Can strengthening my quadriceps help with my knee pain?


Can strengthening my quadriceps help with my knee pain?

What is the quadriceps muscle?

The quadriceps muscle is a group of four muscles (rectus femoris, vastus medialis, vastus lateralis and vastus intermedius) [1]. All four muscles attach into the patella (kneecap) through a common quadriceps tendon and attaches to the tibia (shin) via the patella ligament [1]. The rectus femoris muscle originates from the pelvic bone while the other three muscles originate from surfaces of the femur [1].


What does the quadriceps muscle do?

The anatomy of the quadriceps muscle acts to bend the hip joint and straighten the knee joint [1]. Additional to creating movement at these joints, the quadriceps muscle also functions to stabilise the knee joint during movement [2]. Joint stability during movement is compromised with weak quadriceps muscles, increasing the risk of damage to knee joint structures [2,3]. The quadriceps muscle also acts to absorb load and stresses applied to the knee joint [4]. Hence, weakness in the quadriceps muscles could result in abnormal loading and subsequent structural damage to joint structures, including menisci, ligaments, cartilage and bone [4,5].


Is quadriceps muscle strength related to knee pain?

Although knee pain may result from multiple factors including both biological and/or psychosocial, studies suggest that quadriceps muscle weakness can contribute to worsening knee pain [5]. Contrarily, greater quadriceps muscle strength has been shown to prevent further damage to knee joint structures [5,6]. It is also alluded to in research that a certain amount of quadriceps muscle strength is necessary to protect the knee from adverse loading [5]. Therefore, quadriceps muscle strength is shown to be strongly associated with knee pain and disability [7]. Interestingly, both the strength of the muscle contraction as well as the mass of the muscle contributes to the overall strength of the quadriceps muscle [8,9].  


Is quadriceps muscle strength related to knee injuries?

A common finding in research is that reduced quadriceps muscle strength is a common clinical finding and risk factor among individuals with or at risk of knee osteoarthritis [8]. Additionally, the progression of knee osteoarthritic changes has been associated with quadriceps muscle strength [5,6]. Weakness in the quadriceps muscle is also a risk factor for non-contact anterior cruciate ligament injuries as well as patellofemoral pain syndrome [9,10].


How can physiotherapy help?

1. Exercise therapy

Physiotherapists can provide a range of appropriate exercises specific to an individual’s condition and movement [11]. Though as stated previously, quadriceps muscle strengthening is crucial in the management of knee pain, it is by far not the only therapy required to ensure healthy knee joints. Research studies have demonstrated strong evidence to show that physiotherapy management based on exercise is effective in reducing knee pain and improving function [12]. Concurrently, individual adherence to these exercises is needed to optimise long-term improvements [11,12].

2. Manual therapy

Physiotherapists may also provide manual therapy in adjunct with an exercise-based management for knee pain. Manual therapy may include but not exclusive to soft tissue releases, mobilisation, dry needling and dry cupping. Studies have shown that manual therapy in addition with exercise is effective in relieving knee pain and physical disability in individuals recovering from an acute knee injury as well as individuals with more chronic conditions such as knee rheumatoid arthritis and knee osteoarthritis [12].


3. Motor control and plyometric training

Physiotherapists can also provide a range of exercises focused on motor control and plyometrics. It is well documented that athletes participating in sports involving high impact and agility have a higher incidence of knee injury and pain [6,13]. Studies have demonstrated a decreased incidence of knee injury in athletes that have participated in training programs focused on motor control and plyometrics [13].


Take home message

Although knee pain may result from multiple factors including both biological and/or psychosocial, studies suggest that quadriceps muscle weakness is associated with worsening knee pain [5]. Physiotherapy can provide a range of therapy modalities including exercises, manual therapy, education and advice, which have proven to be effective in reducing knee pain and functional disability [6,11,12].


If you have any questions regarding knee pain or think you may benefit from physiotherapy, please give us a call at (02) 8411 2050. At Thornleigh Performance Physiotherapy, we can give you an accurate diagnosis and treatment, to help you get back in action as soon as possible. We are conveniently located near Beecroft, Cherrybrook, Hornsby, Normanhurst, Pennant Hills, Waitara, Wahroonga, Westleigh, West Pennant Hills, and West Pymble.


  1. Kary JM. Diagnosis and management of quadriceps strain and contusions. Curr Rev Musculoskelet Med. 2010;3:26-31. doi:10.1007/s12178-010-9064-5.

  2. Segal NA, Glass NA. Is Quadriceps Muscle Weakness a Risk Factor for Incident or Progressive Knee Osteoarthritis? Phys Spotsmed. 2011;39:44-50. doi:10.3810/psm.2011.11.1938.

  3.  Winby CR, Lloyd DG, Besier TF, Kirk TB. Muscle and external load contribution to knee joint contact loads during normal gait. J Bio- mech. 2009;42:2294–2300. doi:10.1016/j.jbiomech.2009.06.019.

  4.  Herzog W, Longino D, Clark A. The role of muscles in joint adaptation and degeneration. Langenbecks Arch Surg. 2003;388:305–315. doi:10.1007/s00423-003-0402-6.

  5.  Glass NA, Torner JC, Frey Law LA, et al. The relationship between quadriceps muscle weakness and worsening of knee pain in the MOST cohort: a 5-year longitudinal study. Osteoarthr Cartil. 2013;21:1154-1159. doi:10.1016/j.joca.2013.05.016.’

  6. Thomas KS, Muir KR, Doherty M, Jones AC, O'Reilly SC, Bassey EJ. Home based exercise programme for knee pain and knee osteoarthritis: randomised controlled trial. BMJ. 2002;325:752. doi:10.1136/bmj.325.7367.752.

  7. O’Reilly SC, Jones A, Muir KR, Doherty M. Quadriceps weakness in knee osteoarthritis: the effect on pain and disability. Ann Rheum Dis. 1998;57:588-594. doi: 10.1136/ard.57.10.588.

  8. Petterson SC, Barrance P, Buchanan T, Binder-Macleod S, Snyder-Mackler L. Mechanisms underlying quadriceps weakness in knee osteoarthritis. Med Sci Sports Exerc. 2008;40:422-427. doi:10.1249/MSS.0b013e31815ef285.

  9. Bodor M. Quadriceps protects the anterior cruciate ligament. J Orthop Res. 2001;19:629-633. doi:10.1016/S0736-0266(01)00050-X.

  10. Moller BN, Jurik AG, Tidemand-Dal C, Krebs B, Aaris K. The quadriceps function in patellofemoral disorders. A radiographic and electromyographic study. Arch Orthop Trauma Surg. 1987;106:195-198. Accessed June 24, 2019.

  11. Thomas KS, Muir KR, Doherty M, Jones AC, O’Reilly SC, Bassey EJ. Home based exercise programme for knee pain and knee osteoarthritis: randomised controlled trial. BMJ. 2002;325:752. doi:10.1136/bmj.325.7367.752.

  12. Page CJ, Hinman RS, Bennell KL. Physiotherapy management of knee osteoarthritis. Int J Rheum Dis. 2011;14:145-151. doi:10.1111/j.1756-185X.2011.01612.x.

