How Stressed are your Bones

Being stressed is something that you can probably relate to. However, have you ever put any thought to how stressed your bones might be?

Normal day-to-day activity places a certain level of stress on your bones – this is generally healthy and helps keep your bones strong.

Failure to stress your bones much (i.e. lack of physical activity and minimal incidental activity with day-to-day activity) can contribute to loss of bone density and in time osteoporosis.

Physical activity (especially of the weight-bearing kind) places additional stress on your bones. In most circumstances, your body will respond to this activity load and stress to become stronger and more resilient to higher levels of activity (bone stress) in the future.

Repeated bouts of physical activity or weight-bearing activity, especially if for prolonged periods of time or repeated regularly without adequate periods of rest in between, can lead to over-stressing your bones. Initially this will result in a bone stress reaction, which is where there is oedema (or swelling within the bone) and can be painful. If the bone is continued to be stressed, this can result in a stress fracture!

We see lots of people in the clinic with varying degrees of bone stress reactions & stress fractures. Identifying a bone stress reaction or fracture ASAP is incredibly important, as continuing to place stress on the bone can worsen the injury. Most of these injuries require rest from activity for a certain period of time as part of the required treatment. The worse the bone stress reaction or if a stress fracture has occurred the longer the required period of rest and this may require you to be non-weight bearing which can have considerable impact on work, physical activity and day-to-day activities.

As you can see, bone stress to some extent in normal and actually healthy. It is a continuum and you ideally want to be stressing your bones enough to keep them healthy and strong to be able to tolerate the level of activity that you do whether that be with day-to-day activities or sporting/recreational pursuits.

How would I know if I had a bone stress reaction or stress fracture?

It can often be difficult to differentiate a bone stress reaction or fracture from other injuries – many people will often think that they have a muscle strain or some general post-exercise soreness. There are some key defining features of most stress reactions/fractures:

  • Completion of regular weight-bearing activity or exercise in the lead up to onset of symptoms. This is usually at a higher intensity, duration or frequency than previous levels of activity.
  • Pain tends to be present during activity that places stress through the bone and gets worse as activity is continued.
  • Pain eases after activity, although may linger as the condition worsens (lingering pain especially at rest typically is associated with more significant stress reactions or stress fractures).
  • Pain tends to be quite focal initially and if left to worsen often becomes more disperse.

There are a number of other factors which can influence the likelihood of sustaining a bone stress reaction or stress fracture. These include:

  • Reduced bone densityhormonal factors & low body mass are all associated with an increased risk of bone stress reactions/fractures.
  • Various anatomical differences can increase the risk of certain bone stress reactions/fractures e.g. reduced foot arch height and shin stress injuries.
  • Certain sports are associated with particular types of bone stress injuries:
    • Running sports/walkers – feet & shins
    • Rowing – rib
    • Cricket fast bowlers & gymnasts – lumbar spine
    • Dancers – feet
    • Retail workers (or people standing on their feet for considerable period of time) – feet & shins
  • Other factors can include activity technique, footwear, surface on which activity is performed.

What should you do if you think you may have a bone stress reaction/fracture?

It is incredibly important to get an accurate diagnosis, such that you know whether you do have a bone stress injury and how bad it is. It is also important to know exactly which bone is involved, as different bones require different treatment and differing time-frames to heal. Different bones also have different risk factors which also need to be looked at to ensure that once the injury has healed, that you don’t sustain it again in time.

So, it is incredibly important to see a health professional who has lots of experience in assessing and managing bone stress injuries (we can help with this! Click here to make an appointment for us to assess your bones). If it is suspected that you do have a bone stress injury, you will likely be sent for some form of imaging to help confirm the injury. In most cases this will require an MRI or bone scan. Xrays are not good for looking at bone stress injuries – they only show stress fractures when they are really bad (we often find that people are sent for these to rule out bone stress injuries – they don’t!!).

What treatment is needed for a bone stress reaction/stress fracture?

The treatment required is dependent of the extent of bone stress injury, which bone is involved and whether there are any underlying contributing factors to address. In general, all bone stress reactions will require a period of reduced activity (so as not to continue to stress the bone) – the extent of injury will dictate the length of time for this and how extensively activity needs to be reduced. Once the symptoms have settled and there is evidence of healing, activities that stress the injured bone are gradually re-applied. Whilst the above management of the injury is being conducted, it is important to address any contributing factors to ensure (or reduce the likelihood) that the injury doesn’t reappear – this can be checking bone density, working with coaches to better manage activity load, addressing strength/biomechanical/technique issues or fixing footwear.

