So, we have discussed how the poor 'design' of the knee joint means it is prone to various injuries and dysfunctions, but what does that mean in your everyday life?

Here we will consider the anatomy of the knee a bit further, and discuss some of the ways our knees can give us grief.

It is important to remember that, like most of the other joints in the body, the knee requires its neighbours to be doing a relatively good job in order to perform its own.

So the knee joint consists of the tibiofemoral articulation, between the shin bone and thigh bone, and the patellofemoral joint, between the kneecap and thigh bone.

Both of these will tend to cause pain around or behind the kneecap, at the front of the knee.
So what about pain on the sides, or back, of the knee?

Other sources of posterior knee pain include the nerves in the area, whether from local insult or irritation in the lumbar (low) spine; the posterior cruciate ligament, or PCL, or the blood vessels in the area (e.g. DVT or deep vein thrombosis, or aneurysms).  Interestingly, the patella may also refer pain to the posterior knee.

Note: Another source of pain (in all aspects of the knee) could also be bursitis.

In the next blog, we will consider pain on the sides of the knee - in medical-speak, the medial (inside) and lateral (outside) aspects.

​As with the last blog, we will assume that your low back pain is mechanical, and that it has been screened by a suitably-trained healthcare professional.
So, what are some specific exercises that might help with your low back pain?
Again, please do not perform any of these exercises if they are actively painful (some discomfort is ok).

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​Stretching, particularly when done for rehabilitation or healing (as opposed to mere flexibility for e.g. dancing or martial arts), should always be in pain-free range of movement.   

Please note that discomfort is unavoidable, especially after injury, it is pain we want to avoid.  Go in the direction of the intended stretch, and when you feel the area you are trying to target start to engage, stop.  You do not need to go as far as you can, or put on a brave face and ignore too much discomfort. 
Pain is a warning signal, and while the body gets a bit over-zealous in its protectiveness at times, it is always worth listening to your pain (don’t ignore it or completely give in to it).  

​Current thinking about stretching seems to indicate that gains in flexibility are not due to increasing the length of the muscles (referred to as plastic deformation), but rather due to an alteration in sensation (i.e. the nervous system’s feedback and control systems)[i].  So if we try to take a stretch too far, we are not gaining anything, because it’s pretty much impossible to overrule your spinal cord (imagine trying to not jerk your hand away when you are burned unexpectedly!). 

​If you have ever tried to stretch a muscle out, and get that sort of ‘quivering’ feeling in it; that’s the stretch reflex.  In response to ‘stretch’ signals from the tissues involved, your central nervous system (i.e. brain and spinal cord) are sending back instructions to ‘hold on and protect’; so no matter how long you hold that stretch, you are not going to get any relaxation in the muscles.
So stretch within your limits.

Another question I get asked all the time is how to hold stretches for.  Again, this is more about you than it is about me!  What is the aim of the exercise?  If it is to relax the tissues off, then you want to achieve that goal, right?  So if you have been stretching for fifteen seconds, and haven’t felt any release, then continue…!  One caveat: if you get to about a minute, and haven’t felt any ease, you may be overstretching the area, even without the telltale ‘quivering’ of the stretch reflex.  If that is the case, come off the stretch, get a bit of movement through the area, and either go back in again but more gently this time; or use a more dynamic technique (taking the joint and muscles through their range of movement repeatedly, also known as mobilisation), which is another fantastic way of improving function and decreasing pain (and the topic of yet-another future blog!).  

If you want a slightly more in-depth look at the science of all of this, I strongly recommend The Science and Practice of Manual Therapy by Eyal Lederman, a British osteopath.  It’s a bit dense for the layperson, but riddled with references and research that you can follow up if you like.

Depending on the intent/way you go about these, many of these exercises can be performed as a sustained stretch or a dynamic mobilisation.  Both of these, but particularly the latter, are also good for improving your proprioception (your sense of where you are in space), which is crucial for neuromuscular control, that is, coordination.
​
So on with the exercises…!

1. Knee hugs / Double knee to chest

​Lie on your back.
Bring both knees up towards your chest.
Perform both as a gentle ‘pump’ (30+ times, as a dynamic mobilisation), then as a gentle stretch (hold for 10-30s).

