Dominic will be working at the Olympic Games in the summer as one of the lead physiotherapists at the O2 Arena (or The North Greenwich Arena to use its official Olympic Games title!). This should present an interesting challenge as the venue will play host to Gymnastics and Basketball – a real “little and large” show! Dominic is looking forward to catching up with old friends from the medical teams of many countries and seeing Team GB perform to the best of their abilities! He will also be writing a blog during the games, so watch this space.

As part of our recent refurbishment we have created a dedicated space in the practice for counselling. The room has been specifically constructed with the input of our existing counselling staff for this express purpose, rather than being a treatment room with a bed pushed to one side. The walls and door of the room are acoustically shielded so you and your clients can rest assured that your sessions remain entirely private.

The clinic is very friendly and we work hard to make patients and staff alike feel welcome. There are reception staff on duty from 9am to 7pm and all the facilities you would expect to find in a professional clinic including a secure internet connection. If you would like to develop your practice within our practice please get in touch to discuss how you could fit in.

Pain in the shoulder can be one of the most debilitating types of pain we deal with in the clinic. If you stop for a moment and think about the number of things you do with your upper limb, almost  everything will involve your shoulder joint. The joint is formed between the “ball” of the upper arm bone and the “socket” of the shoulder blade and this may be the description you remember from the biology lessons you had to endure at school. This isn’t in fact a great description of the joint – the ball of the upper arm is only about half a ball and the socket is no more of a socket than if you hold your cupped hand out palm up like you were asking for sweets.

This arrangement results in a joint which is very mobile but the trade off for this is that the joint is in relative terms unstable. Compare the movement you have in your shoulder with the movement you have in your hip which is much more of a true “ball and socket” joint. To make up for the lack of bony stability the shoulder joint has a group of muscles around it (the rotator cuff) which provide dynamic stability and support the joint throughout its movement.

Shoulder pain can take many forms and be present for a wide variety of reasons. Getting the best treatment for your shoulder pain relies on getting an accurate diagnosis and at City Physio you can expect us to take the time to get to the root cause of your problems and we work closely with local shoulder specialists

Mark Freeman demonstrating remarkable shoulder stability

  to arrange further investigations if necessary to give you the best outcome.

Shoulder dislocation

With shoulder dislocation the diagnosis is often pretty clear and it is very unusual for people to arrive in the clinic with an undiagnosed dislocation! Almost all dislocations are where the “ball” of the top of the upper arm bone moves forwards out of the “socket” of the shoulder blade. This almost always follows a traumatic episode of some description and will usually have undergone reduction (the correct term for putting the bone back in its place) in the hospital or less often at the pitch side if the injury occurred while playing sport.

After a dislocation there is quite a high risk of the joint dislocating again (indeed some studies show that the joint is more likely to dislocate again than not). The problem is that in dislocating, the upper arm bone tends to damage some of the surrounding structures and this can lead to instability in the joint and recurrent dislocation. Each subsequent dislocation event tends to make the joint a bit more unstable and does further damage to the joint so it is important that the dislocation is managed carefully in the early stages and that an appropriate course of rehabilitation is followed.  Depending on the level of function that the individual is hoping to achieve after shoulder dislocation, it may be necessary to undergo surgical stabilisation in a small number of cases.

Very rarely, the shoulder dislocates backwards. This occurs almost exclusively in two instances – during an epileptic seizure and in victims of electric shock. This can sometimes be missed on the first visit to the hospital because of its rarity but must be considered with shoulder pain following either of the incidents mentioned.

To give you an idea of how often we see this type of dislocation, in 18 years of practice we have seen just two patients with posterior dislocation. One had suffered and electric shock and had remained undiagnosed for three months, the other suffered with epilepsy. Many physiotherapists will go their entire career without seeing this type of dislocation.