From everyone at Arrow Physiotherapy, we hope that you are stressing your bones adequately to keep them strong and healthy, but hopefully staying short of over-stressing them!

Introducing our Nordboard

Introducing our NordBoard. Our physio, Chris Musgrave, has put his handyman skills to good use recently in constructing this fantastic piece of equipment. To see a video of it in action visit this link.

Chris has written the following information about NordBoards and the benefits they have for those with a history of HAMSTRING strains.

What is the NordBoard?

The NordBoard is a device that allows the use of a Nordic Hamstring curl without the assistance of a partner. With the addition of load cells, the device can be used to measure eccentric hamstring strength (the ability of a muscle to withstand force whilst lengthening).

What are Nordics?

Nordics are a hamstring exercise that has received quite a lot of attention in the sports medicine community in the past few years. As shown in the video – they basically involve lowering yourself as slowly as possible, using your hamstrings to stop yourself falling forwards. Despite some claims that it is a “core” exercise, its is predominantly a hamstring conditioning exercise.

Why do Nordics?

The Nordic exercise in itself has been researched extensively and has been shown to significantly reduce the incidence of hamstring strains. In particular – it appears to be particularly effective in reducing the recurrence of hamstring tears. In a study by Petersen et. al. (2011) recurrent hamstring injuries were reduced by 85% and new injuries by 60%.

How do Nordics work?

Nordics have a few characteristics that make them an efficacious exercise. The primary changes relate to increased fascicle length and increased eccentric strength. In basic terms, fascicle length pertains to the length of individual muscle fibres and eccentric strength is the ability of a muscle to withstand force whilst lengthening. Nordic curls appear to have a large effect on these two features – with short fascicle lengths and low eccentric strength being modifiable risk factors for injury.

However, to gain these benefits it appears that the exercise needs to be performed in a supramaximal fashion and it requires maintenance dosage to retain the benefits. What this means is that the exercise needs to be hard enough that you are unable to lift yourself back to the starting position using just your hamstrings (it is rare to be this strong!).

Who are Nordics useful for?

As suggested above, Nordics are particularly useful for those who have a prior history of hamstring strains. Low eccentric strength and short fascicle lengths occur post hamstring injury, thus reversing these changes is pivotal in reducing future injury risk.

Furthermore, they can be used quite successfully at a group level as well. If you are a involved in any sports with a lot of high speed running, this simple exercise can ensure you keep your athletes fit and firing throughout the season. Sports that are at particular risk of hamstring injuries include soccer, AFL, sprinting, hurdling, rugby.

Standing desks may not be the answer after all

A recent study (Baker et al. 2018) examining a small group of people doing 2 hours of computer work at a standing desk, resulted in:

general body discomfort
lower limb swelling
cognitive function
mental state

However on the plus side, it resulted in:

creative problem-solving ability

As you can see, standing desks should be approached with caution. If you have been a patient of ours and had discussions with us around sitting or standing at work, you will probably have heard us talking about the need to avoid prolonged sedentary postures, whether sitting or standing. The best thing to be doing is to try to move often and if possible vary your work position.

Perhaps as an alternative, we all need a treadmill desk!! If you have been in the clinic at times, you may have seen our physio Chris turning our treadmill into a desk (see photo).


Had an ACL reconstruction you might want to know this

In the last few weeks, one of the only studies looking at the long-term effects following ACL rupture has been published – van Yperen et al. 2018.

Cutting to the chase, after 20 years following ACL rupture there was found to be equal rates of knee osteoarthritis irrespective of whether one was to have an ACL reconstruction or not.

The study looked at 50 athletes who ruptured their ACL 20 years ago. 25 of the subjects did not undergo any reconstructive surgery. The other 25 subjects did have reconstructive ligament surgery using a patella tendon graft – although this was after 3 months on conservative management initially.

After 20 year, the study examined the presence of knee osteoarthritis using xray, looked at any symptoms the subjects may have been experiencing in relation to pain or dysfunction and also a functional activity scale.

Osteoarthritis on xray was found to be present in 80% of those who had an ACL reconstruction and in 68% of those who did not have surgery (despite the difference, this was not a statistically significant difference).

It was also found that there was no difference between the groups of subjects in relation to any symptoms that they may have had or functional ability.

The significance of this study, is that there are very few studies looking at the long-term outcomes following ACL injury or reconstructive surgery. It also helps our understanding in relation to expectation of rate of arthritis following ACL injury, irrespective of having reconstruction or not.

