under my lower back (if that makes sense) and that I should make sure I keep a very small curve.

Now, I'm very happy that the symptoms in my left shoulder are improving, but it is very difficult to be told all these conflicting things. Certainly my experience with the physio earlier in the year has made me question the consistency of diagnosis and the standard of practice in the field across the country. How do I know for sure if someone is prescribing me the correct course of treatment?

Not only that, in the last month or so, the right side of my body has seized up again like it did when I was 18 (my right hip, my right shoulder, my right calf and a fatigued right foot). I'm sure all of this is connected somehow. All I need is someone with the expertise who KNOWS what they are doing. When I go to the doctors about these problems I basically get told to live with it, but I know there is a solution, I'm only 22 and there is nothing obviously wrong with me. It all seems to be a soft tissue problem, but as of yet I've not had a full, confident plan to address it.

If I had an expert tell me I need to do rehab exercise for 16 hours a day for 3 years straight I'd still give it a shot. Sport/fitness means everything to me and at the moment I'm starting to lose hope because I don't have a clear picture on how to proceed.

I would really welcome any thoughts or questions. I've missed a lot of detail out (believe it or not) so it might be hard to help me, but I just wanted to try.

Thanks

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[physiointhesand]

Wow - thats a laundry list you have there man.

Ill keep it short - as its always hard to give a complete response without actually talking to you and asking all I would need to...

1) What sort of weight training are you doing? VERY and I say VERY generally speaking, if you are doing too much bench and have a bad back/shoulder stability sling then your traps will be over active and this can lead to neck/shoulder discomfort. Your shoulder complex is heavily muscular based and joint congruency is reliant on posture. Too much bench press or anterior muscle work and you're going to have problems. I once saw a power lifter that could bench nearly 200kg but couldnt raise his arm forwards as his serratus anterior were atrophied, leading to bad scaps. Be weary of your guy routine... these can be deadly for your shoulders if you have an imbalance.

2) Youre right, we really dont know jack about theosis/itis ideas and the debate still rages. Again - watch the gym work.

3) You've lost your confidence in practitioners - you arent the first and wont be the last. Unfortunately we cant all get it right at times, but you have to look for someone that can clinically reason their way through your condition and not just say what it is... a person that takes a detailed history and listens to your for more that 17 seconds (the reported average listening time for a health care practitioner) is more likely to help

4) As for the R side of your body seizing from ??the hip/back down?? Are you a cricket fast bowler? Have you played recently? When does it get worse and when does it get better?

Sorry, thats a lot of info. Good luck man

[ok_cub2008]

Thanks for your reply!

1) Well, I'm not doing any weight training anymore. I haven't done any since November 2010, where I stopped because I wasn't happy with my left shoulder mechanics. When I was training, I'd train 3 times a week, split between chest, back/shoulders, arms.... I found bench press was the only exercise I gained any strength in. But it was probably the exercise I concentrated on least - I was trying to get back and shoulder exercises right, but I found lat pulldown and shoulder press impossible on my left hand side. I kept telling myself that "it would sort itself out". I wasn't lifting heavy at all (I could barely shoulder press 5kg dumbbells).

4) I did do quite a lot of bowling in my early teens, but I was predominantly a batsman. The problem gets worse during inactivity, but paradoxically once it has started, any activity makes it worse. For example the one thing that was keeping me vaguely sane was going for a 45 minute walk every day. I've had to stop that in the last week because the pain in my hip, my calf, my foot and the tightness in my entire right shoulder, it just makes it impossible to walk and it just gets worse and worse. Instinctively I feel it may be related to extended periods sitting (e.g. at computer) and the poor posture that follows. The last couple of weeks I've developed a pretty unhealthy obsession with seating posture, trying to find the optimum way of sitting at a computer (e.g. lumbar support, trying various incline angles to keep spine in neutral position with minimal effort etc...). It couldn't be sciatica could it?

[MrPhysio+]

Hi,
Before I make some suggestions it would be good to know the answer to the following questions.
1. Would you say that you are generally very flexible even without stretching?
2. If you are flexible, do you have a fair complexion ie red or blonde coloured hair and blue eyes?
3. Do you have Irish, Scottish or Scandinavian heritage?
If so, have you been assessed for hypermobile joints?

If not, do you have any altered sensation eg numbness or tingling.

