Khan’s Mechanotherapy compliments Manual Therapy for Achilles Tendinosis!

Runners are at a 30 times greater risk of tendinopathy as compared to sedentary controls

as stated by Kujala et al. in the Clinical Journal of Sports Medicine 2005.


Achilles Tendinosis Pain is mediated by ‘neurogenic inflammation’ in response to collagen

injury NOT traditional inflammation!!  Therefore there is no prostaglandin release which is

what many NSAIDs target.  There is speculation that local nerve fibres release

peptides which starts the pathophysiological painful process.


Collagen fibre disarray is typical of mid portion Achilles Tendinosis:


Typical clinical features include a gradual onset, morning pain and stiffness,

pain that decreases with activity and recurs several hours after activity.


Thickening of the tendon and ankle or subtalar joint stiffness is also common.

Mobilization of the subtalar or ankle joints are typical manual therapy treatment

strategies with this condition.  Mechanotherapy or Mechanotransduction is another

option for treatment.


The process of Mechanotransduction promotes cells to convert mechanical stimuli into biochemical responses to repair tendon, muscle, cartilage and bone.


Mechanotherapy involves the use of eccentric training drills for increasing the tendon

strength which stimulates tenocytes to produce collagen, reversing the tendinosis cycle.


Here is a sample 12 week Heel Drop Program: (Fahlstrom et al. 2003)


180 drops/day

3×15 reps twice daily, 7 days/ week for 12 weeks

Eccentric only Gastrocnemius Drop and Soleus Drop (knee flexed 45 degrees)

raise back onto toes using other leg or arms and progress until pain-free, then add load.


Collagen production is the key cellular phenomenon determining recovery from tendinosis

and one of the best ways to promote tissue repair is through exercise.


To Your Manual Therapy Success.


Please comment and share


How this Athletic Therapist Manages Concussions?

Concussion management is a hot topic these days and as an Athletic Therapist I have had my share of challenges in managing concussions.

I have interviewed an Athletic Therapist who has dealt with many concussions over the course of her career.

She is an active member in concussion management and is very passionate about spreading the awareness of managing this very serious sport injury to athletes, coaches parents and health providers.

Find out how this Athletic Therapist manages concussions as she gives her insight with a step by step process:

For Complimentary Access to the interview and MP3 Download (valued at $47) click on the link below:



Theo Fleury hosted a Segment on Concussions on “The Current” last week

Theo Fleury hosted a special edition of The Current on CBC. In parts two and three of the show the epidemic of concussions in hockey and the changing demographics of Canadian hockey is discussed.

Below is the link you can use to access the his interesting interview.



A Conversation about Concussions

In my last blog post I talked about my clinical observation
of cervical facet joint dysfunction post concussion.

Although neck related symptoms are fairly straightforward to manage,
the real challenge is managing the concussion itself and determining
when it is safe for the athlete to return to their sport.

To help shed some light on concussion management I will
be conducting a FREE teleseminar.  I will be interviewing an expert
who is involved in the management of concussions regularly.

But I need your help with this…

In order to get the most out of this interview,
I would like you to please post a comment and answer one question:




Post your QUESTION in the comment section and I will
be compiling all your questions in preparation for the interview.

Once I have your questions compiled I will give you the details
for the interview.

Concussions and Manual Therapy??

Concussions have gained alot of attention in the media
these days and is one of the most challenging injuries
to manage in sport today.

It is not uncommon for the Athletic Therapist, Sport Physician
and the Neuropsychologist
to lead and supervise the management
of concussions.

Certainly in my clinical practice I have also seen an
increase of athletes sustaining concussions and seeking
help for it. 

My role as a clinical therapist in managing concussions
has surrounded the associated neck dysfunction that I have
noticed to accompany these mild head injuries.  Since the
mechanism of injury typically involves some sort of head
trauma with associated cervical spine whiplash, it certainly
makes sense that there would be some upper cervical joint
dysfunction following a concussion. 

It is quite plausible that some of the headaches that athletes
complain about post-concussion could be stemming from upper cervical
spine facet joint dysfunction.  Lately, I have treated 3 athletes who
are post-concussive and have neck related pain and restriction of movement.

I have noted that in all 3 of these athletes the OA joint and
C2-3 facet joint were involved as areas of joint dysfunction.  

This is where I think manual therapy techniques have a role
in helping to manage concussions.  After appropriate
mobilisation techniques were performed to restore the
movement restrictions in my 3 athletes, they reported
improved mobility and less headaches and pain.  They still
reported headaches due to the concussion itslef.