Shoulder Impingement and Rotator Cuff Problems

This term describes a pinching or trapping of the muscles which support the shoulder joint between the bone of the upper arm and the bone of the shoulder blade. This tends to cause pain when lifting the arm above shoulder height. Sporting activities or occupations which involve using the arm above the head work the supporting muscles of the shoulder hard and like any other muscle which is worked hard they get bigger. This does not normally cause problems but some activities also habitually put the shoulder in an awkward position. If there is not much room in this part of the shoulder the muscles start to rub between the bones when the arm is used. Over time the muscles can become damaged, causing pain an inability to perform certain activities. Physiotherapy treatment is often useful in helping this type of impingement.

You may gently stretch the soft tissues around the painful area to relieve some of the rubbing, you can re-educate some of the muscles to change the way your shoulder works or perhaps look at your sporting technique to see if anything can be done to alter the action of the muscles.

In some types of impingement, the bone which forms the top of the shoulder joint can become thickened (this is the bone which would sit underneath the epaulettes on your shirt). This may be due to previous trauma or as part of a process of wear and tear through ageing. The thickened bone rubs on the top surface of the muscles beneath it as the arm moves and can become very painful and in severe cases the muscles can rub right through and rupture.

If you have this type of impingement, whilst physiotherapy may help to relieve your symptoms we will not be able to fix the underlying cause. For this type of impingement the normal treatment is to have part of the thickened bone removed surgically to make more space for the muscles and stop the irritation. This is usually performed via “keyhole” surgery and allows a rapid return to normal activity. At City Physio we can help arrange the appropriate referral either directly to a specialist if you have health insurance or via your doctor if you do not. After surgery we work closely with the specialist to ensure your rehabilitation runs as smoothly as possible and you make a speedy recovery.

Frozen Shoulder

If you are suffering with or have ever suffered from a frozen shoulder you will know what a painful and disabling condition it can be. Sometimes developing after a trauma, frozen shoulder is most often of “ideopathic onset” which means we know that you’ve got it but we don’t know why! It is ususally described as having three stages; in the first stage the shoulder becomes increasingly stiff and very painful, in the second stage the pain diminishes but the stiffness remains and in the third stage the movement slowly returns to the shoulder.

In frozen shoulder (or adhesive capsulitis to use the more medical term) the shoulder does not just feel stiff when moved but it is physically impossible to move.  People who come into the clinic and say “It hurts to lift my arm above my head- I think I have frozen shoulder” almost certainly do not! Most people will notice that they have trouble reaching into high cupboards, ladies may have difficulty reaching behind their backs to put their bra on and chaps may find difficulty reaching into a hip pocket.

The good news with frozen shoulder is that they almost always get better, so if you are suffering do take heart from this! There are a number of treatments which may benefit you; physiotherapy to help relieve the pain and maintain/restore your movement is the first course of action and you can expect a series of exercises to help with this.

If your frozen shoulder is not responding as you would like, the next step is manipulation under anaesthetic. As the name suggests, a general anaesthetic is given (you are put to sleep) and the shoulder is moved by an orthopaedic surgeon which can be very useful in restoring movement and relieving pain. As with any procedure which involves a general anaesthetic , there is an element of risk and this procedure is not undertaken lightly.

Here at City Physio, we can help you get the right diagnosis and treatment for your shoulder pain. You can contact us below and you’ll find us happy to help you.

What is Tennis Elbow?

This is a question with a range of answers. Pain on the outside of the elbow can be caused by a number of things (including tennis) and the first task for us is to arrive at an accurate diagnosis to enable the best treatment to take place.

The commonest cause of what would typically be described as tennis elbow is injury to the connective tissues on the outside of the elbow. The muscles which control the wrist and hand are attached to the bone of the upper arm at the bottom end, on the bony bit you can feel if you press on the outside of your elbow. In the last few years there has been a bit of a change in the view of the medical community as to what is happening in the injured tissues. It used to be the prevailing view that the problem was one of chronic inflammation in the tissues and treatment was aimed at reducing the inflammation, be that with ice, rest or even with the use of anti-inflammatory injections such as cortisone.

In the last few years, research has shown that there is often not any inflammation in the tissues affected and in fact the tissues are degenerative. While this might seem to be just a change in the language used to describe the problem, it in fact changes the whole way we approach not just tennis elbow but a range of other connective tissue injuries including plantar fasciitis, Achilles tendon problems and jumper’s knee.