Like all studies, there are limitations, which include:

  • Many people undergoing ACL reconstruction do so relatively swiftly following injury, rather than waiting in excess of 3 months like in the study. This may have an effect on long-term outcomes.
  • Surgical techniques and equipment continue to develop over time and the techniques used these days do differ from what was done 20 years ago. As such, the study may not be comparing apples with apples.
  • All of the surgeries in the study were done using a patella tendon graft. In Australia, patella tendon grafts are not common. Hamstring grafts and even synthetic grafts are more commonly used. As such, this again does not mean that we are comparing apples with apples.


Doms Doms Doms

Muscle soreness following exercise, known as DOMS, is very common for people to experience this time of year as lots of people start or resume exercise – for more read on below.

If you have increased your exercise in recent weeks as part of a new year resolution or got back into exercise after a holiday or perhaps you have started football preseason, you may have experienced some muscle soreness! Muscle soreness after getting back into exercise or on starting a new exercise regime is common – it is typically referred to as DOMS! DOMS stands for Delayed-Onset Muscle Soreness.

If you have had trouble standing up or sitting down or even negotiating stairs for a few days after some leg exercises, it was probably DOMS. For your upper body, if you have had trouble lifting things or even putting on shirts after some upper body weights, it was probably DOMS.

DOMS usually kicks in 24-48 hours after exercise and lasts for a couple of days. It is basically a response to you overstressing your muscles – you will have created quite a bit of microtrauma within your muscles. Your body will adapt to this and future exercise efforts of similar intensity, should not evoke the same response.

DOMS is much more prevalent to exercises like running downhill, activities involving lots of landing or exercises involving a particular type of muscle contraction, known as an eccentric contraction – where your muscles are working hard whilst lengthening at the same time!

So, how do I know if I have or had DOMS?

Basically, if you have exercised heavily (especially with exercises that are either new to you or you haven’t done for some time) and have developed a muscular ache type pain in the proceeding 24-48 hours, then it is likely DOMS!

If your symptoms start immediately during or following exercise or last longer than 48 hours, then it may not be DOMS! Similarly, if the pain is located near your joints rather than your muscles, then it may not be DOMS! In these cases, you should consider seeing your physiotherapist to see if you have actually injured something more significantly.

If I have DOMS, what can I do to help it?

If you have DOMS, the best thing to do is to gently keep moving (e.g. gentle walking or even slow stationary cycling with limited resistance). This is better that resting in static positions. Icing the affected area can also assist. Gentle massage and the wearing of compression garments (e.g. skins) has been shown to shorten the duration and lessen the extent of symptoms.

You should avoid vigorous/strenuous exercise whilst the symptoms are present. Deep tissue massage should also be avoided for the first 24-48 hours. Once symptoms have resolved, you can gradually resume exercise. If you need further guidance, you should consult your physiotherapist.

In summary, DOMS is very common following starting an exercise program or when completing strenuous exercise. The typical symptoms are a dull muscular ache in the affected regions for 24-48 hours. The best thing you can do is to gently keep moving. Compression garments, icing the affected region and gentle massage can also assist with the recovery. If the symptoms persist beyond 48 hours, are not limited to muscle areas, start during or immediately after exercise or return regularly after exercising, then you may not actually have DOMS – in these cases you should consult your physiotherapist for assessment and to be diagnosed accordingly such that appropriate management can commence.

5 tips to keep you healthy injury free this Christmas

With Christmas just over a week away, we wanted to share 5 of our best tips with you to keep you & your family healthy & injury free this festive season.

Every year, we see a spike in certain injuries just after Christmas. There are a number of things for you to be aware of, to make sure these don’t happen to you.

So, here are our top tips to consider this holiday period.


If you have a regular routine of exercises, stretches, icing, etc to manage a particular condition, make sure you continue with this over the holiday period. Every January we see an increase in people presenting to physiotherapy with injury “flare-ups” due to taking a holiday from their injury management routine.


Every year we hear some impressive (& sometimes disastrous) injury stories of adults mucking around with kids toys. So, if you are going to be tempted to play with your child’s new Christmas present, make sure that it can tolerate your weight & perhaps think about the last time you did something like that (e.g. riding a skateboard for the first time in 20+ years often results in broken arms!).


The Christmas period can be a wonderful time of fun, family, food, drink & relaxation. See if you can find some time to get some exercise in. You may even have more time than normal to go for a walk, a bike ride or a swim down at the beach. Exercise is a great way to keep the body moving well.


Alcohol can be a major factor of many injuries over holiday periods. With alcohol consumption comes impaired judgement, reduced steadiness, in-coordination & reduced inhibitions. This combination is perfect for all manor of injuries. So without trying to sound like the Christmas Grinch, perhaps think about what activities you do and take care if you choose to drink this Christmas.