​2. Single knee to chest
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This stretch targets the back of the upper thigh, and gluteal region, rather than the low back itself. Gently draw one leg up to your chest while leaving the other flat on the floor.  If necessary, place a small pillow under the extended leg for comfort.
You should feel the stretch in the thigh and buttock region.  Try moving the leg from side-to-side slightly – this will target different muscles in the hamstring group.  Again, you can perform this as a sustained stretch, or as a more dynamic movement.

​2a. Single knee to chest - variation
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If bringing the leg up with a bent knee targets the upper fibres of the hamstrings, and using a straight leg targets the lower (and back of the knee, and top of the calf), then it stands to reason that bringing the leg up partway, and then straightening the knee, can target somewhere in between.  As before, try drawing the leg up further out to the same side as the leg (to target the inner muscles) or across your body slightly (to target the outer muscles).

3. Gluteal (buttock) stretch

This is a particularly relevant area to much low back pain.  Even more so than with the hamstrings, there are a heap of muscles in the buttock area. This means that varying the angle at which you take your knee will have even more of an impact on where you feel the stretch.  Try to find the tightest/sorest bit, this is likely where needs it most!  A good way of doing this is to take the knee around in a gentle arc, and feel for the bits that feel most restricted and/or uncomfortable. As before, do not overstretch, just take the leg over until you start feeling the tissues engage in the affected area(s).

4. Piriformis (hip rotator) stretch
​
Cross one ankle over the other knee.  Gently bring that knee towards you until you feel a stretch deep in the buttock region.
If you have extremely limited hip and/or knee range of motion you may find this difficult, so may choose to have the other leg flat on the table/bed (as in the top picture in diagram to the [right].  Otherwise, you may start from the lower of the pictures on the [right], or even seated (as below).  Try to avoid bending your whole body towards your knees, remember, this is a stretch targeted towards the hip rotators, not your mid/upper back!
​Also remember to repeat on both sides.

5. ITB (side of thigh and gluteal region) stretch
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Lying on your back, cross one (in the diagram, the left) leg over the other, and use it to draw the right thigh and leg across the midline of the body (to the left, in this instance).  Try and ‘hook’ the calf over the outside of the thigh, this will engage the thick fibrous band that runs between the hip bone and knee and make the stretch more focused.  Again, try to think about where you are targeting – in this instance, the very side of the gluteal/hip/thigh region.  Once your back starts to twist round and leave the floor/bed, you are no longer stretching the intended area any more, you are now stretching the lower back.  This is not necessarily a bad thing, but try to stay focused.  If you want to stretch the low back into rotation, there are more effective (and specific!) ways of doing this.

6. Kneel to prayer
​
You obviously need to have a certain range of motion in your shoulders, knees and ankles, as well as hips and low back, for this stretch to be feasible.  Do not do any stretch or movement you are unhappy with.
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From a kneeling position, sink your weight back onto your heels, while stretching your hands as far forward as possible.  This rounds (or flexes) the low back (lumbar spine) while straightening (or extending the upper-mid back (thoracic spine).  

From here, a nice variation is to ‘wiggle’ your shoulders up and down, to introduce some rotation and sidebending into the spine.
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6a. Kneel to prayer (variant)
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Another variant that can be very useful when one side of the back is tighter/sorer than the other is to grasp on object on the opposite side.  This will make the stretch much stronger where needed.

7. Seated combination stretch
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A nice general stretch that can be played around with to target pretty much any part of the mid or low back.  Essentially, imagine you are trying to reach down and touch the floor on the outside of your knee and leg.  Changing the amounts of rotation, sidebending and flexion (forwards bending) will change exactly where in the back you will feel the stretch.  As long you are gentle and do not push anything too far, you are extremely unlikely to injure yourself, so feel free to play around with the components a bit.