At City Physio we are active in keeping up to date with the latest research and techniques to ensure we follow best practice for our patients and this is reflected in our approach to all the problems we see in the clinic. Dominic regularly lectures on the Masters Degree programme at one of the most respected medical schools in London and this also helps to ensure we are abreast of the latest research in our field.

Why come to City Physio?

There are many potential causes of pain in the elbow in addition to local problems like tennis elbow. Nerve root irritation in the neck, frozen shoulder and elbow joint arthritis can all cause pain on the outside of the elbow and a thorough assessment will allow us to get to the root cause of your pain.

After we have taken the time to find the cause of your elbow pain we can then undertake the most appropriate treatment. If it really is related to your tennis, we may look at your technique, grip size and playing style to ensure that you have the best opportunity to return to your sport as soon as possible.

If you are having trouble with pain in your elbow we can help. Click on the link below for details on how to contact us and make an appointment.

As the title suggests these are championships and events in which athletes from a number of different sports compete at the same event. There are in fact relatively few events such as this around the world each year and for athletes and support staff alike exposure to this environment is hard come by and very much valued in their preparation.

For most sports the Olympic Games is the pinnacle of competition and the ultimate multi-sports event. The fact that they only occur every four years means that for many athletes they are only ever able to be in peak shape and at the top of their performance for one Games. There are a few notable exceptions to this – Sir Steve Redgrave & Sir Chris Hoy spring to mind but the “Sir” in front of their names indicates how special and exceptional they are. There are many factors at an Olympic games which can distract the athlete and detract from their performance; the sheer numbers of people (over 11000 competitors at the Beijing Olympics), the many famous sports people who are quite literally wandering around the village, the 24 hour availability of food in the restaurant, the multitude of different cultures and nationalities etc.

So the question is; how does one get exposure to an environment which only comes around every four years? The answer is that there are other limited opportunities for multi-sports exposure which can be had. The Commonwealth Games, Asian Games and Pan Pacific Games are all open to limited groups but the fastest growing event which is becoming a great place to get multi-sport exposure is the World University Games. The picture shows a typical post training scene from the 2009 World University Games in Belgrade, the boys from the Gymnastics team take a few minutes to get some  work on their suntans and to let the locals see the “Gun Show”.

The first World University Games was held in Sheffield in 1991 and like many things which later became great did not get off to the best of starts, costing the City of Sheffield a small fortune to host but it did kick start the sporting regeneration of Sheffield including the building of Don Valley Stadium, Ponds Forge swimming centre and Sheffield Arena.  The event has grown and is now the second largest multi-sports event in the world, behind only the Olympics in terms of competitor numbers. The University Games is held every two years and was last hosted in Belgrade, Serbia in 2009 when there were 9000 competitors from 145 countries. The next Games will be held in Shenzen, China in 2011.

Dominic was selected to represent Great Britain at the 2007 Games in Bangkok  and the 2009 Games in Belgrade. Unfortunately he will be unable to attend the 2011 Games in Shenzen, China but will instead take part in the selection process for the physiotherapists who have applied to attend.

Types of ankle injury

Ankle sprain or strain – the only difference between a strain and a sprain is the second letter of the word! These terms are used most often to describe what is correctly described as an inversion injury. This is where the foot turns inwards in relation to the lower leg (or more often the foot stays still and the leg moves outwards in relation to the foot). Imagine that you are playing football on one of the less than perfect pitches around Portsmouth and your foot finds a dip in the pitch – your leg remains upright and your foot turns underneath you. This movement is controlled by a collection of supportive structures called ligaments on the outside of the ankle joint; as your foot turns in these structures are stretched and if there is sufficient force they will tear, resulting in an ankle strain.

Treatment of Sprained Ankle

This depends on the exact nature and severity of the injury. Strains are divided into three categories or grades, imaginatively called Grade 1, 2 or 3, with Grade 1 being the least severe. Most sprains we see are Grade 1; there is an egg shaped swelling on the outside of the joint, there is often quite impressive bruising, it can be very painful and you may not have been able to walk on the foot straight after the injury.