  13. Hewett TE, Lindenfeld TN, Riccobene JV, Noyes FR. The effect of neuro muscular training on incidence of knee injury in female athletes. A prospective study. Am J Sports Med. 1999;27:699-706. doi:10.1177/03635465990270060301


Shoulder instability


Shoulder instability

What is Shoulder Instability

Shoulder instability is the term used when the structures around the shoulder joint lose their ability to effectively hold the head of the humerus inside the shoulder socket [1]. In most cases this occurs following trauma of some kind, e.g. a collision during sport, however it can also occur after a minor injury or repetitive strain. The shoulder is held secure by a complex network of ligaments, rotator cuff muscles, and muscles that move the shoulder and scapular [2, 3]. Any imbalance that occurs in this network can contribute to shoulder instability [2, 3].

Shoulder anatomy.jpg


  • Generalised pain in the shoulder

  • You may feel or hear clicking with movements

  • Shoulder may feel loose, or as though it is “slipping”

  • Weakness with shoulder movements


Instability can put the shoulder at a higher risk of dislocations or subluxations in the future. If there is underlying damage to the bone or cartilage, or for those that wish to return to contact sports surgery may be recommended to reduce the risk of reoccurrence. Typically, surgical repair is done arthroscopically and results in good long-term functional outcomes [4, 5].

How can Physiotherapy help

  • Perform a comprehensive assessment of your shoulder and identify any underlying factors contributing to your pain.

  • Correction of poor shoulder biomechanics to optimise function.

  • Design a personalised exercise program to targeting muscle imbalances and restrictions in movement.

  • Provide you with education and tools for you to maintain a strong and healthy shoulder into the future.

If you have any questions regarding your shoulder pain, please give us a call at (02) 8411 2050. At Thornleigh Performance Physiotherapy, we can give you an accurate diagnosis and treatment, to help you get back in action as soon as possible. We are conveniently located near Beecroft, Cherrybrook, Hornsby, Normanhurst, Pennant Hills, Waitara, Wahroonga, Westleigh, West Pennant Hills, and West Pymble.



  1. Jaggi A, Lambert S. Rehabilitation for shoulder instability. British journal of sports medicine. 2010 Apr 1;44(5):333-40.

  2. Labriola JE, Lee TQ, Debski RE, McMahon PJ. Stability and instability of the glenohumeral joint: the role of shoulder muscles. Journal of shoulder and elbow surgery. 2005 Jan 1;14(1):S32-8.

  3. Levine WN, Flatow EL. The pathophysiology of shoulder instability. The American journal of sports medicine. 2000 Nov;28(6):910-7.

  4. Dickens JF, Rue JP, Cameron KL, Tokish JM, Peck KY, Allred CD, Svoboda SJ, Sullivan R, Kilcoyne KG, Owens BD. Successful return to sport after arthroscopic shoulder stabilization versus nonoperative management in contact athletes with anterior shoulder instability: a prospective multicenter study. The American journal of sports medicine. 2017 Sep;45(11):2540-6.

  5. Murray IR, Ahmed I, White NJ, Robinson CM. Traumatic anterior shoulder instability in the athlete. Scandinavian journal of medicine & science in sports. 2013 Aug;23(4):387-405.





What is vertigo?

Vertigo is a broad term used to describe an illusionary sense of motion in the absence of true motion [1] Benign paroxysmal positional vertigo (BPPV) is a specific disorder of the inner ear which results in spinning sensations with changes in head position [1,2]. BPPV can be caused by head trauma/infection of a vestibular nerve (vestibular neuritis) and other complications in the inner ear related to illness or surgery, however, most cases of BPPV do not have a specific cause (idiopathic BPPV) [1,2]. The semicircular canals (anterior, posterior and lateral) in the inner ear which are filled with fluid (endolymph) that moves in response to rotation of the head which bends the cupula hair cells which stimulates vestibular nerves [1,2].

The two most common types of BPPV are BPPV of the posterior semicircular canal (posterior canal BPPV) or BPPV of the lateral semicircular (horizontal canal BPPV). The main mechanisms of BPPV are thought to be:

  1. Canalisthiasis – where free-floating debris in the semicircular canal causes continuous movement of the endolymph after movement has stopped which causes bending of the cupula and provokes vertigo [1-3]

  2. Cupulolithiasis – where abnormal debris attaches to the cupula making it more sensitive to gravity and provoking vertigo [1-3]


How is BPPV diagnosed from other causes of vertigo?

It is important that the specific cause of vertigo is identified to ensure effective treatment or management of symptoms. Other causes of vertigo include but are not limited to:

  • Other disorders related to the ear (otologic disorders) – e.g. Meniere’s disease [1]

  • Neurologic disorders – e.g. Demyelinating disease, central nervous system lesions, stroke [1]

  • Anxiety/panic disorders [1]

  • Cervicogenic vertigo (related to the neck) [1]

  • Side effects from medication [1]

  • Postural hypotension (low blood pressure) [1]

  • Other medical conditions – e.g. toxic, infectious or metabolic conditions [1]

There are specific criteria required to diagnose BPPV – these relate to both the patient’s history and the physical examination. 


Patient history

Patients with BPPV report episodes of vertigo associated with changes in head position relative to gravity [1,2] Common provoking activities include rolling over in bed, moving head to look upward and bending forward.1,2  


Physical examination

Physical manoeuvres are used to confirm presence of BPPV and identify the affected canal clinically. The Dix-Hallpike manoeuvre is used to confirm posterior canal BPPV [1-3]. During the Dix-Hallpike manoeuvre a patient is rapidly moved from sitting to lying position with the head tilted to 45 degrees below horizontal, 45 degrees to the side of the affected ear and downward [1]. The Roll test is used to diagnose lateral canal BPPV [1-3]. The Roll test is performed with the patient lying on their back with head starting in neutral position and turned rapidly to the right side, observing for symptoms, returning to face up position, and then turned rapidly to the left and observing for symptoms.1 In patients with BPPV these manoeuvres provoke vertigo and nystagmus (rapid, involuntary movement of the eyeball) [1-3]

How can BPPV be treated?

Surgery is not recommended or necessary unless it is to address a specific underlying cause (e.g. disease, illness), or there is the occurrence of severe, frequent, recurring episodes without any reduction or remission with other treatment options [1,2] Medication is also not necessary for treatment of BPPV but may be used to manage associated symptoms such as nausea or vomiting [1].

Although many cases of BPPV resolve spontaneously without treatment, some patients experience ongoing symptoms and may experience balance problems which can restrict activities and affect quality of life [1,2].

Current evidence supports the use of canalith repositioning (CRP) manoeuvres as initial treatment for BPPV [1-4]. CRP manoeuvres are performed on the patient and involve moving the patient’s head through a series of positions and using gravity to help move free-floating debris out of the affected semicircular canal [1,2]. CRP manoeuvres can be performed by any health professional in the outpatient setting, including physiotherapy [1,2]. The most commonly used and recognised CRP manoeuvre is the Epley’s manoeuvre which is effective in resolving symptoms in a small number of treatments (usually 1-3) [1,2].  Incorporation of vestibular rehabilitation with CRP manoeuvres is useful for long term management to promote functional recovery and/or as preventive measure [1,3,4]. Vestibular rehabilitation involved exercise- and movement-based interventions performed by the patient, they focus on challenging and promoting adaption of the nervous system to compensate for vestibular dysfunction [3].


If you have any questions regarding vertigo and dizziness, please give us a call at (02) 8411 2050. At Thornleigh Performance Physiotherapy, we can give you an accurate diagnosis and treatment, to help you get back in action as soon as possible. We are conveniently located near Beecroft, Cherrybrook, Hornsby, Normanhurst, Pennant Hills, Waitara, Wahroonga, Westleigh, West Pennant Hills, and West Pymble.


