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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).



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


Medial tibial stress syndrome


Medial tibial stress syndrome

What is medial tibial stress syndrome?

Medial tibial stress syndrome (MTSS) is a common condition mostly affecting runners and recreational sports players. It is an overuse injury resulting from repetitive stress to the bone in the lower leg, the tibia. Stress reactions occur on the tibia and the surrounding muscles when the body is unable to heal properly, and with repetitive stress and inadequate healing, this creates an overuse condition. Tibialis posterior, a muscle in the back of the calf has been the main muscle responsible for this condition. However recent studies have identified that several muscles are involved, including flexor digitorum longus and the soleus, which are two muscles in the calf as well.


What are the symptoms?

The symptoms of MTSS include:

  • Vague diffuse pain in the lower leg near the shin bone
  • Pain that gets worse at the beginning of exercise but eventually subsides
  • Pain the following morning
  • As the condition worsens the pain may persist during activity


What are the risk factors?

The risk factors for MTSS is influenced by your individual biomechanics of movement, and the type of training you are performing. This means that the way your body moves and its positioning during walking and running can make you more susceptible to this condition. Some of these risk factors include:

  • Flat feet (excessive pronation)
  • Training errors
  • Sudden changes in physical activity e.g. sudden increase in intensity or duration
  • Shoe design
  • Surface type
  • Fatigue
  • Decreased flexibility
  • Muscle dysfunction


How do we treat it?

The foundation of treatment for medial tibial stress syndrome is based on identifying the risk factors involved, and treating the underlying pathology. This will ensure that we are treating the cause of the problem so it will not return in the future. Treatment begins with providing relief through rest and ice. In order to keep you active and still exercising you are able to completed pain free activities such as swimming or cycling.

Your physiotherapist will then begin a careful assessment of how your foot, knee and hip alignment are affecting your running and walking. Taping may be used to control your foot pronation (flat foot), and other techniques including strengthening and stretching of muscle imbalances, mobility exercises, motor control and stability exercises. Your physiotherapist will tailor these treatment options to your specific biomechanics which will reduce the stress placed on the tibia.


If you have any questions regarding shin 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. Galbraith, M. Lavallee, M. 2009. Medial tibial Stress syndrome: conservative treatment options. Current Rev in Musculo Med. 2(3) 127-133.
  2. Batt, M. 2011. Medial Tibial Stress Syndrome. British Journal of Sports Medicine. 45(2)1-8.
  3. Franklyn, M. Oakes, B. 2015. Aetiology and mechanisms of injury in medial tibial stress syndrome: current and future development. World J of Ortho. 6(8) 577-589.


Gua Sha


Gua Sha

What is gua sha?

Gua sha is commonly known to be a traditional eastern medicine technique where a blunt tool, such as a ceramic soup spoon, is used to scrape the skin to improve blood circulation and oxygen supply to the soft tissue. A modern take on this technique is often referred to as instrument-assisted soft tissue mobilisation (IASTM).


What happens during tissue injury?

Inflammation usually occurs following an injury to generate new cells. The formation of scar tissue reduces elasticity of the injured tissue and results in adhesion. The scar tissue may also limit oxygen and nutrient supply and thus affect tissue regeneration. If left untreated, chronic inflammation may lead to tissue degeneration and contribute to chronic pain. These areas may also be more susceptible to re-injury.


How does gua sha work for injured tissue?

Adequate pressure and shear force applied during soft tissue mobilisation create micro-trauma in the affected area. This can facilitate the inflammatory response during the healing phase of the tissue. By using an instrument to assist, the clinician is able to deliver a greater force and stimulate adhesive points deeper within the tissue. Removing scar tissue and releasing adhesions help collagen synthesis and realignment. These in turn improve soft tissue function, range of motion, decrease pain and speed up healing.


Do I need gua sha?

Gua sha can be beneficial for conditions including but not limited to:

  • Tennis elbow
  • Patella tendon injury
  • Hamstring tendinopathy
  • Achilles tendinopathy
  • Partial muscle tears
  • Plantar fasciitis
  • Chronic neck pain
  • Chronic low back pain


What should I expect when receiving gua sha?

The clinician will typically start by rubbing lubricant such as cream to the skin before applying the instrument at a tolerable pressure onto the affected area. The clinician will perform smooth firm strokes over the affected area while feeling for restrictions or soft tissue irregularities. This process may take about 5-15 minutes depending on the affected area and condition.