If you have been battling with injuries or illness, make a resolution to better manage or continue to manage these as best you can in 2018. If you don’t have any particular health issues requiring attention, may we suggest the following physical health resolution for 2018 – to commit to meeting the Australian Physical Activity Guidelines at a minimum. For adults these are:

  • Accumulate 2.5 to 5 hours of moderate intensity physical activity or 1.25 to 2.5 hours of vigorous intensity physical activity, or an equivalent combination of both moderate and vigorous activities, each week; and
  • Do muscle strengthening activities on at least 2 days each week.


Have a safe festive period & wishing you a healthy 2018!

Do you experience nerve pain???

Sharp, shooting pain, electric shocks, burning, tingling, pins & needles.These are common descriptions that our patients tell us when they experience nerve injury. You may be able to associate with some of these.

Nerve pain (or neuropathic pain) can be quite different to other forms of pain. It can be quite unrelenting in some circumstances & incredibly debilitating until the underlying cause is addressed.

Nerves send electric impulses around the body conveying messages about all of our senses (touch, taste, sound & smell) as well as messages telling our muscles to work & when to relax, among many other things.

When nerves are damaged through injury or disease, they can cause pain, pins & needles & even numbness. In more serious circumstances, they can even result in loss of strength in the muscles that the nerves supply & even loss of reflexes (this is something that you likely wouldn’t notice yourself!).

You have probably experienced nerve pain at some stage in your life. Knocking your “funny bone” in your elbow is actually nerve pain! It’s not actually a bone at all – it’s what is called your ulnar nerve, & when you compress it against the underlying bone, you get that uncomfortable pain & sensation that you are probably familiar with.

We see many forms of nerve pain in our clinic from all sorts of conditions. Some of the common ones are:

  • Carpal tunnel syndrome – this is where the median nerve gets compressed by the carpal bones (a ring of bones forming a tunnel – hence carpal tunnel syndrome), resulting in pain & potentially pins and needles, numbness & weakness in the hand.
  • Nerve root compression – the part of the nerves that exit our spines are known as nerve root. Nerve roots can be compressed or irritated by a number of spinal conditions including disc bulges. In these circumstances, the disc presses against the nerve root & can result in pain along the length of the nerve which is impacted. This is why you can have a back injury & not necessarily have any pain or symptoms in you back – only pain & symptoms in your leg!

There are also many other forms of nerve pain from trauma, diabetes, inflammatory conditions, side effects from certain drugs & neurological conditions (e.g. multiple sclerosis).

As you can see there are numerous things that can cause nerve pain. If you experience nerve pain, the most important thing is that you find out what is causing your nerve pain – that is, you need a diagnosis! Only once you have this, can you seek the appropriate treatment required for your condition.

As physiotherapists, we routinely see people with nerve pain. Physiotherapy is often a key treatment for many nerve related conditions. Other treatments depending on the condition require certain medications or medical management that target nerve pain or the underlying cause.

If you are experiencing nerve pain, our physiotherapists are able to assist with diagnosing the cause of your pain & in many circumstances providing the appropriate treatment for the condition.

If you would like to make an appointment to see one of our physios, call 8850 7770 or click here to book online.

Got a sore back maybe you need a new car

Got a sore back? A new car might be the answer!

Whilst this may sound extreme, it is exactly what I recommended to one of our patients recently! And guess what…the patient called me just this week to advise that their back pain had gone since getting a new car!

So, you might be thinking – how did I know it was the car that was causing the back pain?

Well, you see we take the time to thoroughly examine our patients as well as get a detailed history of what has been going on to develop a comprehensive picture of the injury, including all the contributing factors (in this case the car!).

The key elements of this patient’s presentation, were:

  • the back pain was relatively new;
  • the pain seemed to have commenced roughly around the time of getting a new car;
  • the patient drove the car for in excess of 3 hours a day commuting to and from work (often 6 days a week);
  • the pain was better on days when they didn’t work,
  • the lumbar support in the car was pretty poor (yes, I physically went and inspected the car to check this out);
  • after conducting a full physical examination, the back pain did not appear particularly serious in nature;

With this information, it seems pretty clear that the car appears to have been a significant contributing factor to this patient’s pain! Yet, the patient themselves hadn’t really linked the two.

This happens commonly for us in that what may appear obvious in hindsight, often isn’t the case to someone in pain. Getting to know the patient and taking the time to ask the relevant questions and conduct a thorough assessment means that we can identify the contributing factors.

Was getting a new car entirely necessary? Possibly not. We could have explored means of trying to improve the back support in the car and also means of making the patient’s back more resilient to the posture the car held him in (with an appropriate exercise program).