A word on X-rays: We are often told by our patients that the ankle was not X-rayed when they went to the hospital and that surely it must be broken as the ankle is so swollen and painful!   Hospitals follow protocols in the management of these injuries – guidelines which indicate the appropriate actions to take and whether investigations like an X-ray are necessary. These protocols are well established; the vast majority of ankle injuries do not need an X-Ray and an X-Ray will not be performed “just to make sure”. Rest assured, if your ankle is X-rayed it was because the doctor was already pretty certain it was broken!

Immediate treatment of a sprained is aimed at reducing the pain and swelling and limiting further injury. As time progresses, treatment aims to help the damaged tissues repair as fully as possible and in the later stages is aimed at returning the ankle to full strength, flexibility and stability. Most people who suffer an ankle sprain will suffer the same injury again at some point and so are treatment is aimed at making sure this does not happen. Many people after an ankle injury will complain that the ankle feels unstable or that they do not feel confident if they are walking over uneven ground. It is quite rare to develop true instability in the joint and this would normally follow a Grade 3 strain where the ankle ligaments are completely ruptured; in most cases it is a feeling of instability and this relates to one of the body senses called proprioception.

Proprioception or position sense is the bodies awareness of where it is in space – we do not need to see our arm to know whether it is bent or straight, we can feel it. After an ankle strain, the proprioception of the joint is reduced and this is the root cause of most instances of  re-injury. We must work hard to regain this sense. When sport is being played we do not concentrate on the positions of our joints – we are thinking of our performance in the match and exercises which help to regain this innate sense of position are an essential part of rehabilitation.

Sportsman’s Ankle

This term is used to describe changes which occur in the ankle joint and are seen most in sports which involve jumping and landing in potentially awkward positions (think of a defender jumping in a congested penalty area or a gymnast landing a vault). If repeated poor landings are made the bottom of the shin bone (which forms the top of the ankle joint) impacts onto the top surface of one of the bones in the foot and eventually forms a ridge on the bone. This causes a painful pinching in the front of the joint, worse when running or walking on an uphill slope. Treatment from the physiotherapist is aimed at maintaining the mobility of the joint to ensure that the normal pattern of walking is not affected.  The pain may also be helped by using an orthotic or insole in the shoes to improve the function of the joint. In the most severe cases, surgery may be required to remove the bony ridges from the bone. This can normally be performed via keyhole surgery and a return to sport would be expected in the vast majority of cases.

Most episodes of low back pain will resolve themselves and will require no more treatment than some painkillers and a little time, however some episodes of back pain last significantly longer or are so painful that seeking professional help becomes a necessity.

What can we do for you?

There are many types of low back pain and our first priority will be to take a thorough history of your problem to help us establish the nature of the condition and the best way to help. After taking a detailed history, we will then make a physical examination of your spine, initially observing your posture and movements before using our hands to palpate the muscles, bones and other connective tissues in the area. We will be looking (and feeling) for areas of uneven movement, stiffness at a particular level of the spine, the way that your muscles work to support the spine and produce movement as well as any othe problems which may be relevant such as a hip or knee problem which may be causing awkward movement in the spine itself.

Once we have concluded our examination, we should be able to explain in a way that makes sense to you, the nature of your problem and what we can do to help you. Most often treatment is a partnership – there are things that we can do for you and things that you can do to help yourself. We may have identified a stiff joint in the spine which might need mobilising to improve its movement or you may have weakness in the muscles which support your back, for which we will give you a guided series of exercises to improve.

For most people a short course of treatment is enough to completely resolve the back problem. For some people whose condition is of a chronic nature (for instance arthritis in the spine) we will reach an agreed level of improvement where they can manage their problem themselves with appropriate exercises or modification of their lifestyle. This group of patients may come to see us intermittently for help if they have a flare up of their condition or, a bit like going to the dentist, they will come in a couple of times a year for us to check on their progress or perhaps to modify their exercises as their condition changes.