Overall, a set of problems that become chronic can occur for a number of reasons.
The problems may be unrelated, caused by an initial problem that results in your body
compensating resulting in poor biomechanics, underlying genetics or as you have suspected
bad treatment / assessment.
The lower limb problem could be sciatica - look up piriformis syndrome. I can assist with
a home treatment if the net infom is insufficient.
The shoulder problems may be due to a C7 nerve root irritation that has progressively altered
your correct posture. Overtight pectorals will bring the shoulder ball forward in the socket
and the muscles between your shoulder blades will become inhibited. Eventually you will
create a shoulder that will grab at 90 degrees when lifting the elbow away from your side.

Eventually the human shoulder has problems - 100% of 80 year olds, 80% of 70 year olds
and 50% of 60 year olds show rotator cuff tears on scanning, even without symptoms.

Over use of shoulders speeds the process.

Let me know if any of the above makes sense. I agree with physiointhesand that advice without hands on assessment is
risky, but we are trying to help anyway.
mrphysio+ [email protected]

[ok_cub2008]

1. I'm not very flexible without stretching, no. In fact quite the opposite. Until about 6 months ago, I could barely reach down to the height of my ankles, let alone my toes (with straight leg). I started to spend an hour a day doing general stretches to try and help my left knee problem, and now I can nearly get my palms flat on the floor. But yes, I'm not naturally very flexible.

I am not of those descents either, I'm white but not the freckly type, but as far as I know I'm English going back many generations (hope that doesn't put you off as an Aussie ).

The feeling in my right shoulder alters from a "dull constant pain" as if it is made of stone, to a sharper "fresh" tension feeling. The dull feeling tends to be when I wake up in the morning, whereas it gets to a more "traditional" feeling of tension as the day goes on. I do get some tingling in the right side of my face and neck (very slight), as if almost like an echo of the feeling in my traps. The first symptoms of this pain were when I was playing a PC computer game for long periods when 17 (I was doing no activity at the time because my chiropractor had made me afraid to do anything).

The pain in my hip/right leg varies also. Most of the time the hip area just feels "heavy", like when I try and step forward with my right leg, it feels like the muscles in my side have to lift the whole hip up, rather than the right leg just being able to raise forwards in a relaxed manner, like it does in my left leg. I do get a shooting pain in my right leg, but usually only after walking a lot the day before. I must stress I haven't had these symptoms (at least noticeably) for a few years until recently. When I saw my physio at the time about it, he said I had a glute weakness and that the glutes weren't firing, and the exercises he gave me seemed to "cure" it.

I really appreciate your reply, and I know it is pretty dangerous to make suggestions without a proper assessment. But at the moment I just don't know what direction to take. When I go to my GP they don't take me seriously because they think I am just being a perfectionist. But I still feel that there hasn't been enough investigation from people with the right expertise. I know when people get older things start to break down, but I'm only 22, the last 5 years have devastated my social life and had a big impact on my mental health, and if there is anything I can do now to get as close to perfect health as possible I want to do it, so at least I can have a shot at preventing some of those degenerative problems from happening when I'm older.

[MrPhysio+]

Hi again,
In one way it is good to know that you do not have the gene for hypermobility of joints, as there is little to do to change your genes.
The two main problems seem to be the shoulder and leg.
Initially these areas should be treated separately.
The more you report the more likely it is that you have a nerve compression at C6-7. This area can give a very broad referral pattern on the affected side.
The pattern, if you have all areas active, can refer to the bottom of your shoulder blade, up the neck, back of the head and behind the eye as well as down the arm along the tricep around the outside of the elbow and to the hand, mainly thumb side. The feeling to the face can also occur.
The worse the compression the more of the above symptoms you may experience.
What I said before about the shoulder alignment happens as a secondary problem. The sub deltoid bursa can become inflamed, jamming the shoulder. Shoulder pain of inflammatory nature will usually cause worse pain at night and in the morning. Nerve pain is deep seated and hard to describe - usually not pin pointed by a finger point but described by a wipe of the hand.

For the neck you will need to have quite specific treatment to the neck facet joints at this level. Neck traction and mobilisation is best - not manipulation.
The deltoid bursa needs deep tissue massage.
The pectorals require stretching, the rhomboids need to be strengthened, shortened and have their endurance increased. The shoulder exercises need to be gradual and progressive - I can send them to you via attachment if you wish.

