Knee pain in adolescents – Is it because of SLJ Syndrome?


Sinding Larsen Johansson Syndrome

Sinding Larsen Johansson Syndrome is a condition causing knee pain in early adolescent (10-15years) age group. It is often seen in active individuals involved in high impact sporting activities which involve repetitive jumping or running. Basketball, volleyball and track and field are common examples but it can also be seen in sports like squash, tennis, gymnastics and soccer.

Excessive and repetitive stress on knee leads to irritation and inflammation of the growth plate of the patella (knee cap).  The growth plate which is present at the inferior pole of the patella is attached to the patella tendon. The other end of the patella tendon is attached to the shin bone. Increase in traction forces of the patellar tendon on the growth plate leads to its inflammation. Symptoms include pain, swelling and tenderness at the bottom of the knee cap (patella). Pain increases with activities like running, jumping, kneeling, squatting and even climbing up and down the stairs.

Read contributing factors and treatment on Page 2


Tarsal tunnel Syndrome


Tarsal Tunnel Syndrome


Tarsal tunnel syndrome is a similar condition like carpal tunnel syndrome, where the symptoms are caused from compression of the nerve. The location of tarsal tunnel is inner side of the ankle and the nerve getting compressed is posterior tibial nerve. It is covered with a thick ligament known as flexor retinaculum and base is formed by ankle bones.

Symptoms usually start gradually and get worse overtime. Common symptoms are pain, numbness, tingling and burning sensation over inner side of ankle and sole of the foot. It might result in loss of sensation overtime. Symptoms are constant, i.e. present all the time and are aggravated with activity like walking and running.

People suffering from tarsal tunnel syndrome find it difficult to stand or walk for prolonged time. Movements like eversion (moving foot outwards) and dorsiflexion (moving foot upwards) gets limited as they provoke the symptoms. Same as carpal tunnel symptoms may become worse in the night.

Read causes and treatment options of Tarsal Tunnel Syndrome on Page 2

How to Give Your Ankle Sprains the Perfect Rehabilitation and Reduce Risks of Recurrence


Article by Timothy Maiden

Tim photo
Senior Podiatrist at The Foot Practice (Singapore)


Untreated ankle sprains can lead to chronic problems such as pain, joint instability, and diminished range of motion. Yet many patients with acute ankle injuries never seek medical attention [1].

Not to scare you, but poor recovery from ankle injury and long-term ankle instability ­­is associated with the development of painful degenerative joint disease. This risk can be reduced or eliminated with proper ankle care and rehabilitation. Ankle sprains are among the most common injuries to the musculoskeletal system, accounting for approximately 2 million injuries per year [2].

It’s no surprise that the most important risk factor for ankle sprains is a history of previous ankle sprains! Therefore, it’s absolutely imperative to follow an up-to-date rehabilitation program. An ounce of prevention is worth a pound of cure, and prevention of ankle sprains is especially crucial during the seven-week period after acute injury. In this guide, we’ll discuss ankle injury severity, the four-step rehabilitation process and the application of an orthosis (brace for an ankle injury).


Ankle Injury Severity

Depending on injury severity, ankle sprains are graded from I to III. It’s helpful to familiarize yourself with the grades, since injury severity informs treatment.

Grade I ankle sprains exhibit minimal loss of functional ability, pain or swelling, and an intact ankle ligament. A grade II ankle sprain entails a partial ligament tear and moderate pain, swelling, and loss of function. Finally, grade III is characterized by a complete ligament tear, with severe loss of function, pain, and swelling, as well as marked difficulty bearing weight.

The Perfect Ankle Sprain Rehabilitation Regimen

What’s the goal of ankle rehabilitation? Isn’t it enough to relax on the couch and let the healing process occur by itself? Rest and relaxation are certainly an important part of rehabilitation, but there are a number of other steps you can take to hasten recovery and prevent future injuries.

The goal of ankle sprain rehab is to I) decrease inflammation, II) regain your full range of motion, III) increase muscle strength, power, and endurance, and IV) improve proprioception. Proprioception is just a fancy word for how you perceive different parts of your body. Amputees, for example, would have disturbed proprioception as a consequence of their injury.

Start Rehabilitation Early! 

Early rehabilitation hastens recovery after ankle sprains [3]. Recent evidence suggests that early movement by range-of-motion exercises and isometric/isotonic strength exercises improves healing. Or in medical jargon: a study that found early mobilization leads to a beneficial orientation of collagen fibers compared to an immobilized ligament [4].