Common Types of Low Back Pain

Disc related problems

The disc is a structure which sits between the bones of the spine and performs two jobs; it helps to cushion the impact of activities such as walking and it helps to limit the movement of the spine. In the lower back the disc is up to a centimetre thick and to do two jobs it contains two types of tissue – there is a soft central area which cushions impact and a tough outer coating which wraps around the central area and acts to control movement in the spine.

Degenerative disc disease

This “disease” can be considered the normal ageing process of the spine. Many people who are told this is the cause of their back pain are concerned – degenerative implies that the condition will worsen over time and if their pain is bad now, what will it be like in 20 years time? The good news is that the condition  responds well to treatment and in fact for many people the pain associated with the disease gets better over time rather than worse.

In degenerative disc disease the disc itself narrows or loses height. As this happens, the disc loses its ability to cushion impact and the bones which sit either side of the disc come closer together. The X-Ray image below shows a typical narrowed section of the spine below a normal segment.

What can be done to help?

Avoiding impact activities – if the spine has lost some of its ability to cushion impact then it is a good idea to lessen the impact that the spine is subjected to. These activities include running on hard surfaces, water skiing, off-road cycling and motorcycling and high impact aerobics. Exercises which strengthen the muscles around the spine without causing impact are an important part of treatment and include Pilates, exercise classes in water (aqua aerobics) and walking.

Managing you body weight – if the bones in the spine are closer together than normal, to compres them as little as possible would seem a sensible idea. Keeping your body weight at an appropriate level helps greatly especially in men who tend to hold excess weight around their waist which puts further strain on the lower back.

Physiotherapy treatment particularly during a flare up can help by gently mobilising the affected area and relieving any painful muscle spasm which accompanies a flare of this condition. Your physiotherapist will also help devise a suitable programme of exercises for you to perform on a regular basis as well as giving guidance on activities to avoid and those to actively undertake.

Slipped Disc

This is a commonly used term which is not very descriptive at all and in fact gives rise to a lot of misconceptions about peoples back pain. A “slipped” disc has not slipped anywhere at all! What is being described is a change in the shape of the disc (bulging disc) or damage to the exterior of the disc which lets the soft central part protude (prolapsed disc). Both of these conditions cause pain because the bulging or prolapsing disc presses on the structures around it and irritates them. This gives pain locally in the back and may cause pain elsewhere in the body – referred pain.

The structure often compressed by the disc is called a nerve root – these nerve roots become the nerves which supply different parts of the body with perception of pain, sensation and movement. Pressing on the nerve root can cause pain, weakness and loss of sensation. The commonest example of this is sciatica, pain in the low back, buttock and back of the leg (the area of the body supplied by the sciatic nerve). The pain may vary in severity and the part of the leg it affects; some people with sciatica have no back pain at all but may have severe toothache like pain in the leg.

Most people with disc problems respond well to physiotherapy treatment and only a very small number of people require further medical treatment and fewer still ever require surgery. To give a rough indication of the numbers involved, the practice has been established for 17 years and around one third of our patients come in with low back pain. In 17 years we could count less than ten people we have seen who have required surgery to treat their back problems.

Being a Host Nation physiotherapist means that you are there on behalf of the hosting country to provide immediate physiotherapy treatment at the Competition and Training venues for those participants who for a number of reasons may have come without their own medical support. This brings many challenges not least the linguistic ones (although “ouch” seems to be pretty universal). There is less contact with the athletes and the provision is more reactive than the planned care you provide when you are the Team physio.

Some of the medical team also have further training in paramedic skills and will react in the event of potentially more serious injuries.

The disconsolate looking German whose competition has just finished before it has begun is Fabian Hambeuchen. Fabian is a big star in Germany and often has a film crew with him, he has been World & European Champion and is an Olympic medal winner. He has enough of a sense of humour  to laugh when the physio in the background told him “For you, the war is over…” in a thick German accent.

Jessica Gil Ortiz

The injured gymnast at the centre of a lot of medical attention is Jessica Gil Ortiz. She landed on her head during her floor routine and looked like she ought to have broken her neck (the routine is available to view on Youtube (link below) but don’t watch if you are squeamish).