8. Quad and hip flexor stretch
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Like the muscles on the back of the thigh (the hamstrings), the quadriceps(or ‘four-headed muscle’) on the front of the thigh also can play a big role in maintaining lower back dysfunction.  Unfortunately, due to the anatomy of the area, it is difficult to target the whole muscle group.  Most stretches will be felt predominantly in the central, superficial muscle (rectus femoris, or ‘straight muscle of the thigh’, if you are interested!).  This muscle attaches to the front of the pelvis, so if you stretch it, it will try to tilt the pelvis forward, increasing the arch of the lower back.  To prevent this, make sure you ‘tuck your tailbone in’, or slightly tighten your abdominal muscles to help keep the low back nice and neutral. 

The human hand is such a sensitive and specialised structure; anatomically complex and strategically engineered by time and nature, having the ability to create such varied and precise movements.  ​

Our hands contain so many weird and wonderfully specialised sensory cells that function to collect information via touch, position, pressure or temperature in relation to our current surroundings. 
The information is continuously relayed to our brain where the appropriate networks of neurons pass precise instructions via the spinal cord, neural networks and down the nerves in our arms to the muscles responsible for generating the gestures we require.

This intricate sensory/motor control system is continuously checking itself and making small adjustments.  We could be typing away in an attempt to conquer the monstrous, multi-headed hydra-like inexhaustible queue of office emails, operating an electric sander to remove tired paint in an effort to restore an antique to its former glory or just the general lifting and carrying as we go about our everyday activities.  

With all these moving parts and capabilities made possible with our hands, we can create works of art and express ourselves.  .  

​When we’re limber and feeling good, we barely notice how much we rely on and require that normal baseline level of ease.  
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However, when things don’t go as planned and if an injury occurs, whether caused by simple tasks or other health conditions, the loss of our normal function is very apparent.  

One possible common condition responsible for hand pain is Carpal Tunnel Syndrome (CTS). 
It affects 4-5% of the population (1) and can be quite disruptive, affecting a variety of people, from pregnant women, office workers and the elderly, to tradesman and others who work directly with their hands. 

It seems to be caused by multiple factors, which could include (2);

Many of the structures that operate the hand are sandwiched together and must pass through a channel at the wrist (the carpal tunnel) bordered by sturdy carpal (or wrist) bones and ligaments, particularly the transverse carpal ligament as the ‘unyielding ceiling’. 

Most of the space in this channel is occupied by rigid tendons that control finger movements, leaving only a small potential space for the squishy median nerve, which can be easily compressed here (1, 2). 

​Being the main sensory and motor supply for the palm of the hand, a squished median nerve can result in the frustrating and restrictive experience that Carpal Tunnel Syndrome is known for.  

If you are experiencing signs and symptoms such as those described, the best course of action is to consult your GP or manual therapist as early as possible. 

This could limit the impact on your everyday life activities and the need for any interventions in future. 

If CTS is left to progress, a cortisone injection may be beneficial. It was reported that approximately 75% of patients experience improvement following this procedure (4, 5).

Failing that, a small surgical procedure can be recommended.  It involves releasing the transverse carpal ligament (the mentioned ‘ceiling’ of the carpal tunnel), creating more space for the muscle tendons to glide together at the wrist, alleviating the direct pressure placed on the median nerve. 
Luckily surgical intervention for CTS has a very high success rate, with over 90% of patients reporting alleviation of symptoms (6, 7, 8),

However, it is important to remember that as far as your body is concerned, there is no such thing as 'minor' surgery! Even in the best case scenario, the carpal tunnel now has (even more rigid and unyielding) scar tissue around it, which can cause other issues.

So the best thing to do is avoid any intrusive interventions.

And it’s entirely possible!

Along with osteopathic techniques for treatment, there are some simple and inexpensive things to try, some examples include (2, 3); ​

Developing an understanding of how and why this is happening; knowledge alone can alter the experience and help settle the worry. 

Being informed is a powerful position to be in as you can select the best course of action and knowing what the possible benefits or disadvantages of the available options are. 


​CTS can be debilitating and impact negatively on your health and wellbeing and day-to-day activities.  That’s why getting treated as soon as possible is so important.  

By finding the right combination of strategies that are best for you, your osteopath can get you moving and back into your daily routines, whether it be gardening, writing, creating a masterpiece, or tackling a home renovation. 
Not to mention going back into battle with inexhaustible email queues – the multi-headed hydras!