In physiotherapy, gua sha may be used in conjunction with stretching and strengthening exercises depending on the type of injury and the stage of recovery. These exercises help restoration of function and prevent re-injury.


Are there any side effects with gua sha ?

Gua sha should not be painful during treatment. The rubbing and scraping may cause small blood capillaries near the surface of the skin to burst and result in redness, light bruising or soreness. These symptoms should resolve in a few days and can be managed with ice if necessary.


If you have any questions regarding whether gua sha can help, 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. Kim J, Sung DJ, Lee J. Therapeutic effectiveness of instrument-assisted soft tissue mobilization for soft tissue injury: mechanisms and practical application. J Exerc Rehabil. 2017;13(1):12-22.
  2. Lambert M, Hitchcock R, Lavallee K, et al. The effects of instrument-assisted soft tissue mobilization compared to other interventions on pain and function: a systematic review. Physical Therapy Reviews. 2017;22(1-2):76-85.


Triangular Fibrocartilage Complex


Triangular Fibrocartilage Complex

What is the TFCC?

The TFCC (triangular fibrocartilage complex) is a cartilage structure located on the small finger side of the wrist, it consists of ligaments and tendons. The function of this group of structures is to provide stability and smooth movement of the wrist joint. The TFCC keeps the forearm bones, the radius and ulna, stable when the hand grips objects or when the forearm rotates. An injury or tear to this structure can cause chronic wrist pain.


Types of TFCC injuries

There are two types of TFCC injuries:

  • Acute injuries: this is a traumatic tear. This can result from a fall onto the hand or from excessive arm rotation.
  • Chronic injuries: this is a degenerative tear or a tear that has lasted a long time. This can occur due to repetitive loading over a long period.



The symptoms of a TFCC tear include:

  • Pain at the base of the pinky side of the wrist
  • Pain worsens as the wrist is bent from side to side, and any activity that requires forearm rotation produces pain. For example: turning a doorknob or a key in the door, or lifting a heavy pan with one hand.
  • Tenderness over the back of the wrist
  • Reduced grip strength
  • Sometimes a clicking in the wrist


How is it diagnosed?

TFCC tears are diagnosed through careful assessment of the wrist and forearm. This involves your physiotherapist determining how your pain began, looking at the location of your pain, and how your pain is affecting the movements of your fingers, wrist and forearm. From here your physiotherapist is able to implement a treatment program.


How is it treated?

Throughout your assessment your physiotherapist would have determined the likely cause of your pain, which movements are painful and which movements are affected by your injury.

If the wrist is still stable, conservative treatment is taken. This involves beginning to decrease inflammation and pain around the area. You may be given a splint to wear for a short period of time to assist in pain reduction, and activity modifications will be applied to movements which cause pain such as heavy grasping and turning and twisting the wrist. Your physiotherapist will assess how you perform daily tasks, so these activity modifications can be manageable in your every day life.

Once pain and inflammation have been controlled, the focus of treatment will be on strength and mobility of the wrist and hand. Mobility will be addressed by improving the bending and straightening of the wrist, turning the palm up and then turning it back, along with making sure all of your fingers have proper mobility as well. Strength exercises will be prescribed to improve your grip strength, your ability to exert force when twisting the wrist, grabbing items, and bearing weight through the wrist. Additional exercises will be prescribed for you to be able to perform your activities of daily living with no pain.

Through mobility and strength exercises given by your physiotherapist you should be able to return to sport and return to normal activity.


If you have any questions regarding your wrist 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.



Lubiatowski, P. Romanowski, L. Splawski, R. Manikowski, W. 2006. Treatment of injury of the Triangular Fibrocartilage Complex TFCC. Ortop Traumatol Rehabil. 30:8(3). 256-62.


Extensor Tendinopathy


Extensor Tendinopathy


A 53 year old female presented with gradual onset of pain to her right elbow localised to the lateral side of elbow and forearm.  She described her pain to worsen with gripping, reaching and lifting tasks, especially when attempting to use scissors at work. What can physiotherapy do to help?


Clinical examination

At rest, with her forearm relaxed on a pillow the patient had minimal to no symptoms. During active and passive range of motion examinations, pronation (inward rotation) of her forearm with the elbow extended and flexion of the wrist were the most provocative movements. Resisted extension of her wrist and 3rd finger also reproduced her symptoms and she was tender upon palpation over the lateral side of her right elbow and presented with painful and decreased grip strength. No reproduction of symptoms was evident following a screen of her right shoulder and neck, indicating a non-referral pain diagnosis.