The sciatica may be from a discal bulge given the sharp pain into the leg, but may also be due to the piriformis muscle being tethered to the sciatic nerve. If so, deep tissue massage will be necessary. Done properly this will be very quick but brutal. You may have bruises on the treated buttock. Light massage is useless. stretching without the deep massage can work but not in the long term. Sometimes stretching without the massage aggravates the problem.
It is wise to treat the piriformis first, do a set of exercises for hamstring and gluteals, then assess how much improvement occurs.
Should symptoms remain, they should be assessed to see if they could be related to discal problems - lumbar traction may help, or lumbar extension exercises.

Remember, discal changes need to be worse than moderate before symptoms are attributed to the disc. That is, you can have small to moderate bulges without symptoms.
This explanation is getting very long. If you would like more details, email me.
MrPhysio+

[ok_cub2008]

Thanks again for your reply.

If you believe that it might be nerve compression in C6-C7, how would I get that diagnosed, I mean how would someone know that was the problem for sure?

Also, I've never experienced any real discomfort around my neck vertebrae throughout this entire period (although coincidentally in the last few days the bones at the base of my neck have been sore, which I guess would be the C6-C7 area). Would I have not felt some discomfort directly around the area if there was compression, or is it just that that particular irritated nerve root carries the signals from the area that I feel pain (as you can tell my knowledge is poor).

As you say, it is dangerous to make a diagnosis without full assessment, not that I don't want you to make suggestions, you have been brilliantly helpful, it's just I'm the type of person to get fixated and worried about this type of thing.

Would you say this is a pretty standard thing that any physio would check, or would you envisage there to be a risk of making an error such as trying to address the problem as purely about muscular imbalance through a combination of strength exercises and stretching??

It's just I'm not really sure how to go forward with this problem - when I search google for "specialist shoulder physio" or similar, you just get swarmed by websites for physiotherapy practices, that I'm sure are very reputable, but I don't know who really holds the expertise to help me (if that makes sense). Ideally I'd like to be able to go to the doctor and say "I would really like a full assessment to see what the is going on e.g. x-ray, MRI if necessary", but they just don't take me seriously now because to them it looks like I've "tried physio, it hasn't worked, so let's not waste any more time, let's look at learning to deal with the pain long term", but instinctively I feel like this can be resolved, or at least improved substantially!

[MrPhysio+]

Hi,
I understand your frustration and need to address the problem via safe and skilled assessment / treatment.
It is difficult for me to find therapists when I need to refer, let alone patients finding someone. As you have experienced, trial and error is not
always successful. Theoretically we have the training as therapists to treat most problems or refer to those that do. In practise the system
can fail due to clinic marketing, poor networking or lack of experience. Therapists tend to have different levels of experience due to chance dependent
upon who walks in the door over many years. I have worked in closed head injury neuro, multi orthopaedic trauma, community health, nursing homes,
District hospital as head physio and private practice (over 19 years). All therapists with experience tend to have strong opinions regarding their areas
of interest and it can be difficult to refer and have the therapist treat as recommended. As I am in Australia and you are in England the difficulty is magnified.

I believe that you would benefit from a very deep tissue massage to the Right Levator scapulae muscle trigger points (where the muscle joins onto the scapula).
This is different to usual massage and only takes two to three seconds. Warning: it hurts! I use my index finger middle joint. Then the scalene muscle attachments onto
the Right facet joints of the neck are given deep tissue massage at C5,6,and 7. Levatore scapulae stretches are taught. C6 and 7 facet joint mobilisation is given.
If you have a therapist that has been trained with the (Australian) Maitland method they would use a fact joint glide twice per level at a grade 4 plus. Don't worry
about the jargon, it is just a rating system that helps communicate what we do, like music notation speaks to a musician.
Regarding MRI etc, you may not require this type of scan for your level of problem in the neck. I treat this regularly without need for scans. Scans are more relevant for
more serious referral with other presentations. The shoulder rotator cuff may benefit from an ultrasound scan to check the bursa and supraspinatus tendon. If you have an acromial spur (smal bony spur underneath the bony shoulder overhang near your AC joint) a specific x-ray view can confirm.

The shoulder alignment exercise follows. You could try this, but it may be better to have the neck treated first. If you have a sub deltoid bursitis it can be eased by a specific deep tissue technique
where pressure is applied at a 45 degree angle underneath the acromian and above the arm bone where it fits into the socket. There is a small gap there that occurs with the arm hanging by the side. You cannot easily do this to yourself. If that doesn't work a cortisone injection can help. Try Voltaren or Feldene non steroidal gel if you wish to avoid an injection.