  1. Bhattacharyya N, Gubbels SP, Schwartz SR, et al. Clinical practice guideline: benign paroxysmal positional vertigo (update). J Otolaryngology – Head Neck Surgery. 2017;156(3_suppl):S1-S47.


  2. Hilton MP, Pinder DK. The Epley (canalith repositioning) manoeuvre for benign paroxysmal positional vertigo. Cochrane Database of Systematic Reviews. 2014(12).


  3. Rodrigues DL, Ledesma ALL, de Oliveira CAP, Júnior FB. Physical Therapy for posterior and horizontal canal benign paroxysmal positional vertigo: Long-term effect and recurrence: A systematic review. J International archives of otorhinolaryngology. 2017.


  4. McDonnell MN, Hillier SL. Vestibular rehabilitation for unilateral peripheral vestibular dysfunction. Cochrane Database of Systematic Reviews. 2015(1).



Electrical stimulation: Does it serve a purpose, or does my physio just want to zap me?


Electrical stimulation: Does it serve a purpose, or does my physio just want to zap me?

Electrical stimulation (e-stim), most people are familiar with the term. It has become a mainstay in many physiotherapy practices, but what actually is it? Did you know there are actually many different types?

What is e-stim?

E-stim is an umbrella term for various different electrotherapy devices with different intervention goals. Of the most commonly used are Neuromuscular Electrical Stimulation (NMES), Transcutaneous Electrical Nerve Stimulation (TENS) and Inferential Stimulation (IFT). Despite these devices conducting electrical currents through the body via electrodes on the skin, they are in fact used to treat different things and thus their practical application varies [1].



NMES is used with the primary outcome to maintain strength and flexibility in order to restore, maintain and improve function [1,2]. Normally our brain sends messages to our muscles to initiate contractions. After muscular injuries, our muscle’s ability to activate becomes inhibited due to pain, swelling and/or trauma [1,2]. This leads to muscle wastage and poorly controlled muscle activation patterns, limiting the individual’s ability to properly recover during the healing process and placing them at an increased risk of future injury [2]. To prevent this, NMES is used to send an electrical current into the muscle to cause it to contract. In doing so, the muscle is being used and thus minimises muscle wastage; whilst also aiding to regain strength and restore correct movement patterns [1,2]. NMES has a wide practical application with research supporting its efficacy in chronic disease management [3],  post ACL repairs [2] and even in neurological injuries such as stroke [4]. The small battery-operated device is portable and thus can be used on essentially any type of land-based exercise whether that be in laying down or during a functional movement.  



TENS is similar to NMES, however where NMES is used for muscle activation, TENS is used for pain management [5,6]. The pulsed currents are sent through the muscle to help stimulate the release of various chemicals [5]. These chemicals help assist in reducing the sensitivity of the muscles and surrounding tissue by inhibiting neural pain pathways to the brain [5,7]. Current research demonstrates proven efficacy for TENS in decreasing pain compared to both placebo and anti-inflammatories [5]. TENS is often used for a multitude of different conditions including arthritis (both osteo and rheumatoid) [5], neuropathic (nerve related) [8] and even post- surgical pain [5]. It is a small portable battery-operated device, making it easily portable and usable regardless of whether you are at home, in the clinic or at work.



IFT is a form of TENS where rather than sending one frequency current, it utilises two alternating currents simultaneously [1]. These two currents become superimposed on each other where they intersect, enabling the ability to stimulate deeper within the targerted tissue [1]. This results in a reduction in pain in a similar underlying mechanism to TENS [9]. Compared to placebo, IFT has been found to have a positive effect on pain reduction [5]. IFT also can have positive effects on improving circulation and decreasing oedema by assisting in the removal of fluid in both the circulatory and lymph systems [1]. Unfortunately, unlike NMES and TENS, IFT is a larger stationary device and thus does not provide the portable convenience like the others.


Take home message

There is a variety of different e-stim devices all used for different purposes. Current research supports their use as an adjunct to therapy, meaning they aren’t a complete cure within themselves [1]. The use of e-stim is relatively safe with the most common side effects reported including pain, discomfort and skin irritation [10]. Several contraindications and precautions do come with the use of these devices [1], but your physio will assess you to clear these risks before starting the treatment to ensure your safety.


If you have any questions regarding e-stim or think you may benefit from its application, please give us a call at (02) 8411 2050. At Thornleigh Performance Physiotherapy, we can give you an accurate diagnosis and treatment, to help you get back in action as soon as possible. We are conveniently located near Beecroft, Cherrybrook, Hornsby, Normanhurst, Pennant Hills, Waitara, Wahroonga, Westleigh, West Pennant Hills, and West Pymble.



  1. Brukner P. Brukner and Kahn’s Clinical Sports Medicine. 4th Editio. McGraw-Hill Australia; 2012.

  2. Kim K-M, Croy T, Hertel J, Saliba S. Effects of Neuromuscular Electrical Stimulation After Anterior Cruciate Ligament Reconstruction on Quadriceps Strength, Function, and Patient-Oriented Outcomes: A Systematic Review. J Orthop Sport Phys Ther. 2010;40(7):383-391. doi:10.2519/jospt.2010.3184

  3. Jones S, Man WD-C, Gao W, Higginson IJ, Wilcock A, Maddocks M. Neuromuscular electrical stimulation for muscle weakness in adults with advanced disease. Cochrane Database Syst Rev. 2016;(10). doi:10.1002/14651858.CD009419.pub3

  4. Pomeroy VM, King LM, Pollock A, Baily-Hallam A, Langhorne P. Electrostimulation for promoting recovery of movement or functional ability after stroke. Cochrane Database Syst Rev. 2006;(2). doi:10.1002/14651858.CD003241.pub2

  5. Sluka KA (Kathleen A, International Association for the Study of Pain. Mechanisms and Management of Pain for the Physical Therapist. and management of Pain for Physical therapists&f=false. Accessed February 26, 2019.

  6. Gibson W, Wand BM, Meads C, Catley MJ, O’Connell NE. Transcutaneous electrical nerve stimulation (TENS) for chronic pain - an overview of Cochrane Reviews. Cochrane Database Syst Rev. 2019;2:CD011890. doi:10.1002/14651858.CD011890.pub2

  7. Ahmed S, Haddad C, Subramaniam S, Khattab S, Kumbhare D. The Effect of Electric Stimulation Techniques on Pain and Tenderness at the Myofascial Trigger Point: A Systematic Review. Pain Med. January 2019. doi:10.1093/pm/pny278

  8. Gibson W, Wand BM, O’Connell NE. Transcutaneous electrical nerve stimulation (TENS) for neuropathic pain in adults. Cochrane Database Syst Rev. 2017;9:CD011976. doi:10.1002/14651858.CD011976.pub2

  9. Almeida CC de, Silva VZM da, Júnior GC, Liebano RE, Durigan JLQ. Transcutaneous electrical nerve stimulation and interferential current demonstrate similar effects in relieving acute and chronic pain: a systematic review with meta-analysis. Brazilian J Phys Ther. 2018;22(5):347-354. doi:10.1016/j.bjpt.2017.12.005

  10. Samuel SR, Maiya GA. Application of low frequency and medium frequency currents in the management of acute and chronic pain-a narrative review. Indian J Palliat Care. 2015;21(1):116-120. doi:10.4103/0973-1075.150203


Concussion in Sport


Concussion in Sport

What is concussion?

Concussion is a type of traumatic brain injury that is caused by direct or indirect force to the head or any part of the body that transmits to the brain [1,2]. Although concussion is commonly associated with contact sport, it is important to acknowledge that concussion may also occur in non-contact sports. Concussion is a complex injury which presents differently among individuals and its full pathophysiology is not yet understood [1,2].