The only research that I have been able to find on this specific
topic was a study done by J Treleaven, G Jull, L Atkinson on
Cervical Musculoskeletal Dysfunction in Post-Concussional Headache.
Cephalalgia August 1994 14: 273-279.

Their results suggest that a “high proportion of post-concussion headache
sufferers have physical signs of cervical musculoskeletal dysfunction,
particularly in the upper three cervical joints, and support the need
for a precise and sensitive physical examination of the cervical spine
in patients complaining of persisting post-concussion headaches.”

Has anyone else observed this?

Have you found any research to support this clinical observation
that I am witnessing??

Please post a comment and share your insights!

Low Back Pain and the Hip Joint

Happy New Year!

I hope 2011 brings you health and happiness…

So I wanted to write a post about a client who
came to see me for low back pain.

Quick History:
57 year old female with chronic nagging low back pain,
hyperlordosis and an avid golfer who especially complains
of pain with walking.

I treated her lumbar spine for segmental flexion restriction
using manual therapy techniques, specifically unilateral
flexion mobilisation of the right L4-5 and L5-S1 facet joints.

Also treated her for a presenting right sacroiliac upslip
using long leg distraction manipulation of
the right sacroiliac joint.

Her lumbar spine mobility and sacroiliac joint function both
improved however she still continued to report lumbar pain
especially after any walking activites.

This prompted me to look more closely at her gait pattern as
this is when she complained of her pain. I noticed that she
had a decreased left stride length and decreased left hip
extension on the right.

So I looked at her hip joint more closely and found her to
have restricted hip extension and external rotation. Manual
therapy assessment of her hip joint revealed anterior capsular
restriction with inhibited gluteals.

Manual therapy treatment of her hip consisted of an anterior glide
joint mobilsation in an extension and external rotation quadrant.
I have included a picture below for your visual benefit.

After three treatments in this manner and supplimenting with
gluteal activation through a bridging exercise and
external rotation stretching, her back pain dissappeared.

The Lesson of this post:
Sometimes low back pain is secondary to a hip extension restriction.
The low back pain is due to the lumbar spine hyperextending
for the lack of hip extension during gait.
So look for it!

To Your Manual Therapy Success!


Low Back Pain and a Seated Unloading Exercise for your Sitting Clients

An interesting clinical pilot study was recently
published in The Spine Journal that looked at changes in lumbar
disc height before and after normal sitting with the use of
a seated unloading exercise intervention.

Fryer et al. (2010) used upright MRI to measure changes in height
and configuration of the lumbar discs after sitting and a chair-care
decompression exercise.

Their premise is that sitting is associated with loss of lumbar lordosis
disc compression and height loss which possibly increases the risk of
low back pain.  So they proposed a practical strategy for the sitting based
jobs to prevent lumbar flattening and perhaps low back pain.

MRI scans of the disc height were taken at various intervals:
before sitting, after 15 minutes of relaxed sitting, immediately after
the seated unloading exercise and again at the 7 minute mark after
the exercise.

Their limited anectodal findings indicate that the chair-care exercise
has an immediate effect on the sitting related low back pain through
a spinal decompression effect.

Below is a picture of the exercise:

it involves 5 seconds of unloading and 3 seconds of reloading

and repeating the sequence 4 times

Although the current study has several limitations this seated unloading
exercise may represent for the manual therapist a symptomatic and even
preventative intervention for sitting pain among sedentary workers.

Adapted from:
Fryer J, Quon J, & Smith F. Magnetic Resonance imaging and stadiometric assessment of the lumbar discs after sittingand chair-care decompression exercise: a pilot
study.  The Spine Journal 10 (2010) 297-305.

To Your Manual Therapy Success!



Does Manual Therapy Really Help Mechanical Neck Pain?

Yes it does….

Gross et al. 2007 report in their
systematic review of 84 randomized controlled
trials (RCTs) that there exists strong evidence
of being able to control mechanical neck pain.

However, a multimodal approach including stretching
and strengthening exercises, and mobilization and
manipulation techniques, was significant in
improving function and decreasing subacute and
chronic mechanical neck pain.

There was moderate evidence to support the use
of intermittent traction as a manual therapy
technique. This is especially true when combined
with direct neck strengthening and stretching
exercises for chronic neck pain.