Her mechanism of injury and clinical presentation indicate an extensor tendinopathy or commonly known as “tennis elbow”.



A multimodal treatment incorporating education, unloading of the tendon from aggravating factors, pain relief and restoring tissue capacity and control was used to manage her extensor tendinopathy appropriately. Pulsed ultrasound was firstly used to promote the initial healing of soft tissue. She had active trigger point pain along her forearm muscle, that is a common occurrence in the presentation of extensor tendinopathy. The patient responded well with dry needling to her right forearm muscles which assisted in relieving muscle tension and forearm pain. She was provided with education regarding the use of ice as a form of pain management and unloading strategies. Isometric muscle activation exercises and stretches were also prescribed to be completed at home. She was also provided with a counterforce brace to be worn during working hours to assist her in gripping with reduced pain.

Over the next couple of weeks, the main focus was to restore the tissues capacity to withstand loads with minimal to no pain. This is achieved through appropriate rest and unloading of the tendon. Completing a progressive home strengthening exercise program with appropriate loads and tendon stretching. These strategies allowed time for the patient’s tendon to heal appropriately and reduce the symptoms the patient was experiencing. Manual therapy techniques and dry needling were used in conjunction to relieve any associated muscle tension. Following a couple weeks, she was able to return to full work duties with minimal to no issues.


If you have any questions regarding elbow pain, and need an assessment, please give us a call at (02) 8411 2050. Here 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.


What does your pillow do to you?


What does your pillow do to you?

With approximately one third of our lives spent sleeping, it is essential to have good quality sleep in order for the body to maintain normal physiological function and biological processes [1,2]. However for many of us, a good night’s rest is interrupted by uncomfortable neck pains that most likely will wake us during the night and persist throughout the day. Studies have shown that problems sleeping and in sufficient time of rest can also be indirectly linked with increased risk of diseases, hormonal changes, sleeping disorders and associated stress [3]. So you may ask, what can be done to ensure you get a more comfortable nights’ rest and reduced neck pain?

Studies have concluded that the proper selection of pillow can significantly reduce neck muscular tension and pain, improving an individual’s overall quality of sleep [1]. Poor neck support increases the work of neck and upper back muscles during sleep, causing increased biomechanical stress and morning pain [2]. Therefore the posture we adopt during a night’s rest can be related to musculoskeletal injuries of the neck and upper back, with muscular tension found to be a contributing factor to constant headaches [2].


What can be done?

Muscular tension and neck pain can therefore benefit from an appropriate pillow type as an adjunct management strategy to neck exercise training [1,4]. There are many various pillows on the market designed to help create the most relaxed position for the neck joints and surrounding muscles. How do you know what pillow to choose?

Here are some tips:

  • A pillow that has firm support to cervical lordosis (neck contour) which holds the head and neck region sufficiently in a neutral alignment to the upper back, reducing the biomechanical load to these regions [2] 
  • A neck pillow with the appropriate shape and consistency [5] 
  • A pillow of the correct height that will correctly support the cervical lordosis [5]
  • A one size fits all approach does not exist.


What has studies shown?

Studies have found that after 18 months of use of a supportive pillow, 84% of users achieved clinically important relief from neck pain [1] Compared to conventional pillows cervical pillows were shown to be effective in reducing neck pain and discomfort [1]

Another study found that muscle activity was higher in those with shoulder and neck pain, with a change of pillow height to a more suitable height significantly lowering the amount of muscle activity [2]. This study also showed that a pillow height of 10 cm not only had the lowest muscle activity but also resulted in similar muscle activity on both side when in side lying positions. They concluded that the best perception of comfort was associated with better head and shoulder alignment which produced the lowest amount of muscular activation [2]. A study that compared the comfort of certain material types of pillows found that memory foam pillows performed best with reduced waking pain and improved sleep quality, whilst the feather pillow performed the worst [6].

However, changing a pillow may be beneficial in improving a night rest and reduce pain, but for those who experience acute and chronic neck pain clinical treatment is most advantageous in conjunction with a suitable pillow.


How can Physiotherapy help?