How do I know if I have a concussion?

Due to the complexity and variable presentations of concussion there is no single test or method for diagnosis and is often difficult to diagnose [1-3]. Any suspicion of concussion must be appropriately assessed and managed by a qualified medical professional. There does not have to be loss of consciousness for concussion to be present, a sign of concussion can be as minimal as someone reporting they just “do not feel right” [1]. Commonly reported symptoms with concussion include visual disturbance, feeling foggy, lethargic or slow, sensitivity to light or noise, feeling dizzy or nauseous or headaches [1]. It is important to remember that individual signs symptoms of concussion will vary greatly, and signs and symptoms may even be delayed (e.g. for house following the actual incident).

The Sport Concussion Assessment Tool 5th Edition (SCAT5) can be used by health professionals to assist in the diagnosis of and assessment of symptoms [4], and the Concussion Recognition Tool 5 (CRT5) can be used by anyone in the community to help recognise concussion [5]. Neither of these tools should be used in isolation in the recognition and management of concussion, there should always be appropriate follow up and seeking of medical advice [1].

SCAT 5 - [4]

CRT 5 - [5]

When and how do I return to sports and daily activities?

Anyone with suspected or confirmed concussion should not return to physical activity or sport, should not drive or consume alcohol or any medications (unless medically prescribed) until they have been assessed and cleared by a medical professional. It is also important that someone experiencing concussion symptoms is monitored by a responsible adult.

It is currently recommended that individuals should rest for the acute period (24-48 hours) post injury and gradually increase cognitive and physical activity [1,3]. Return to cognitive and light-moderate physical activity after the acute post-injury period may assist the recovery process but should be directed and monitored by a healthcare professional [1,3,6]. Most individuals will recover fully in 7-10 days but some may experience persistent symptoms relating to concussion that may last more than 2 weeks in adults, or 4 weeks in children and will require further medical assessment and intervention [1,7].

How can physiotherapy help?

As a health professional, physiotherapists can help assess and manage signs and symptoms of concussion as well as monitor and assist with return to activity or sport. Physiotherapists can also provide interventions around managing specific concussion-related symptoms and impairments. Physiotherapists can help treat symptoms related to the cervical spine (neck) or vestibular system using specific rehabilitation techniques including manual therapy, exercise and balance/vestibular training [1,7]. This is shown to be particularly beneficial for individuals experiencing persistent concussion-related symptoms [7].

Where can I get more information?

If you have any questions regarding  your concussion, please give us a call at (02) 8411 2050. At Thornleigh Performance Physiotherapy, we can give you an accurate diagnosis and treatment, to help you get back in action as soon as possible. We are conveniently located near Beecroft, Cherrybrook, Hornsby, Normanhurst, Pennant Hills, Waitara, Wahroonga, Westleigh, West Pennant Hills, and West Pymble. 


  1. Elkington L, Manzanero S, Hughes D. Australian Institute of Sport Concussion in Sport Australia Position Statement. 2019

  2. McCrory P, Feddermann-Demont N, Dvořák J, et al. What is the definition of sports-related concussion: a systematic review. Br J Sports Med. 2017;51(11):877-887.

  3. McLeod TCV, Lewis JH, Whelihan K, Bacon CEWJJoat. Rest and return to activity after sport-related concussion: a systematic review of the literature. Journal of athletic training. 2017;52(3):262-287.

  4. Sport concussion assessment tool - 5th edition. 2017;51(11):851-858.

  5. Concussion recognition tool 5©. 2017;51(11):872-872.

  6. Lal A, Kolakowsky-Hayner SA, Ghajar J, Balamane M. The Effect of Physical Exercise After a Concussion: A Systematic Review and Meta-analysis. The American Journal of Sports Medicine 2018;46(3):743-752.

  7. Schneider KJ, Meeuwisse WH, Nettel-Aguirre A, et al. Cervicovestibular rehabilitation in sport-related concussion: a randomised controlled trial. Br J Sports Med. 2014;48(17):1294-1298.


Stubborn SIJ: a potential cause of your back pain


Stubborn SIJ: a potential cause of your back pain

You’ve probably heard about the SIJ before. But did you know the SIJ, or sacroiliac joint, could be part of the cause behind your back pain?

What is the SIJ?

The SIJ provides the connection between the spine and the lower limbs. Our bodies have two SIJ’s, both attaching the left or right ilia (part of the hip) to the left or right sacrum (tailbone) respectively [1,2]. Primarily these joints play an integral role in transmitting force between the upper and lower body during movements such as walking, running, bending and jumping [1].


What is SIJ Dysfunction?

Pain and irritation of the SIJ is commonly referred to as sacroiliac dysfunction [3]. The SIJ’s are a primary cause of back pain in up to 30% of back pain presentations [1].  Due to the joint’s role in lumbopelvic stability, SIJ dysfunction can refer pain into the groin, buttock and thigh region [2,4].



  • Pain below the level of L5 (bottom of the lumbar spine) [1,2]

  • Tenderness in the PSIS region [2,4,5]

  • Pain when rising from a chair [6]

  • Problems rolling in bed [1]

  • Difficulty with stairs [1]

  • Potential relief when lying supine [6]



  • Mechanical imbalance between the muscles that bring the thigh forward (hip flexors) and the muscles that bring the thigh backwards (hip extensors) [2]

  • Mechanical imbalance between the muscles that rotate the thigh inwards in the hip socket (internal rotators) and outwards (external rotators) [2]

  • Leg length discrepancies [2,4]

  • Abnormalities in gait and movement patterns [2,4]

  • Scoliosis [4]

  • Heavy Physical Exertion [4]

  • Trauma to the hip or low back region [4]

  • Recent pregnancy [4]

How Can Physiotherapy Help?

The first step will be for the physio to conduct an appropriate assessment to determine where the pain is derived from [2,3].If it is indeed SIJ related several treatment options may be utilised to help reduce pain, disability and improve stability around the pelvic region [5]. Potential treatment options include but are not limited to;

1.Exercise Therapy

Exercise therapy is an integral component of recovery from SIJ dysfunction. This consists of both strengthening and stretching various muscle groups. Your physio will provide exercises to help strengthen weak muscles and address any muscle imbalances [2,5]. This plays a crucial role in restoring correct movement mechanics and aids in your body’s efficiency in transferring force through the hip and spine [2]. A primary focus of this treatment is to work on strengthening the core, gluteal and hip muscles whilst stretching muscles that have become tight and sore from overuse or guarding [2,4,5,7].

2.Manual Therapy

Manual therapy is an umbrella term for any hands-on treatment such as joint manipulations, mobilisations and soft tissue massage [2]. Stiffness and decreased joint range of motion, whether it be from your joints or surrounding musculature, can impair the ability to transmit force between the upper and lower body [2,5]. Altered or impaired force transmission can place increased strain on certain structures like your SIJ. Therefore, overall these therapies help address these movement limitations to play a role in decreasing the strain on your SIJ; to decrease your pain and improve your function [2,5].

3.Motor Control Retraining

Motor control refers to the ability to recruit muscles to effectively coordinate movement. This is specifically the case around the lumbopelvic (core) muscles, which are responsible for the control and coordination of movement between the spine and pelvis [2]. After an injury to the SIJ or low back, the recruitment of lumbopelvic muscles becomes impaired [7]. Consequently, we lose the stability between the spine and the pelvis thus placing more stress on the SIJ joint [7]. Therefore, not only is it important to strengthen these muscles but it is equally important to retrain the body’s ability to synchronise correct movement patterns [7]. Various techniques can be used to achieve this such as training lumbopelvic stability [2,5] and taping to help provide feedback for correcting movement patterns [4].