Remember grade III ankle sprains? This was the most severe kind of ankle injury. Well, for grade III ankle sprains, 7-14 days of immobilization (using a brase or orthosis) assisted by crutches may be needed if you’re in constant pain. Oral NSAIDS are useful for pain relief and reduce inflammation. Remember, decreasing inflammation was goal #1 of ankle sprain rehabilitation.

There are four phases of ankle rehabilitation:

  1. Manage pain and swelling
  2. Restore range of motion
  3. Begin muscle strengthening
  4. Regain full strength, functional rehabilitation, and return to normal activity


Ankle Bracing and Orthotic Therapy

Orthotics is a medical specialty that designs and applies orthoses – devices used to modify the structure or function of the musculoskeletal system. An example of an orthosis is an ankle brace.  Ankle braces come in three flavors: I) lace-up, II) stirrup, or III) an elastic configuration.

What are ankle braces for? They provide mechanical stability to the injured area and facilitate the healing process. Orthosis has a number of advantages: cost-effectiveness, ease of use, and you can do it yourself at home (you don’t need assistance from a medical professional to apply it!)

Orthotic therapy has been shown to enhance joint position sense, provide added stabilization, support, and sensorimotor feedback during exercise, improve balance after injury, reduce postural sway, fatigue and pain perception and protect against future injuries without significantly affecting athletic performance.


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Tennis Elbow : Causes and treatment

Tennis Elbow

Tennis elbow is a general term for Lateral Epicondylitis, pain arising from outer side of elbow. This condition is not just limited to tennis players but can be seen in other racquet sports and activities such as typing, painting or plumbing. It is an overuse injury which gets worse over time if neglected. Onset of symptoms can be sudden but majority have a gradual pattern. The area affected is around the lateral epicondyle (outer bony prominence of elbow), from where majority of the forearm muscles originate.

Increase in load or duration of repetitive activities, involving wrist and forearm muscles can lead to micro tears/inflammation (tendinosis) of tendons. Prolonged typing, using screwdriver, racquet sports, painting are common examples where forearm muscles are used repetitively for prolonged duration. Initial symptoms can be pain, tenderness or feeling of tightness on the outer elbow.  As the condition worsens, pain becomes more or less constant and gripping becomes weak.

Similar condition but occurring at inner side of elbow is called as Golfer’s elbow or Medial epicondylitis. Symptoms would be around inner bony prominence of elbow (medial epicondyle).


  • Activities involving repetitive use of wrist, e.g. typing and racquet sports.
  • Weak and tight forearm muscles
  • Poor sporting/work technique
  • Equipment fault – grip size of racquet or cricket bat or change in string tension of racquet
  • Poor workplace setup
  • Increase elbow joint stiffness

Treatment options – Next page

Cervicogenic Headache : Causes & Treatment

Cervicogenic headache

There are many kinds of headache, which people experience ranging from migraine, tension or sinus headache. Cervicogenic headache is one type of headache which is often misdiagnosed and never gets treated the way it should be.

Cervicogenic headache, as the name suggests, originates from neck (cervical spine) especially the sub occipital area. The sub occipital area refers to the upper back of neck just below the occipital region of the head. Disorders affecting the neck muscles, joints or nerve can lead to this kind of headache.

Nerves which supply the upper neck also supply the areas in head and face. That’s why it is a secondary headache, referred/caused by a neck lesion or disorder.

Sign and symptoms

Usually the pain starts in the neck as a dull ache, which gradually leads to the head. Aggravating Factors may include prolonged sitting or lifting heavy things with a poor posture. Upper neck area might be tender to touch in people suffering from this condition. Apart from pain patient can experience stiffness in the neck, dizziness, nausea and light headedness.


Activities or posture which causes stress on the neck, especially upper neck can result in cervicogenic headaches.

  • Poor posture (slouched posture, forward head posture)
  • Working on computer for prolonged hours
  • Heavy lifting activities with poor posture
  • Trauma (e.g. whiplash)
  • Increased upper body stiffness/ limited movement
  • Poor breathing technique
  • Stress
  • Improper work desk setup


Get a proper diagnosis done by a physiotherapist or an orthopedic

In most of the cases conservative treatment does the trick.