  • Provide suitable tailored maintenance strategies to decrease muscular tension, pain and headache symptoms
  • Create a personalised exercise and stretching program to increase neck and upper back muscle strength
  • Undertake a postural and movement assessment of neck and upper back and provide recommendations on adjustment of seating posture
  • Help assist you with selecting the correct pillow for you through analysing posture and upper back and neck biomechanics
  • Provide education to encourage self-management strategies.


If you have any questions regarding neck pain and sleeping posture please give us a call at (02) 8411 2050. Here 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. Erfania P, Tenzif S, Guerriero RC. Assessing effects of a semi-customized experimental cervical pillow on symptomatic adults with chronic neck pain with and without headache. Journal of the Canadian Chiropractic Association. 2004;48(1):20-28.
  2. Sacco ICN, Pereira ILR, Dinato RC, Silva VC, Friso B, Viterbo SF. The effect of pillow height on muscle activity of the neck and mid-upper back and patient perception of comfort. Journal Of Manipulative And Physiological Therapeutics. 2015;38(6):375-381.
  3. Lavin RA, Pappagallo M, Kuhlemeier KV. Cervical pain: A comparison of three pillows. Archives of Physical Medicine and Rehabilitation. 1997;78(2):193-198.
  4. Helewa A, Goldsmith CH, Smythe HA, Lee P, Obright K, Stitt L. Effect of therapeutic exercise and sleeping neck support on patients with chronic neck pain: a randomized clinical trial. The Journal of Rheumatology. 2007;34(1):151-158.
  5. Persson L, Moritz U. Neck support pillows: a comparative study. Journal Of Manipulative And Physiological Therapeutics. 1998;21(4):237-240.
  6. Gordon SJ, Grimmer-Somers K, Trott P. Pillow use: The behaviour of cervical pain, sleep quality and pillow comfort in side sleepers. Manual Therapy. 2009;14(6):671-678.


What is Osteoarthritis (OA)?


What is Osteoarthritis (OA)?

What is osteoarthritis?

Osteoarthritis (OA) is a complex degenerative non-inflammatory joint disease that affects the whole joint including subchondral bone, articular cartilage, ligaments and muscles that surround a synovial joint1 [1]. It is characterised by progressive cartilage loss, subchondral bone remodelling and formation of osteophytes narrowing the joint space [2]. Low-grade local synovial inflammation occurs believed to be a result of release of inflammatory mediators from the degradation of articular cartilage [3]. OA is the most common type of arthritis that leads to a gradual decline in health, physical function and well-being if not managed correctly [1]. Hands, hips, lower back, knees and feet are the areas that are most affected by OA.

OA is commonly referred as a “wear and tear” form of arthritis as it is thought to occur as a part of an aging process, however it has been found that aging is not a predictor of OA [1]. The aetiology of OA is however due to the result of excessive mechanical stress applied in context of susceptibility modifiable and non-modifiable factors such as age, genetics, gender, ethnicity, local mechanical factors, obesity and joint injury [2]. OA is a highly preventable and manageable disease, with 70 per cent of cases within Australia preventable by avoiding excess weight gain and joint injuries [1].


How common is OA?

OA currently affects one in 12 Australians and is the leading cause of chronic pain and disability world-wide [1,4]. Although the incidence of OA has been found to increase with age, osteoarthritis can occur at any stage, with more than half of the people being of working age [1 ]. It is estimated that within the next four years, the prevalence of OA will have doubled due to the higher rates of obesity also placing people at a higher risk of death compared to a general population [2].


Common Causes and Contributing Factors of OA

The causes of OA are not well understood however it has been shown that several biomechanical, genetic, behavioural and environmental factors contribute [1].

Person-level factors [5]

  • Genetics
  • Excess weight and obesity
  • Gender: Higher prevalence in women, incidence rates increases around menopause.
  • Age: Main risk factor however not an inevitable factor of OA

Joint- level factors

  • Abnormal joint irregularity, joint malalignment, muscle weakness and ligament rupture are some local mechanical contributing factors that increase susceptibility and progression of OA [2]
  • Joint injury and certain repetitive joint loading occupational activities [2]


 Common Symptoms of OA [6]:

  • Limited/reduced range of motion
  • Stiffness
  • Clicking or cracking sound
  • Mild swelling around joint
  • Pain- worse at the end of day
  • Tenderness
  • Muscle weakness
  • Mild effusion
  • Joint and limb deformity


How can physiotherapy help?