I’m sure you can see that getting a new car won’t fix everyone’s back pain! However, if you have back pain or any injury for that matter, you might want to think about things in your life that may be contributing factors. As in this example, it isn’t always clearly obvious to the patient, so it may be worthwhile to see one of our physiotherapists who can conduct a thorough history and examination to help you understand your condition and any underlying circumstances that may be contributing. Only once the contributing factors are identified, can you go about addressing the issue!

To make an appointment with one of our physios, call 8850 7770 or click here to make an appointment online.

Brendan Limbrey
Principal Physiotherapist

Kids that play hard need to sleep hard

  • Are your mini athletes getting enough sleep each night?
  • Are your kids getting fatigued whilst playing sport?

We see lots of children and adolescents in the clinic with all manner of aches, pain and injuries. When asked about sleep patterns, it would seem that many are not getting enough shut eye!

So, how much sleep is enough? And what are the risks of not getting enough sleep?

There is clear research that shows that the risk of injury increases if you are not recovering from bouts of activity with appropriate sleep combined with good nutrition. Consistently good sleep partnered with nutritious food intake can help your children perform at your best. This may not sound surprising to many; but are your children actually getting enough sleep?

A 2016 study of adolescent athletes showed that getting more than 8 hours of sleep significantly reduced the risk of injury by 61%. A further study in 2014, showed that adolescents who received less than 8 hours of sleep a night were 1.7 times more likely to sustain an injury compared to those receiving 8 or more hours of sleep a night.

The message here is simple – children and adolescents need to be consistently getting 8 hours or more of sleep a night to ensure they are playing their best and minimising any risk of injury.

If your children do have any niggling injuries, sleep is not the only factor to consider. Our physios are well equipped to assess and treat any aches or pains that your children may be experiencing.

von Rosen, P. et al. (2016), Too little sleep and an unhealthy diet could increase the risk of sustaining a new injury in adolescent elite athletes. Scand J Med Sci Sports. doi:10.1111/sms.12735

Milewski et al. (2014). Chronic lack of sleep is associated with increase sports injuries in adolescent athletes. J Pediatr Orthop. 34(2); 129-33.

Painful lump behind your knee what you need to know

Do you get pain behind your knee? Does it feel like you have a lump behind your knee? If so, you may have a Baker’s cyst.

Baker’s cysts can be quite common however are often misunderstood even by many health professionals.

We’re not too sure what a painful lump at the back of your knee has to do with Bakers!

So, what is a Baker’s cyst?
It’s a collection of fluid (swelling and normal joint fluid) in a pouch at the back of the knee. It is like an overflow reservoir for when there is too much fluid in the knee already. When the pouch becomes full with fluid it is termed a “Baker’s cyst”.
What is the problem with a Baker’s cyst?
A Baker’s cyst can cause pain which can be quite uncomfortable directly behind your knee. It can also cause a tightness or pain up the back of the leg (usually in the calf region). If it becomes so enlarged it is even possible for the cyst to rupture or burst which results in the fluid leaking out into your calf where is can become quite swollen or even bruised.
What is the BIGGER problem with a Baker’s cyst?
Besides from the issues mentioned above, the bigger issue with having a Baker’s cyst is that the fluid has to be coming from somewhere. This mean that there absolutely has to be something injured or irritated within the knee. The bizarre thing is that often the knee isn’t particularly sore anywhere else except for behind the knee where the Baker’s cyst is. The common injuries which are present in those with a Baker’s cyst are meniscus or cartilage damage or arthritis. There can also be a number of other injuries and nasty things going on deep in your knee which can cause fluid leading to a Baker’s cyst.

Despite having pain from the Baker’s cyst, which understandably you will just want gone, it is IMPERATIVE to find out what the underlying cause is!

This leads me to what frustrates me with Baker’s cysts. It is not uncommon for people with Baker’s cysts to have cortisone injections into them or even have them drained. Whilst this may relieve the pain, as it gets rid of the fluid, it does absolutely nothing in addressing any injury which is causing the cyst! When this happens, you open yourself up to the issue simply coming back again and again.

The good news! We see quite a lot of these in the clinic and there is quite a lot that can be done to give initial relief from the pain of the Baker’s cyst and also to address the underlying cause. The most important thing is have the underlying cause identified and our physiotherapists are well trained to assess for conditions which can cause a Baker’s cyst. Once identified a plan can then be established as to how to treat or best manage this underlying cause.
If you have had Baker’s cysts in the past and have only ever had the symptoms of the cyst treated and not the underlying cause, then you ought to find out what has been causing these Baker’s cysts. To arrange an appointment with one of our physiotherapists for this phone 8850 7770 or make a booking online.