Acute pain was defined as pain lasting
less than 30 days, subacute pain 30-90 days
and chronic pain as being greater than 90 days.

Clinically, I have found that when I have
incorporated exercise with manual therapy techniques
of the neck, pain and mobility significantly improve.

Adding in exercises like deep neck flexor
strengthening, and stretches of muscles like
Levator Scapula, Scalene Muscle group and
Suboccipital Muscle groups have been very
useful for my clinical practice.

For more detailed information on this topic,
I highly recommend to read the following article:

Gross et al. Conservative Management of Mechanical
Neck Disorders: A Systematic Review. 
The Journal of Rheumatology 2007; 34:3

To Your Manual Therapy Success!

Please comment and Share.

When Manual Therapy Techniques Are Not Enough – Part 3

Here is the final post for this series on elbow
muscle stabilization in facilitating the treatment
of Lateral Epincondylitis.

There are three important muscles to consider
retraining, especially after any Manual Therapy
Techniques have been performed to the elbow.

Elbow Muscle Stabilization Techniques:

Try these on yourself as you read along.

Anconeus Muscle Retraining Technique

Activation with tactile feedback,
Elbow flexed to 90 degrees, neutral, palpate
posterior/inferior to the lateral epicondyle.

Then resist extension with low effort in
pronation ( or supination)

Then perform eccentric elbow flexion and
during deceleration of elbow flex, anconeus activates.
Then stop midrange and maintain tension in anconeus.

Supinator Muscle Retraining Technique

Activation with elbow flexed to 90 degrees with a
neutral position, then resist low effort activation
of supinators.

Add deviation and move from radial to ulnar deviation
to facilitate the deep supinator fibres.

Pronator Quadratus Retraining Technique

Activation with elbow flexed to 90 degrees with a neutral
position, then reisist low effort contraction of pronation
while palpating at anterior distal radius.

Have the client manually self distract the distal
radial-ulnar joint with their thumb on anterior distal
radius and index finger on posterior ulna.

Have them actively pull the 2 bones back together while
resisting pronation with a low effort isometric contraction
with the wrist in a neutral position.

Add a power gripping progression with a low effort
ball gripping motion in neutral wrist.  This has an effect
on the palmar fascia which is continuous with Pronator Quadratus.

 I have used these very successfully clinically and have found
them to be especially useful with distal radial-ulnar joint
dysfunction at the wrist.

You may want to include some of these techniques to compliment
your Manual Therapy practice. 

Please comment, share and let me know if you

have any success with using these

Elbow Muscle Retraining Techniques.

To Your Manual Therapy Success

When Manual Therapy is not Enough, Part 2 of 3 – Ideal Elbow Movement Patterns

If I left you hanging from the previous post,
I do apologize. It has been a busy summer with
taking a medical diagnostics course, teaching,
family activities and life in general.

As a follow up to the previous post here are the
ideal elbow movement patterns using 4 base clinical tests.

So the next time you are faced with a client who presents
with lateral epicondylitis, try looking at these movement patterns
and observe for uncontrolled movement or “Give”.

Four Base Elbow Movement Pattern Tests:

(Try these on yourself)

1. Elbow Flexion – Extension Test
Neutral forearm - ideal movement pattern is without radial or ulnar
deviation or wrist extension or pronation

Pronated Forearm - ideal pattern is without wrist extension,
radial deviation, excessive pronation, glenohumeral external
rotation or glenohumeral adduction

Supinated Forearm - ideal pattern is without wrist flexion
and ulnar deviation, wrist extension with ulnar deviation,
glenohumeral external rotation, glenohumeral adduction

2. Pronation – Supination Test
ideal movement pattern is without ulnar or radial deviation,
GH ER/ADD or GH IR/ABD, elbow flexion or extension, thumb
flexion or extension.

3. Wrist Flexion – Extension Test
ideal movement pattern is without radial or ulnar deviation,
thumb flexion or extension, elbow movement, pronation or supination.

4. Finger Flexion – Extension
ideal pattern is without ulnar or radial deviation, excessive wrist
flexion or metacarpalphalangeal hyperextension or elbow movement

If uncontrolled movement or “Give” is observed then there may
exist a restriction at the elbow joint. If so, perhaps some manual
therapy techniques may be indicated, but it should also be
followed up with some elbow muscle stabilization exercises.

Part 3 will cover the elbow stabilization exercises.

To Your Manual Therapy Success.

Please comment and share with your colleagues!