References:
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1. Aboonq, M.S., 2015. Pathophysiology of carpal tunnel syndrome. Neurosciences, 20(1), p.4.
2. Siu, G., Jaffe, J.D., Rafique, M. and Weinik, M.M., 2012. Osteopathic manipulative medicine for carpal tunnel syndrome. The Journal of the American Osteopathic Association, 112(3), pp.127-139.
3. Scott, K. and Kothari, M.J., 2005. Evaluating the patient with peripheral nervous system complaints. The Journal of the American Osteopathic Association, 105(2), pp.71-83.
4. Girlanda, P., Dattola, R., Venuto, C., Mangiapane, R., Nicolosi, C. and Messina, C., 1993. Local steroid treatment in idiopathic carpal tunnel syndrome short-and long-term efficacy. Journal of neurology, 240(3), pp.187-190.
5. Gelberman, R.H., Aronson, D.A.V.I.D. and Weisman, M.H., 1980. Carpal-tunnel syndrome. Results of a prospective trial of steroid injection and splinting. The Journal of bone and joint surgery. American volume, 62(7), pp.1181-1184.
6. Schmelzer, R.E., Della Rocca, G.J. and Caplin, D.A., 2006. Endoscopic carpal tunnel release: a review of 753 cases in 486 patients. Plastic and reconstructive surgery, 117(1), pp.177-185.
7. Quaglietta, P. and Corriero, G., 2005. Endoscopic carpal tunnel release surgery: retrospective study of 390 consecutive cases. In Advanced Peripheral Nerve Surgery and Minimal Invasive Spinal Surgery (pp. 41-45). Springer, Vienna.
8. Park, S.H., Cho, B.H., Ryu, K.S., Cho, B.M., Oh, S.M. and Park, D.S., 2004. Surgical outcome of endoscopic carpal tunnel release in 100 patients with carpal tunnel syndrome. min-Minimally Invasive Neurosurgery, 47(05), pp.261-265.

 

NOTE:  This blog post is essentially a copypasta of the page on the same topic; but it is so important a subject I wanted to make the information was available to all of our blog subscribers as well...

Low back pain (LBP) can be due to any one of a number of different causes. 

Obviously, stressing/straining the local muscles, ligaments, joints etc. will cause pain and discomfort, but as with the shoulder, other structures in the body are also capable of ‘throwing’ pain to a distant location. 

The kidneys, small intestine, colon/rectum, stomach, pancreas, spleen, gallbladder etc. are all known to cause low back pain. 
​Surprising few of the female readers of this blog, the ovaries and uterus (womb) are also more than capable of causing low back discomfort (especially at ‘that time of the month’ or during pregnancy); as are problems with the blood vessels, heart, various types of infection, cancers, and hormone disorders. 

Because of this, it is always important to have your back pain screened by an appropriately-trained healthcare professional, especially if you have noticed other changes before or after the onset of the pain.

For the purposes of this blog, we will ignore all of the slightly more esoteric factors, and instead focus on non-specific (or mechanical) low back pain.  As mentioned above, this is usually due to irritation of the moving parts of the spinal column, namely muscles, tendons, ligaments, vertebral bodies, intervertebral discs (the ‘shock absorbers’ between the vertebrae), and facet joints (the joints between one level of the spine and another).

Most mechanical low back pain resolves on its own, most often within 2-4 weeks.  However, that can feel like a long time when you are in pain!  So, what can you do to help speed that process up?

Such as osteopathy can help to alleviate the symptoms of low back pain.   This is largely done by influencing the central nervous system (your brain and spinal cord) rather than directly affecting the areas being worked on, but mobilising restricted joints, stretching out tight muscles, and improving blood flow to the affected areas, can all help to mitigate the impact of mechanical LBP.

This is such a big topic that I will only devote a few words to it here, saving the rest for another blog post.
Maintaining mobility and flexibility is one of the biggest things you can do to help prevent injury, but in the instance that it’s a little bit late (after all, you’re reading this looking for tips as to how to manage your existing low back pain), there is also a lot you can do now.  In general, the basic tenet is that movement is medicine, and both stretching to relax muscles and general mobilisation (taking the joints and muscles through their normal range repeatedly) can help significantly with your symptoms.  For further details, please see here.