  • Joint mobilization
  • Soft tissue massage
  • Posture correction
  • Correcting muscle imbalance around neck and upper body area
  • Stretching exercises for neck and pectorals
  • Strengthening exercises for neck and upper back muscles
  • Deep neck flexors retraining
  • Improving thoracic/rib cage mobility
  • Activity modification
  • Correcting workplace setup and sleeping position
  • Improving breathing technique
  • Tapping

Rehab Mantra
Stay Fit. Love Life


Shoulder Impingement : Simplified

Shoulder Impingement – Causes & Treatment

The term impingement itself explains some kind of pinching or compression in shoulder joint. Most common location of shoulder impingement is under the sub acromion arch followed by less common sub coracoid impingement.

Sub acromion arch is formed by clavicle (collar bone) and acromion process of scapulae (shoulder blade). The space below sub acromion arch comprises of one of the rotator cuff muscle (supraspinatus) and a bursae which sits over the head of humerus (arm bone). If the space between sub acromion arch and head of humerus decrease it causes compression and irritation of supraspinatus muscle and the bursae.


It is more common in middle aged group but can also be seen in active sporting individuals at young age. Usually, the symptoms are pain, stiffness and clicking. Pain is worse with overhead arm movements and sleeping on the affected shoulder. Location of pain is around tip of the shoulder and might refer down till mid arm on outer side. Hand behind back might also be painful in some cases.

In sub coracoid impingement the affected muscle is another rotator cuff muscle (subscapularis). Location of symptoms is more in front of the shoulder as compared to subacromion impingement.


  • Poor posture – protracted shoulders, thoracic kyphosis (hunch back)
  • Stiff and decreased mobility in thoracic area
  • Altered position and movement of scapula
  • Tight and overactive pectorals muscles and deltoids
  • Weak rotator cuff muscles and scapular stabilizers
  • Repetitive overhead movements
  • Poor sporting technique
  • Involvement in activities performed away from body (painting , desk work)
  • Type II and Type III acromion (Curved or hooked acromion)
  • Development of  a bone spur on front or side of acromion


 Conservative treatment

  • Posture correction
  • Ergonomic advice – workplace setup
  • Strengthening scapular stabilizers and rotator cuff muscles
  • Stretching exercises for tight muscles(e.g.: pectorals)
  • Soft tissue mobilization
  • Joint mobilization
  • Sporting technique correction
  • Improving overall core strength and control to reduce stress on shoulder in activities like throwing, smashing.
  • Taping
  • Icing to reduce inflammation
  • Correcting sleeping position


Rehab Mantra
Love Life. Stay Fit


Plantar Fasciitis : Most common cause of heel pain

Plantar Fasciitis

Plantar fasciitis is one of the most common conditions leading to heel pain. It is commonly seen in people who spend long hours standing. Plantar fascia is a thick fibrous tissue which runs from heel to toes and is responsible in maintaining the arch and overall shape of the foot. Excessive forces on plantar fascia causes micro tears and degeneration which leads to inflammation and pain. Pain is worse early in the morning and after prolonged hours of sitting or standing. Location of pain is usually at the heel but in some cases it can be present at the arch of the foot.


  • Jobs involving prolonged standing
  • Weak and tight foot and ankle musculature
  • Stiff ankle joint
  • History of ankle sprain
  • Overweight
  • High arch or flat foot type
  • Improper footwear with reduced support

Treatment options:

Get a proper diagnosis done by a physiotherapist or an orthopedic

  • Conservative treatment
  • Injection treatment (cortisone shot)
  • Shock-wave therapy

Conservative treatment:

  • Stretching exercises for plantar fascia and calf muscles (see pics 1,2,3 below)
  • Ball roll on plantar fascia (see pic 4)
  • Foam rolling on calf and hamstrings to improve flexibility
  • Strengthening exercises of foot and leg to improve shock absorption
  • Icing over the inflamed area
  • Ankle joint mobilization
  • Soft tissue mobilization
  • Wearing proper footwear with good arch support
  • Avoid walking barefoot
  • Use of night splints to keep muscles and fascia in stretched position
  • Tapping helps supporting the foot and reduce strain on Fascia
  • Custom Insoles or orthotic devices to correct foot biomechanics if required

Plantar Fascia stretch


Pic 1

Calf Stretch


Pic 2 – Bend Knee calf (Soleus) stretch


Pic 3 -Straight Knee (Gastrocnemius) Stretch

plantar fasciitis

Pic 4 – Ball roll on plantar fascia


Rehab Mantra
Stay Fit. Love Life


Tips to prevent and treat Osteoporosis

Tips to prevent and treat Osteoporosis

Osteoporosis is a disease in which the quality and density of bone is reduced and the bone becomes porous. The major risk in osteoporosis is getting a fracture which affects one’s mobility and independence. There is a reduction in bone mineral density which makes it susceptible for fractures. There are many contributing factors in development of osteoporosis and one of them is lack of physical activity. Regular exercise is important in prevention and treatment of Osteoporosis.