Currently physiotherapy treatment and management of OA is focused on reducing mechanical loads and symptom management [1]. Physiotherapy management includes the use of a variety of low impact exercise programs which has been shown to be effective [7]. Exercise based treatment approaches such as walking programs to water and land based strengthening programs have been proven to be beneficial in managing symptoms of OA [7]

Other management strategies include [4]

  • Electrical based therapy
  • Prescription equipment/aids
  • Taping
  • Weight loss program
  • Manual therapies
  • Education on pain and self-management.

Studies has found that the benefits of exercise in OA in relation to pain and physical function has a similar effect to that gained by analgesic and non-steroidal anti-inflammatory medications with fewer side effects [2] Physiotherapy treatment and management will be tailored to target each individual taking into account specific risk factors and patient characteristics.

If you have any questions regarding managing OA better, 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. Arthritis A. Time to Move: Osteoarthrtis. Arthritis Australia;March 2014.
  2. Hunter DJ. Osteoarthritis. Best Practice & Research Clinical Rheumatology. 2011;25(6):801-814.
  3. Berenbaum F. Osteoarthritis as an inflammatory disease (osteoarthritis is not osteoarthrosis!). Osteoarthritis and Cartilage. 2013;21(1):16-21.
  4. Larmer PJ, Reay ND, Aubert ER, Kersten P. Systematic review of guidelines for the physical management of osteoarthritis. Archives of physical medicine and rehabilitation. 2014;95(2):375-389.
  5. Palazzo C, Nguyen C, Lefevre-Colau M-M, Rannou F, Poiraudeau S. Risk factors and burden of osteoarthritis. Annals of Physical and Rehabilitation Medicine. 2016;59(3):134-138.
  6. Michael JW-P, Schlüter-Brust KU, Eysel P. The epidemiology, etiology, diagnosis, and treatment of osteoarthritis of the knee. Deutsches Arzteblatt International. 2010;107(9):152.
  7. Rosedale R, Rastogi R, May S, et al. Efficacy of exercise intervention as determined by the McKenzie System of Mechanical Diagnosis and Therapy for knee osteoarthritis: a randomized controlled trial. journal of orthopaedic & sports physical therapy. 2014;44(3):173-A176.



Middle back pain and left arm pain


Middle back pain and left arm pain


A 50 years old female, Mrs L., presents with middle back pain and left arm pain gradually developed over the weekend without clear mechanism of injury. The only potential reason that she could think of was gardening. She had ongoing back stiffness; otherwise she is normally healthy and active. What could be the cause of her problem?


Clinical examination

Mrs L’s left arm pain is provoked when she is reaching forward. Her left shoulder range of movement is normal. She has reduced neck and middle back range of movement, specifically cervical retraction and thoracic extension.

In neurological examination, Mrs L’s biceps and triceps jerk reflex are normal. Her strength and sensation were also normal. On palpation, her left mid thoracic area is stiff and her arm pain is also provoked.

It appears that Mrs L’s left arm symptom is related to her left thoracic spine.



Mrs L’s left arm symptoms and thoracic spine stiffness are reduced after some thoracic spine joint mobilisation. She was then given some cervical and thoracic mobility exercises to restore her loss of range of movement. Her symptom is almost completely abolished in two weeks.

It is not uncommon that sometimes the arm pain that patient experienced come from a different body part, typically cervical or thoracic spine. A systematic examination procedure will help identifying the source of the symptoms, and aid an appropriate management approach.


If you have any questions regarding suspicious arm pain and need and assessment, 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.


Conservative Management of Meniscal Tear


Conservative Management of Meniscal Tear


A 47-year-old male presents with an acute left knee injury from rotational standing up movement from a seated position at lunch. He felt immediate pain in the medial side of his knee and reports a locking sensation when attempting to straighten his knee. What can physiotherapy do to help.


Clinical Examination

The patient was unable to weight bear on his left leg as he could not straighten his left knee due to pain and catching sensation. During passive range of motion movements, his knee could be flexed to full range, however was painful at end of range and when moving leg back into extension. Passive patella movement did not reproduce his symptoms, though symptoms reproduced upon palpation of medial border of knee cap and medial knee joint. No swelling was evident at time of review, however this is expected in the acuteness of his injury.

His mechanism of injury and clinical presentation indicate an acute torn flap of his medical meniscus.