If you have any questions regarding SIJ or back pain, please give us a call at (02) 8411 2050. At Thornleigh Performance Physiotherapy, we can give you an accurate diagnosis and treatment, to help you get back in action as soon as possible. We are conveniently located near Beecroft, Cherrybrook, Hornsby, Normanhurst, Pennant Hills, Waitara, Wahroonga, Westleigh, West Pennant Hills, and West Pymble.



  1. Chien GCC, Grandhe RP, Fortin JD. Sacroiliac Joint Dysfunction. In: Treatment of Chronic Pain Conditions. New York, NY: Springer New York; 2017:177-181. doi:10.1007/978-1-4939-6976-0_49

  2. Brukner P. Brukner and Kahn’s Clinical Sports Medicine. 4th editio. McGraw-Hill Australia; 2012.

  3. Polly DW, Swofford J, Whang PG, et al. Two-Year Outcomes from a Randomized Controlled Trial of Minimally Invasive Sacroiliac Joint Fusion vs. Non-Surgical Management for Sacroiliac Joint Dysfunction. Int J Spine Surg. 2016;10:28. doi:10.14444/3028

  4. Al-subahi M, Alayat M, Alshehri MA, et al. The effectiveness of physiotherapy interventions for sacroiliac joint dysfunction: a systematic review. J Phys Ther Sci. 2017;29(9):1689-1694. doi:10.1589/jpts.29.168

  5. Nejati P, Safarcherati A, Karimi F. Effectiveness of Exercise Therapy and Manipulation on Sacroiliac Joint Dysfunction: A Randomized Controlled Trial. Pain Physician. 2019;22(1):53-61. Accessed February 10, 2019.

  6. Ou-Yang DC, York PJ, Kleck CJ, Patel V V. Diagnosis and Management of Sacroiliac Joint Dysfunction. J Bone Jt Surg. 2017;99(23):2027-2036. doi:10.2106/JBJS.17.00245

  7. Vleeming A, Schuenke MD, Masi AT, Carreiro JE, Danneels L, Willard FH. The sacroiliac joint: an overview of its anatomy, function and potential clinical implications. J Anat. 2012;221(6):537-567. doi:10.1111/j.1469-7580.2012.01564.x


Small Group Exercise Classes


Small Group Exercise Classes

PhysioStrong - Circuit Training focusing on strength, flexibility, balance and cardiovascular system

  • 45-minute sessions combining functional upper and lower body plus core exercises.

  • Exercises performed using body weight, dumbbells, resistance bands, pulley cables, exercise balls, and more.

  • Different exercises every week to keep the sessions challenging and fun!

When are PhysioStrong classes?

  • Every Tuesday 6.30 PM

  • Every Thursday 7.00 AM

  • Every Thursday 9.30 AM

Body Tension - A gymnastics inspired core strengthening experience

  • 45-minute sessions focusing on abdominal and back muscles strength, as well as spine and shoulder stability.

  • Exercises performed using body weight, exercise balls, and other small equipment.

  • Different exercises every week to keep the sessions challenging and fun!

When is Body Tension class? 

  • Every Wednesday 9.30 AM

Terms and Conditions for group classes PhysioStong and Body Tension

1.       Casual entry and pack options – Both PhysioStrong and Body Tension classes are available casually or in pack of 10. Packages for classes attract a discount rate and expire 12 weeks from the commencement of the first class.  Clients are responsible for making sure all their sessions are completed before the expiry date.

2.       24 hours cancellation policy – If you cannot attend a class, more than 24 hours notice is required to be able to reschedule. If you cancel your class less than 24 hours before it starts or are absent for your class you will forfeit your session.

3.       Bookings – Bookings are currently made through reception by:

  • Calling the clinic on 02 8411 2050 (if it is outside our operating hours please leave a message and we will get back to you on the next business day)

  • Emailing us at

  • In person

4.       Priority – Please be aware classes are booked on a first come first serve basis. We do however give preference to clients in existing classes to continue on at their existing time before it is opened up to others. To avoid disappointment, please let us know your preference or your intentions to continue before your pack expires so we can make the required arrangements.

5.       Securing your spot – Your place in classes is only secured once payment is received. If payment is not received your spot will become available for those on the wait list.

6.       Rescheduling – Rescheduling classes is your responsibility, you may reschedule missed classes once. If you are unable to attend your rescheduled class you will forfeit that credit.

7.       Waiting list – If a class you particularly want is fully booked you may put your name on a waiting list. However, we would also suggest you book into another class just in case that one does not become available.

8.       Initial assessment – PhysioStrong and Body Tension sessions require an initial assessment to be performed so the physiotherapist can custom design your program and familiarise you with the equipment.

9.       Number of participants – Each class is limited to 4 participants.

10.    Non-refundable and non-transferable – Casual classes and packs are non-refundable and non-transferable.

11.    Class modification – Instructors and classes are subject to change without notice. Thornleigh Performance Physiotherapy reserves the right to cancel classes if necessary.

12.    What to bring – A clean towel and a water bottle are required for all classes. Please wear comfortable clothing that you can move freely in. Close fitting clothes are preferable as dangling or loose-fitting clothing, hair or jewellery may get caught in the equipment.

13.    Start and finish time – Sessions start and finish at the time indicated in the booking – all classes are 45 minutes

14.    Payment – Payment methods include:


  • Credit Card

  • Cash

15.    Health Fund – All PhysioStrong and Body Tension classes are claimable under your private health insurance. Contact your Health Fund for more information about your own available rebates. The tax invoice for each session will be provided by email by the day after the class.

16.    Cancellation policy – Both PhysioStrong and Body Tension class sizes are small and fill up quickly, so clients must adhere to our cancellation policy. Cancellations will need to be made 24 hours prior to your class beginning at the latest in order to be able to reschedule your session.

17.    Payment policy – Payment needs to be made upon booking. To book into a class you must either have credits in your account or pay at the time of booking. By booking into a class you automatically agree to the above terms and conditions.


Blood Flow Restriction Training


Blood Flow Restriction Training

What is blood flow restriction training?

Blood flow restriction training (BFRT) refers to resistance training performed with a reduction of blood flow in the exercising muscles with the use of a compression device. The compression device used can either be a belt, an inflated air cuff (pneumatic cuff), a sleeve (elastic wrap) or a specific tape. Contrary to common resistance training routines, the intensity of BFRT is very low, performed with a load between 20 to 40% of an individual’s 1-RM [5].

The compression device reduces the level of oxygen circulating through the exercising muscles, and in doing so, muscle adaptation occurring after working at low intensity is greater than the benefits of low intensity with a normal level of oxygen in the working muscle [5]. However, it is unclear whether low load BFRT reaches the same benefits as high load training or not [1,3].

BFRT is a relatively new type of resistance training, inspired from KAATSU, a Japanese strengthening method invented in 1966. Over the last years, studies have been conducted to understand the benefits of BFRT, how it is best to be implemented for different conditions and its safety [4].

Benefits of BFRT

Most studies found that BFRT brings physiological and functional benefits for the general population as well as people with various conditions, such as knee osteoarthritis, tendon injuries and ACL reconstruction. Physiologically, BFRT has been found to increase muscle size (hypertrophy) and muscle strength in the general population. Functionally, the use of BFRT may reduce pain and recovery time in people with specific conditions [1,2,3].