Osteoporosis is diagnosed through BMD (Bone Mass Density) testing. The most common technique used for testing BMD is DXA scan but there are also other test methods available.

Exercise and Bone Strength

Bone grows stronger in reaction to forces acting on it and exercise increases these forces more than normal. Many studies have indicated that around the age of 30 – 35 years, bone reaches its maximum density and strength. This explains why regular exercises done before 30 – 35 years of age are important for maximizing bone strength. And those who continue exercising in their middle age and beyond reduce the risk of acquiring osteoporosis, as it slows down the bone loss with aging.

Exercise as treatment for osteoporosis

By now we know that exercise is important for bone strength, which is why exercise is an important part of treatment for osteoporosis. People suffering from osteoporosis are prone to fractures in cases involving falls or other high impact incidents. Osteoporosis can also lead to spinal fractures following bending, twisting or compression of the spine and also from postural factors. As you grow older and get caught up with Osteoporosis, your upper back gets hunched easily, which thereby increases compressive forces at spine and can result in fracture.

Weight bearing aerobic exercises like jogging, marching, brisk walking and dancing are a good way to target osteoporosis. Apart from these exercises, balance and muscle strengthening exercises are also important. Muscular strength and balance helps in fall prevention. Strengthening of back muscles helps in supporting spine and reduces chances of spinal fractures.

Before you start

It’s important to undergo a medical health screening and risk stratification, for a person who has been diagnosed with osteoporosis and wants to start exercising. Once the risk stratification is done, an optimum exercise plan is prescribed by the health care professional.

Special consideration

Patients with osteoporosis should avoid high impact and explosive movements. Movements involving bending, twisting and compression at spine should be avoided. A low to moderate intensity controlled activities are prescribed which do not cause pain.

Frequency of weight bearing exercises can range from 3 – 5 times a week with 2 – 3 sessions of resistance training per week. Resistance exercises can be performed using light weights, exercise bands or tubes, whereas balance exercises should be a part of every exercise session and can also be performed separately. Examples of balance exercises are single leg balance supported/unsupported or heel to toe walk.

Rehab Mantra
Stay Fit. Love Life


All You Need To Know About Knee Pain – Part – 2

This article is in continuation to the previous knee pain article. If you missed the previous one, click here to read.

Meniscus degeneration/impingement/tear



Medial and lateral meniscus. Courtesy Grays anatomy


Meniscus is a horseshoe shaped cartilaginous structure present in knee. There are 2 meniscus in each knee – medial meniscus and lateral meniscus. They act as shock absorber for the knee joint and also help in reducing friction between the joint.

Injury to meniscus can cause pain, swelling, clicking, limited range of motion and knee joint dysfunction. Meniscus can be affected by overtime degeneration, impingement due to change in knee mechanics, or tear from an injury or trauma.


  • Poor lower limb mechanics
  • Deep squatting movement
  • Forceful pivoting or twisting movement
  • Weak knee musculature


  • Get a proper diagnosis done by a Physiotherapist or an orthopedic
  • In suspect cases patient have to undergo MRI investigation
  • Know what are the contributing factors to your problem and start working on them
  • Strengthening knee musculature
  • Change in ergonomics and activity modification
  • Electrotherapy
  • Icing

** Meniscus tear cases have to undergo surgery if meniscus doesn’t heal and symptoms persist. Depending upon the age, physical activity level and type of tear in meniscus the surgery is decided – meniscectomy (removal of torn part of meniscus) or meniscal repair (stitching the torn area)


Knee ligament injury


Pic showing all 4 ligaments. Courtesy Grays anatomy


There are 4 main ligaments in a knee joint. They all provide stability to the knee joint in different directions

  • ACL – Anterior Cruciate Ligament
  • PCL – Posterior Cruciate Ligament
  • MCL – Medial Collateral Ligament
  • LCL – Lateral Collateral Ligament


Three different grades of injury to ligament are:

Grade 1 – Strain to ligament (overstretched) with no tear

Grade 2 – Partial tear

Grade 3 – Complete tear


  • ACL – Anterior Cruciate Ligament

This is one of the most commonly injured ligament in knee. The function of ACL is to prevent forward gliding of tibia (leg bone) on femur (thigh Bone) and internal rotation of tibia.