Small meniscal tears can be managed conservatively if a person’s range of motion is not greatly affected, have minimal swelling and are able weight bear. The first phase of conservative management of an acute meniscal tear includes maintaining knee extension range of motion and providing stability to the knee to reduce any risk of further injury. Small amplitudes of passive accessory movements were undertaken in attempt to normalise joint range of motion. He was provided with education regarding the importance in maintaining knee extension and encouraged to undertake light knee extension stretching techniques to aid in this. Kinesiology tape was used to strap his knee to promote healing, support, reduce swelling and assist in pain reduction. The patient responded well with dry needling to his hamstrings and calf muscles which assisted in off-loading the knee joint from muscle tightness. Following the initial treatment, the patient had a reduction in pain symptoms and ability to weight bear as tolerated through left leg.

Over the next two to three weeks, the focus was to eliminate swelling and achieve full range of motion and focus on hamstring and quadriceps strength. Through the completing all home strengthening and stretching exercise program, this patient improved well and could obtain full range of knee extension with a reduction of pain and an increase of muscle strength. He was provided with full range squats and lunges as a progression to his hamstring and quadriceps strengthening exercises with added endurance training program for his hip external rotators. After another few weeks, he could return to his home-based fitness program and work schedule without any issues.


If you have any questions regarding your knees or are interested in seeing if we can help you, please give us a call at (02) 8411 2050. Here 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.


Ankle Sprain from Basketball


Ankle Sprain from Basketball


A 15 years old boy presents with a recent right lateral ankle sprain from landing on someone’s foot and rolled inwards during basketball. What should he do to facilitate return to sports?


Clinical examination

In observation, the patient has mild lateral ankle swelling but no bruises. He is able to walk without pain. Symptoms are provoked during eversion and lunging. His anterior talofibular ligament (ATFL) is tender on palpation. Ligament stability tests (anterior and posterior drawer tests) are negative.

The examination findings suggest that he has a low grade right ATFL sprain.



A combination of education, RICE (rest, ice, compression and elevation) approach will be appropriate to manage his acute symptoms. In this scenario, his symptoms are able to further reduce with joint mobilisation and strapping. 

Over the next two weeks, he is able to gradually progress his exercises from range of movement exercises to proprioception and strengthening exercises, specifically single leg balance and single leg heel raise. He was able to perform thirty repetitions in single leg heel raise which is clinically indicative for exercise progression and trial return to modified sports. 

It is indicated from research that the reinjuring rate after the first ankle sprain within the first year is remarkably high, up to eighty per cent. It is also suggested that proprioceptive (balance) and ankle strengthening exercises will significantly reduce the risk of recurrence, and the exercises program should at least last up to two months. It is important to be aware that free of symptoms and ‘feeling good’ do not always mean the ankle function is fully recovered.


If you have any questions regarding ankle sprain and ankle braces, and need an assessment, please give us a call at (02) 8411 2050. Here 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.


ACL Tear


ACL Tear


A 15 years old female Miss K who is a netballer presents with a right ACL reconstruction surgery one week ago. Her surgeon has referred her to do physiotherapy. What does she need to do in rehab?


Clinical examination

The patient is walking with two crutches. Her knee is moderately swollen. Her wound is covered by wound dressings. Her knee extension range is -5 degrees (meaning it’s in a slightly bended position) and her flexion range is about 20 degrees, both motions are limited by pain and stiffness.



It is expected that ACL reconstruction rehabilitation to be a lengthy process. It generally takes at least six months to twelve months to return to sports. Most surgeons would provide the patient and the physiotherapist a rehabilitation protocol, but it is common to have variations which depend on the graft choice and individual factors.

Initial stage of ACL-recon for Miss K focuses on swelling control and restoring her loss of knee extension range. This is critical as it allows her to walk with normal gait as soon as possible and avoid the development of compensation strategies. Her treatment includes manual therapy, compression therapy, and inner range closed chain quadriceps exercises. 

In six weeks times, Miss K has recovered full knee extension and ninety per cent flexion range of motion.

Depends on the sports type, most patients can return to sports after six to twelve months. In between this six to twelve months, there is a variety of exercises need to be covered to allow successful return to sports. That includes improvement on proprioception, strength, balance, flexibility, agility, functional strength, plyometric ability and sports-specific skills.

As Miss K is very compliance to her rehabilitation program and keen to return to sports. She performs her exercises well and on schedule. She is able to return to low level netball in nine months.


If you have any questions regarding your post operative rehabilitation or are interested in seeing if we can help you, please give us a call at (02) 8411 2050. Here 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.