The authors of a systematic review compared low load BFRT to low and high load training without BFR, for population presenting with various musculoskeletal conditions (ACL reconstruction, knee osteoarthritis, and older adults at risk of sarcopenia). Low load BFRT showed a greater increase in strength compared to low load training without BFR, whereas it was found to be less effective than heavy-load training [3]. However, another study focusing on women with knee osteoarthritis found that low load BFRT provided the same increase in lower limb strength than high load training [1]. This study also looked at muscle size, function and pain. The authors found that (1) low load BFRT and high load training provided a greater increase in lower limb muscle size compared to low load training; (2) low load BFRT and high load training led a greater improvement in function compared to low load training; (3) low load BFRT and low load training provided a greater reduction in pain compared to high load training [1].

People with patellofemoral pain may also benefit from BFRT. Compared to standard rehabilitation, the use of BFRT provided a greater increase in knee extensors strength and a greater reduction in pain in daily activities [2].

Safety, precautions, contra-indications

The safety of BFRT is a common and legitimate question as blood flow is voluntarily restricted within the exercising muscles. A study conducted in Japan in 2006 indicated that KAATSU training  (original name given to BFRT) is a safe method for training athletes and healthy persons, and it can also be applied to persons with various physical conditions [4]. The most common side effects are subcutaneous hemorrhage (13.1%) and temporary numbness (1.3%), while serious complications are rare (venous thrombus (0.055%), pulmonary embolism (0.008%) and rhabdomyolysis (0.008%)) [4].

Take home message

BFRT is an effective way to increase strength and muscle size while only working at low intensity. Thus, it appears to be a good clinical rehabilitation tool, especially for people suffering from knee osteoarthritis, tendon injuries, and ligament injuries (such as ACL reconstruction). During rehabilitation, the use of BFRT provides greater gain in muscle strength and muscle size than low load training, while avoiding pain caused by high load training.

Due to the potential side effects of BFRT, we recommend you to use this method in the presence of health professionals. They will set it up safely for you and will monitor throughout your training in order to minimise the risks of side effects.

If you have any questions regarding whether you think you could benefit from doing some supervised blood flow restricction training, please give us a call at (02) 8411 2050. At Thornleigh Performance Physiotherapy, we can give you an accurate diagnosis and treatment, to help you get back in action as soon as possible. We are conveniently located near Beecroft, Cherrybrook, Hornsby, Normanhurst, Pennant Hills, Waitara, Wahroonga, Westleigh, West Pennant Hills, and West Pymble.


1. Ferraz RB, Gualano B, Rodrigues R, et al. (2017). Benefits of Resistance Training with Blood Flow Restriction in Knee Osteoarthritis. Medicine & Science in Sports & Exercise, 897-905. DOI: 10.1249/MSS.0000000000001530

2. Giles L, Webster KE, McClelland J, et al. (2017). Quadriceps strengthening with and without blood flow restriction in the treatment of patellofemoral pain: a double-blind randomised trial. Br J Sports Med, 51, 1688–1694.

3. Hughes L, Paton B, Rosenblatt B, et al. (2017). Blood flow restriction training in clinical musculoskeletal rehabilitation: a systematic review and meta-analysis. Br J Sports Med, 51, 1003–1011.

4. Nakajima T, Kurano M, Iida H, et al. (2006). Use and safety of KAATSU training: Results of a national survey. Int. J. KAATSU Training Res., 2, 5-13

5. British Journal of Sport Medicine (blog) (2018). Bood flow restriction: miracle return to play adjunct or therapy fad? Retrieved on 18/01/2018 from


What the Cup?


What the Cup?

What is cupping?

Cupping has been used since 3000 BCE, it originated in ancient Egypt where it was used to remove toxins from the body [1]. Since then cupping has spread throughout the world and been used in many cultures as a treatment for a variety diseases. Today cupping is mostly seen in traditional eastern medicine, where it is used to correct blockages and help the flow of Qi throughout the body [2]. It involves suctioning special cups to the skin of a patient, in the form of wet cupping or dry cupping. Wet Cupping is invasive and involves suctioning small amounts of blood through minor incisions made in the skin, this means it is usually not performed by physiotherapists in western practices [3].

What is dry cupping?

Dry cupping is non-invasive, as it doesn’t involve exposure to blood. It is mostly used to treat musculoskeletal pain in the chest, stomach, back and buttocks [4]. Smaller cups can also be used to treat regions on the arms and legs.

Cups vary from 38-50mm in diameter and are generally made of plastic or glass [3].

The cup is suctioned and held in place by heating the air in the cup then placing the rim of the cup on the skin so it is air tight, or by suctioning air out of the cup using an air pump after placing it on the skin [3]. This negative pressure inside the cup suctions the skin and feels like your skin and soft tissue underneath is being pulled or stretched. Then it is generally left in place for 5-20 minutes or can be moved around to cover a larger area using lubricant so that it can slide without interrupting the vacuum seal made between the skin and the cup [5].


How does dry cupping work?

The vacuum inside the cup creates a tensile force that stretches the skin, subcutaneous tissue and fascia lying beneath [2]. This also causes the small blood vessels in that area to expand. The larger the cup and more suction created the stronger it stretches the soft body tissues underneath, and the longer it is left in place the more blood that is drawn to that area [2].  

This means dry cupping has the potential to be used for a number of benefits such as:

  1.  Relieving muscle and surrounding fascia tightness [3]

  2. Aiding muscle and soft tissue healing [6]

  3. Increase blood circulation and aid removal of toxins from muscles [4]

  4. Improve immune function by aiding flow of lymph [6]

  5. Provide pain relief through stimulating pain inhibiting nerves [7]

  6. Promoting deep relaxation [7]


Is it safe?

Yes, provided it is performed by a suitably trained therapist. Patients may feel warmer and may sweat during a cupping treatment, this is just a result of blood vessels expanding and drawing more blood and heat to the skin [3]. Patients may also experience redness, swelling and bruising of areas of skin that have been cupped after a treatment, this is normal and should go away within a few days or weeks [4]. You should not having cupping therapy if you are pregnant, menstruating, have metastatic cancer or have cupping therapy over an area with a bone fracture, deep vein thrombosis, palpable pulse or skin irritation [8]. 

Complications to cupping are very rare and usually due to a lack of therapist training and incorrect practice, which have lead to only a few reports of skin burns, contamination and pressure wounds [9].


What does research say about the effectiveness of dry cupping?

There have been several studies investigating the treatment effects of dry cupping on a variety of musculoskeletal conditions. The findings of these studies are:

  • 2 weeks of cupping treatment significantly reduced chronic neck pain [10]

  • 2 weeks of pulsating cupping effectively relieved pain, improved function and quality of life in patients with chronic neck pain [11]

  • Cupping and exercise together is effective in improving neck pain and neck function, and better at improving pain than using a heating pack [12]

  • Patients with sub acute and chronic lower back pain felt less pain and improved flexibility in their lower back after 1 treatment [13]

  • Pulsating dry cupping is effective at relieving symptoms of knee osteoarthritis [14]

There is however a need for future studies to focus on confirming comparing these effects to standard treatments as well as understanding long lasting effects of dry cupping.


If you have any questions regarding treating your aches and pains or cupping therapy, please give us a call at (02) 8411 2050. At Thornleigh Performance Physiotherapy, we can give you an accurate diagnosis and treatment, to help you get back in action as soon as possible. We are conveniently located near Beecroft, Cherrybrook, Hornsby, Normanhurst, Pennant Hills, Waitara, Wahroonga, Westleigh, West Pennant Hills, and West Pymble.