ACL injuries are mostly seen in sporting population. Multi-directional sports contact or non-contact which requires lots of cutting movements and impact like (soccer & rugby).

Depending on grade of injury and sporting background, conservative and operative treatment is decided.

Grade 1 & 2 can be managed conservatively but for grade 3 athletes have to go for surgical reconstruction.

Conservative treatment non- operated ACL

Initial phase

  • Rest icing
  • Bracing if suggested by your attending physiotherapist or orthopedic.
  • Electrotherapy

Later phase

  • Muscle strengthening Specially Hamstring muscle as they support ACL
  • Proprioceptive/ joint awareness exercises
  • Taping

Post op management

Post op rehab will last from 6 to 9 months depending on individual base athletic level.

Your Physiotherapist will plan out your rehab program which will have different phases such as 0-6 week’s phase 1 and so on. Each phase will have its goals, duration, exercises and treatment techniques. The duration of each phase can change during the rehab depending on your progress.


  • PCL – Posterior Cruciate Ligament

It works exactly opposite to ACL. It prevents backward gliding of tibia (leg bone) on femur (thigh bone).

Commonly injured due to fall on knee when there is impact on the tibia (leg bone).

Grade 1 & 2 PCL can be managed with conservative treatment and heals better. But for Grade 3 surgery is required.

Conservative treatment would be same as above except

  • Brace to lock knee in extension for initial 4- 6 weeks
  • Focus more on Quadriceps strengthening than hamstring

Post-operative management would bit longer than ACL lasting around 12 months.


  • MCL – Medial Collateral Ligament

The function of MCL is to provide stability from the inner – side of the knee joint. It holds the joint and acts against valgus stresses (which will tend to separate the inner- side (Medial) of the knee)

MCL gets injured if the landing is improper or there is a traumatic force directed inwards from outer (lateral) side of the knee for e.g, getting kicked hard.

All 3 grades of MCL can be treated conservatively. If there is involvement of other ligaments or meniscus, or if there is an ongoing instability after completion of conservative treatment, then patient needs to have surgery.

Conservative treatment

  • Icing
  • Electrotherapy
  • Bracing for grade 2-3
  • Strengthening exercises focus more on hip abductor muscles
  • Proprioceptive/joint awareness exercises
  • Taping


  • LCL – Lateral Collateral Ligament

Runs parallel to MCL on outer side of the knee and functions are just opposite to MCL.

It works against varus forces (which will tend to separate outer side of the knee).

If there is excessive varus forces on the knee from direct trauma/blow, the LCL gets injured.

Mostly LCL injuries are treated conservatively. Only in rare cases where symptoms are ongoing, surgery is considered.


Conservative treatment

  • Icing
  • Bracing
  • Strengthening exercises
  • Proprioceptive / joint awareness exercises
  • Taping


Rehab Mantra
Stay Fit. Love Life


Foam Roller – A friend worth having

Foam Roller

Muscle tightness is a common thing, be it a sportsperson or someone who has a sedentary lifestyle. The only difference would be in the muscle group getting affected with respect to their sport and lifestyle. It will always be the more dominant muscle group used in any sport or activity prone to tightness. For example, a runner would develop tightness in leg muscles, a kayak will develop tightness in upper body and a desk bound person would develop tightness in upper back and neck. Many of the musculoskeletal conditions such as knee pain, hip pain, neck pain, muscle/tendon injuries and many more are a result of muscle tightness.

Muscle tightness and trigger points, commonly known as “Knots” in the muscle, are a result of activities or compensation happening in our bodily movement through our sports or lifestyle. Both have same contributing factors such as training load, poor posture, lifestyle factors, hydration, lack of rest, stress and diet. When these factors increase and exceed our ability to recover, it results is tight muscles and trigger points.

The most commonly used method to target muscle tightness is stretching and massage. Stretching is one of the easiest and cost effective techniques known but it’s also the most ignored and incorrectly done technique at the same time. In many cases only stretching is not sufficient to target muscle tightness. Massage is a convenient and relaxing technique but at the same time costly and time consuming. Not all types of massage target your muscle tightness until they are deep tissue massage or sports massage.

Foam Roller

This is where Foam Roller comes in handy as an easy and convenient way to work on the tight muscles. Foam rolling is a self-administered technique, which is both time and cost effective.

Continue Reading – frequency, duration and technique

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