Give the neck and shouldr time to recover. Imagine the nerve root in the neck like a garden hose. If you park you car tyre on the hose then drive off the next morning, the hose will have
a kink in it even though there is no compression anymore. The water will not flow at full pressure until the kink is reduced. The nerve impulse acts the same way. Give it time. All the muscles will require strengthening and need to learn how to act in the proper synergy before full symptom reduction occurs. By the way, you can have a painfree C7 yet still have referred pain.

Let me know any urther thoughts you may have.


There is a procedure for the sciatica as well, also involved, if self treating.

Shoulder retraining and strengthening
1. In sitting - Place your fists on the seat at each side of your hips, and
slightly behind you.
2. Look forward keeping the chin level.
3. Lift your shoulders toward your ears, and roll them back and down
feeling your shoulder blades pinch together.
4. Keeping the shoulder blades pinched back, push down onto your
fists gently as if you are to lift your bottom off the seat.
5. Hold the position for 10 seconds, repeat 10 times at the first session,
and do 2 sessions per day.
6. Progress each day by increasing the number seconds held or the
number of holds per session on alternate days. For example: Day one
10 secs/10 times; Day two 11 secs/10 times; Day three 11secs/11
times; 12/11;12/12 etc
Over 3 weeks gradually build up your tolerance to eventually achieve
20 second hold and 20 repeats, twice daily.
Once you have achieved this level reduce to 20 seconds 20 repeats
once a day for a week.
Congratulations, you have corrected the problem by improving muscle
strength endurance & length as well improving posture. The next step is
to maintain the good work by doing the exercise occasionally.
Hints
Be certain that the shoulder blade pinch is maintained when pushing
down with your fists. Use a rolled towel each side of your hips if the
surface is soft eg a padded couch or bed.
If you feel muscle tightness across the abdomen you are leaning back
too far.
If soreness is felt through the neck you may be pushing down too hard
with your hands or not keeping the head level.
It is normal to feel exercise muscle soreness, especially when beginning
this exercise. If you are concerned regarding any symptom change,
please phone your therapist for advice.

Write the procedure onto a calendar AM & PM then tick off as you proceed.
MrPhysio+

[MrPhysio+]

Additional from MrPhysio+
Sorry about some spelling mistakes in the previous post. Keyboard a bit funny and not registering some letters unless pushed harder.
eg 'fact' should read 'facet' joint and shouldr is shoulder. I won't correct the whole thing. Sorry.
MrPhysio+

[MrPhysio+]

Hi again,
Thanks for the added information, video link.
It is frustrating for both of us that I cannot just reach out and treat the problem for you.
The added info sent reinforces my opinion that you have a number of problems, all of which should respond well to simple but very specific treatments.
1. The ache in your arm is probably due to a sub deltoid bursal impingement, but may include a small intrasubstance tear in the supraspinatus tendon. That is not a complete tear, but a small section that has a defect. Direct pressure over the bursal region and supraspinatus tendon where it can be accessed may ease the problem. Cortisone injection for chronic cases may be required, but give up to 12 weeks for recovery if you go down this path. Scans to ensure no tears in the tissue could be undertaken, ultrasound not that accurate at times, MRI better but expensive. The exercise I sent is a better bet once the initial deltoid bursitis is addressed. The symptoms include grab through range - a painful arc of movement 80 through 120 degrees of the arm out to the side. Another symptom can be an ache half way down the outside of the arm.
2. C6-7 nerve root compression will give the tight cord feel down the arm to the wrist, into the chest and shoulder and possibly the neck and head (behind the eye and across the head).
Mobilisation of the neck as previously described, with levatore scapulae stretches are likely to decrease the arm pain.
3. Sciatic pain, hitched hip can be caused by the piriformis being tethered. You may also have a mild SIJ irritation as well. Deep tissue massage of the piriformis then gluteal and hamstring stretches are done for a few days.

Problems 2 & 3 are unlikely to show on scanning.
I see 5 or 6 cases like yours every week (not the same people!) Most people respond to what I have suggested. The difference with your case is that you have not been treated correctly, in my opinion from thousands of kilometres away.
I cannot treat you, therefore I can only provide the opinion and suggest the treatment likely to assist. Finding a therapist to do exactly what I do is impossible, just as I cannot treat like other therapists. We all have our techniques.
What I do is not gentle. Gentle does not seem to work for these cases.
Once again, I hope this helps.
Note: I may not be able to respond quickly over the next few days as my Father is in hospital (coronary care unit).
MrPhysio+