  1. Nickel, J.C., Management of urinary tract infections: historical perspective and current strategies: part 1—before antibiotics. The Journal of urology, 2005. 173(1): p. 21-26.

  2. Tham, L., H. Lee, and C. Lu, Cupping: from a biomechanical perspective. Journal of biomechanics, 2006. 39(12): p. 2183-2193.

  3. Rozenfeld, E. and L. Kalichman, New is the well-forgotten old: The use of dry cupping in musculoskeletal medicine. Journal of bodywork and movement therapies, 2016. 20(1): p. 173-178.

  4. Yoo, S.S. and F. Tausk, Cupping: east meets west. International journal of dermatology, 2004. 43(9): p. 664-665.

  5. Turk, J. and E. Allen, Bleeding and cupping. Annals of the Royal College of Surgeons of England, 1983. 65(2): p. 128.

  6. Ahmadi, A., D.C. Schwebel, and M. Rezaei, The efficacy of wet-cupping in the treatment of tension and migraine headache. The American journal of Chinese medicine, 2008. 36(01): p. 37-44.

  7. Musial, F., D. Spohn, and R. Rolke, Naturopathic reflex therapies for the treatment of chronic back and neck pain-part 1: neurobiological foundations. Complementary Medicine Research, 2013. 20(3): p. 219-224.

  8. Chirali, I.Z., Traditional Chinese medicine: cupping therapy. 1999: Elsevier Health Sciences.

  9. Cao, H., X. Li, and J. Liu, An updated review of the efficacy of cupping therapy. PloS one, 2012. 7(2): p. e31793.

  10. Lauche, R., et al., The influence of a series of five dry cupping treatments on pain and mechanical thresholds in patients with chronic non-specific neck pain-a randomised controlled pilot study. BMC complementary and alternative medicine, 2011. 11(1): p. 63.

  11. Cramer, H., et al., Randomized controlled trial of pulsating cupping (pneumatic pulsation therapy) for chronic neck pain. Complementary Medicine Research, 2011. 18(6): p. 327-334.

  12. Kim, T.-H., et al., Cupping for treating neck pain in video display terminal (VDT) users: a randomized controlled pilot trial. Journal of occupational health, 2012. 54(6): p. 416-426.

  13. Markowski, A., et al., A pilot study analyzing the effects of Chinese cupping as an adjunct treatment for patients with subacute low back pain on relieving pain, improving range of motion, and improving function. The Journal of Alternative and Complementary Medicine, 2014. 20(2): p. 113-117.

  14. Teut, M., et al., Pulsatile dry cupping in patients with osteoarthritis of the knee–a randomized controlled exploratory trial. BMC complementary and alternative medicine, 2012. 12(1): p. 184.


Don’t run from the P.O.L.I.C.E.


Don’t run from the P.O.L.I.C.E.

So, you rolled your ankle, you're thinking it will be fine, I’ll just walk it off. Little did you know as you continued to play the last 10 minutes of the game, the phases of healing have already begun. As you continue to run, your ankle throbs and feels unstable beneath your body. You feel sick as the pain won’t go away but continues to get worse. Thoughts race through your mind, what have I done? Should I see someone? Finally, you make the decision to come off the court, but what do you do now?

In the past, the process to assist with recovery was known as R.I.C.E.R. (Rest, Ice, Compression, Elevation and Referral). This has been proven to be effective, however, methods of management have changed to the P.O.L.I.C.E. protocol [1] :

P – Protection: this reminds individuals that a little bit of pain is okay but if the injury causes severe pain then the ankle should be protected using bandages, taping or crutches to off-load the ankle.

O – Optimal: the right amount of pain/discomfort (not too much but tolerable).

L – Loading: placing weight on the ankle (optimal-loading is advised).

I – Ice*: applied for 8-10 minutes at a time [2,3] alternating between 10 minutes on then 10 minutes off. This should be done as often as possible in the first 48 hours.

C – Compression: apply a compression bandage around the ankle, ensuring it is firm enough without cutting off circulation to the foot (Pinch test: squeeze toe, it should turn white then red again).

E – Elevation: raise leg above heart height to prevent pool of blood around the ankle due to gravity.

* Warning: any burning sensations in the region REMOVE the ice. Do not place ice directly on skin (apply a 1-2 cm cloth in between ice and skin). Never place ankle on top of the ice but rather the ice on top of the ankle.


Why this protocol?

Recent studies have shown that protecting the joint should be only as required as resting or offloading the joint could be detrimental causing changes as to how the tissue recovers [1, 4, 5]. These studies therefore promote optimal loading, where an individual can start placing body weight onto the ankle, as tolerable. This encourages correct fiber type and alignment to develop, early mobilisation and can facilitate accelerated recovery times [1, 4]. Further benefits of optimal loading are positive as changes to mechanical properties regarding load alter sensory feedback. This informs the brain that this painful feedback, which it was experiencing earlier on, is no long dangerous thus de-sensitizing the injury and reducing pain levels [4]. Previously the R.I.C.E. [6] method did not consider optimal loading and referral but rather focused on resting and went straight into management. Though icing is effective, studies have shown this has a limited effect depending on the duration and severity of the injury and should only be utilised in the acute phases [3]. Benefits of using ice should still be utilised as icing reduces the analgesic (pain) response and facilitates optimal healing by reducing swelling that would otherwise delay an individual’s rehabilitation process [7, 8].

So, when in doubt, don’t run, follow the P.O.L.I.C.E. protocol. If pain persists or worsens or you are unable to weight bare, contact your local physiotherapist and book an appointment.


What would a Physiotherapist do to help?

  • Perform a thorough movement examination of the lower body to provide education and understanding of the condition.
  • Provide tailored strategies and modifications to correct improper biomechanics of the ankle, i.e., taping, ergonomic assessment.
  • Design a personalised exercise program tailored to resolving muscle imbalances that would otherwise cause ankle instability.
  • Assist with improving range of movement and pain management strategies.
  • Provide education on self-management techniques.
  • Improve balance and retrain an individual back to pre-injury status.


If you have any questions regarding your acute injury, please give us a call at (02) 8411 2050. At Thornleigh Performance Physiotherapy, we can give you an accurate diagnosis and treatment, to help you get back in action as soon as possible. We are conveniently located near Beecroft, Cherrybrook, Hornsby, Normanhurst, Pennant Hills, Waitara, Wahroonga, Westleigh, West Pennant Hills, and West Pymble.