The collection of physiotherapists and doctors practice for just this eventuality – happily the gymnast was not seriously injured (beyond a pretty sore neck) and was released from hospital after appropriate investigation.

“Being the team physiotherapist gives you a unique insight into the day to day lives of the athletes, spending most of the day with them during the competition period. You can become as much a counsellor as a physiotherapist, giving athletes the chance to talk about their pre-event nerves, the fact that they may be missing home or loved ones as well as their concerns regarding their injuries.”

“This is a typical scenario on a training day at The European Championships in Volos (Greece) in 2006. The guy with the “guns” on the receiving end of treatment is Ross Brewer, a stalwart of many GB teams over the years and a multiple British and Commonwealth Champion. This picture was taken by a photographer from a major newspaper looking for a different angle in a story to run about the Championships. He was kind enough to send this to me after the event”

This picture illustrates the other side of the Team physio role. The gymnast here is Adam Cox who has sadly just fallen during his HighBar routine at the European Championships in Slovenia, ruining his (quite realistic) chances of making the final and winning a medal. With the coach helping the next competitor to prepare, it is left to me to pick up the upset gymnast and explain that this is also team event and that he has three more pieces of apparatus to complete and five teammates who are relying on him to put in decent scores. This is one of the unique aspects of Gymnastics competition; that it is a Team event but with chances for Individual achievement.

The image below probably best illustrates how most of the time is spent at major Championships – sitting around hoping that something won’t happen but ready to help if it does! Fortunately although the days can be long, the company is often good. The gentleman to Dominic’s left is John Aldridge, a consultant Orthopaedic Surgeon, who was the driving force behind getting proper medical support for gymnastics in Great Britain and who has been an ever pesent at Olympic, Commonwealth and World Championships since the 1980′s.

In its purest terms physiotherapy is the treatment of disease by physical means. In practice physiotherapists treat a wide range of conditions ranging from sports injuries to back and neck pain, neurological conditions such as stroke or cerebral palsy and also help people return to health following surgery.

Here at City Physio we specialise in musculo-skeletal conditions. We see sports injury from recreational to elite athletes, neck and back pain, whiplash injuries following road traffic accidents and also work closely with a number of local consultants to ensure the speedy recovery of their patients following surgery.

All treatment provided by our physiotheraists is underpinned by a scentific base and based on widely accepted best practice principles. We maintain our clinical knowledge by attending regular professional development courses and Dominic also lectures widely to other health professionals including Masters Degree students at Queen Mary University London.

Our Physiotherapists

Here at City Physio, all of our physiotherapists are registered with the Health Professions Council and are also members of the Chartered Society of Physiotherapy. We are legally entitled to use the protected titles “Physiotherapist”, “Physical Therapist” or “Chartered Physiotherapist”. Only those individuals who have followed an approved course in Physiotherapy at a recognised University are eligible for membership of the Chartered Society and are able to Register with the Health Professions Council.

Their registration details are below and you can check them by clicking on the links:

Dominic Dentry    CSP Number: 052929  Health Professions Council Registration Number: PH46170

Rachel Heda        CSP Number: 077076  Health Professions Council Registration Number: PH78689

Jon Charman       CSP Number:                 Health Professions Council Registration Number: PH60709

Chartered Society of Physiotherapy

The Chartered Society of Physiotherapy was granted its Royal Charter on 11th June 1920 for what was then known as the Chartered Society of Massage and Medical Gymnastics! For many years “Chartered Physiotherapist” was the legally protected title and many physiotherapists will still refer to themselves as Chartered Physiotherapists. Members of the Society are entitled to use the initials MCSP after their name.

Protection of Title

Since 2002 the titles “physiotherapist” and “physical therapist” have been protected by law. Anyone using one of these titles must be registered with the Health Professions Council, or they may be subject to prosecution and a fine of up to £5,000.

The Health Professions Council maintains a register of professionals in a number of groups (including paramedics, radiographers, podiatrists and dietitians) and sets standards for training, behaviour and levels of skills necessary to practice within the profession.

The Health Professions Council was formed in 2002 and took over the role previously played by the Council for Professions Supplementary to Medicine.