  1. Bleakley CM, Glasgow P, MacAuley DC. PRICE needs updating, should we call the POLICE?. British Journal of Sports Medicine. 2011 Sep 7:bjsports-2011.
  2. Adie, Naylor, & Harris. (2010). Cryotherapy After Total Knee Arthroplasty: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. The Journal of Arthroplasty,25(5), 709-715.
  3. Prins, J., Stubbe, J., Van Meeteren, N., Scheffers, F., & Van Dongen, M. (2011). Feasibility and preliminary effectiveness of ice therapy in patients with an acute tear in the gastrocnemius muscle: A pilot randomized controlled trial. Clinical Rehabilitation, 25(5), 433-41.
  4. Glasgow, P., Phillips, N., & Bleakley, C. (2015). Optimal loading: Key variables and mechanisms. British Journal of Sports Medicine, 49(5), 278-279.
  5. Bleakley, C., Dischiavi, S., Taylor, J., Doherty, C., & Delahunt, E. (2017). Rehabilitation reduces re-injury risk post ankle sprain, but there is no consensus on optimal exercise dose or content: A systematic review and meta-analysis. British Journal of Sports Medicine, 51(20), British Journal of Sports Medicine, Oct 15, 2017, Vol.51(20).
  6. Hing, Wayne, Lopes, Justin, Hume, Patria A., & Reid, Duncan A. (2011). Comparison of multimodal physiotherapy and "R.I.C.E." self-treatment for early management of ankle sprains. (RESEARCH REPORT)(Report). New Zealand Journal of Physiotherapy, 39(1), 13-19.
  7. MacAuley, D. (2010). Effect of accelerated rehabilitation on function after ankle sprain: Randomised controlled trial. BMJ. British Medical Journal (Clinical Research Ed.), 340(10), 1122.
  8. Bleakley CM, O'Connor SR, Tully MA, et al. Effect of accelerated rehabilitation on function after ankle sprain: randomised controlled trial. BMJ. 2010; 340:1964.


Patello-Femoral Pain Syndrome


Patello-Femoral Pain Syndrome

What is PFPS?

Patellofemoral pain syndrome (PFPS) is prevalent in approximately 25% of the athletic population and most commonly affects young adult females [1].  PFPS is characterised by anterior knee pain in and around the patella [2,3]. When bending at the knee joint, the patella should normally track in a lateral to medial direction before moving laterally again at full knee flexion. This motion is controlled by the quadriceps muscle group, particularly the vastus medialis oblique and vastus lateralis components. Poor coordination or weakness of these muscles can lead to inflammation of soft tissues (lateral retinaculum, infrapatellar synovium and fat pad) in addition to stress on cartilage and bone causing pain [3].


  • Acute or gradual onset
  • Aggravated by increased on unaccustomed loads on the patellofemoral joint (e.g. higher training volume, increased running speed, hill/stair running and bounding)
  • Varied presentations including achy/sharp pain, poorly localised under or around the patella
  • Knee/s may feel like it is gives way or buckles [2,3]
  • Pain during squatting [4]


  • Inadequate neuromuscular control or weakness of quadriceps muscles
  • Patella position (tilt/rotation)
  • Pronated foot type [1,2]
  • Increased knee valgus or femoral internal rotation
  • Reduced strength, coordination or range of motion of hip abductors causing increased stress on frontal and transverse forced around the knee [3]


May predispose to the development of patellofemoral osteoarthritis.

How can Physiotherapy help?

  • Provide education and advice about your condition and promote strategies to reduce your pain and symptoms
  • Provide an accurate and comprehensive assessment of your condition and address any underlying biomechanical factors contributing to your pain
  • Provide condition specific treatment including manual therapy, massage and stretches
  • Create an individualised exercise program to target muscular imbalances in the hip and/or knee and improve coordination of quadriceps muscles
  • Taping to correct abnormal positioning of the patella [2,5]


If you have any questions regarding your knee pain, please give us a call at (02) 8411 2050. At Thornleigh Performance Physiotherapy, we can give you an accurate diagnosis and treatment, to help you get back in action as soon as possible. We are conveniently located near Beecroft, Cherrybrook, Hornsby, Normanhurst, Pennant Hills, Waitara, Wahroonga, Westleigh, West Pennant Hills, and West Pymble.



  1. Nunes, G. S., Stapait, E. L., Kirsten, M. H., De Noronha, M., & Santos, G. M. (2013). Clinical test for diagnosis of patellofemoral pain syndrome: Systematic review with meta-analysis. Physical Therapy in Sport, 14(1), 54-59.
  2. Brukner, P. (2012). Brukner & Khan's clinical sports medicine. North Ryde: McGraw-Hill. 4th Edition, 87. 725-726.
  3. Panken, A., Heymans, M., Van Oort, L., & Verhagen, A. (2015). Clinical prognostic factors for atients with aterior knee pain in physical therapy: A systematic review. International journal of sports physical therapy, 10(7), 929.
  4. Collado, H., & Fredericson, M. (2010). Patellofemoral pain syndrome. Clinics in sports medicine, 29(3), 379-398.
  5. Collins, N. J., Bisset, L. M., Crossley, K. M., & Vicenzino, B. (2012). Efficacy of nonsurgical interventions for anterior knee pain. Sports medicine, 42(1), 31-49.


Shoulder bursitis


Shoulder bursitis

What is shoulder bursitis?

The shoulder contains numerous structures (muscle, bone, ligaments, tendons and bursae) that work closely together to allow optimum functioning. Within each shoulder is two purse-like sacs that contain fluid: the sub-acromial and sub-deltoid bursae. These both help to reduce friction over adjacent surfaces (i.e. muscle on muscle, bone to muscle) [1]. When irritated, this leads to a thickening of the bursa causing a painful condition known as bursitis [2].

This is considered an active warning sign that the surrounding structures have undergone repeated trauma from overuse or have been involved in a single incident (i.e. collision) [1, 2, 3]. Poor body mechanics can also be a contributing factor to the onset of bursitis [2]. It has been commonly associated with chronic shoulder pain, rotator cuff tears and degenerative tendinitis of the rotator cuff [3].



  • Tender, swelling, painful when directly palpated
  • Pain when lying on shoulder
  • Pain when lifting shoulder
  • Limited range in all directions due to pain
  • Gradual onset of pain and limitations
  • Difficultly doing overhead activities


Complications – Septic Shoulder

Is a rare condition in which the bursa becomes infected. Sepsis is caused in the bursa because of direct contact piercing through the skin in the form of isotretinoin therapy and corticosteroid injections [4]. Individuals will feel the same symptoms as listed above, however, they may also become feverish, tired and sick. The shoulder may appear red and radiate heat [2, 4, 5]. Treatment should be sought from a medical practitioner to provide antibiotics to prevent the spread of the infection [2, 4, 5].


How can Physiotherapy help?

  • Perform a thorough postural and movement examination of the upper body to provide education and understanding into condition.
  • Provide tailored strategies and modifications to correct improper biomechanics of the shoulder, i.e. taping, ergonomic assessment.
  • Design a personalised exercise program tailored to resolving muscle imbalances that would otherwise cause shoulder bursitis.
  • Assist with improving range and pain management strategies.
  • Provide education on self-management techniques.

If you have any questions regarding your shoulder pain, please give us a call at (02) 8411 2050. At Thornleigh Performance Physiotherapy, we can give you an accurate diagnosis and treatment, to help you get back in action as soon as possible. We are conveniently located near Beecroft, Cherrybrook, Hornsby, Normanhurst, Pennant Hills, Waitara, Wahroonga, Westleigh, West Pennant Hills, and West Pymble.


  1. Lennard, T. (2011). Pain procedures in clinical practice / Ted A. Lennard ... [et al.]. (3rd ed.). Philadelphia: Saunders
  2. What is shoulder (subacromial) bursitis? (2013).
  3. Santavirta, S., Konttinen, Y., Antti-Poika, T., & Nordström, I. (1992). Inflammation of the subacromial bursa in chronic shoulder pain. Archives of Orthopaedic and Trauma Surgery,111(6), 336-340.
  4. Drezner, J., & Sennett, B. (2004). Subacromial/subdeltoid septic bursitis associated with isotretinoin therapy and corticosteroid injection. The Journal of the American Board of Family Practice, 17(4), 299-302.
  5. Khan, H., & Al-Tawil, K. (2013). Spontaneous Isolated Infection of the Subacromial Bursa. Case Reports in Orthopedics, 2013, 3