Joint Conditions In The Lower Body

SIJ dysfunction occurs when there is compromise to the ligaments that help stabilise the joint between your pelvis and spine. These ligaments restrict the small amount of movement that occurs in this region, and limit any forces and loading placed on the area. When they fail to stabilise the region, irritation and inflammation occurs at the joint.

Those with SIJ dysfunction (about 68% are female) often report increased pain with high-impact activities such as running, hopping and sideways movement because the area is unable to cope with high levels of loading and shearing forces.

The condition is frequently caused by high-impact accidents, including car accidents and general trauma to the area following a fall, hard running, twisting or awkward lifting. Pregnancy as well as repetitive loading can also cause issues.

Common symptoms will include localised pain to the area of the buttocks. This will generally be on one side and travel down the side of the coccyx (tail bone). Pain can radiate from the buttocks and down the side of the leg or into your pelvis, scrotum, labia or penis. Additionally, sufferers can experience spasm throughout their gluteal muscles as well as pain across the base of their lower back.

Aggravating activities can include arching your back, twisting in bed, long car journeys, walking uphill and going down stairs. While SIJ dysfunction is difficult to diagnose with more common forms of imaging such as MRI and X-Ray, a more effective method is a SPECT CT scan which has a high rate of clinical accuracy for this condition.

Physios are skilled in assessing and treating the area of lumbopelvic and hip pain and can differentiate sacroiliac pain from other areas that can refer to the region, including the lower back and hip. Once diagnosed, your physio will recommend a program of manual therapy to the pelvis and surrounding joints and muscles. This hands-on treatment will be combined with a comprehensive functional exercise program to build control and dynamic strength through the lumbar spine, pelvis and hips, for everyday life, work and sport.

SIJ inflammation is a condition that involves arthritic changes or inflammatory responses from local injury or systemic inflammatory conditions that may be either inherited or acquired.

SIJ inflammation may occur with high-impact accidents, including car accidents and general trauma to the area following a fall. High-volume activities such as labouring, gardening, lifting or overdoing pushing or pulling tasks, can result in repetitive loading of the joint, which results in inflammation. Inflammation is the body’s response to an injury or a disease which can increase muscle spasm, compression of nerves and generalised discomfort.

In some cases, the condition is due to inherited or acquired inflammatory disorders such as ankylosing spondylitis or psoriatic arthritis. Symptoms for these conditions tend to show signs initially in the SIJ region, that progress to other areas.

The most intense pain is generally felt in the middle of the night when sleeping, typically between 2-5am. Pain is related to stiffness in the area and is occasionally felt as a hot or burning feeling. Prolonged static postures, such as standing and sitting, are the most common factors that make pain worse. Pain will tend to remain constant throughout the day. Over-the-counter anti-inflammatory medications may help in the short term.

Physio is a major component of a comprehensive rehabilitation program, in combination with anti-inflammatory medications or anti-inflammatory injections into the SIJ. Once the anti-inflammatories have relieved the symptoms, physiotherapy treatment will aim to increase mobility through the lumbopelvic and hip region and build strength and control through the hip to unload the pelvis and lumbar spine, facilitating a return to work and sporting activities.

FAI syndrome is a condition of abnormal movement within the hip joint where the ball (femoral head) and socket (acetabulum) rub abnormally. This leads to symptoms, clinical signs and changes in the form, shape or structure of the hip. For a firm diagnosis of FAI there must be both clinical signs and findings on medical imaging.

FAI Syndrome occurs when an overgrowth of bone on the ball, socket or both parts of the hip joint prevents normal movement of the joint. It is likely that FAI syndrome is the result of a combination of a person’s genetics and environment. Some experts believe that significant athletic activity before skeletal maturity leads to an increase in the risk of FAI, but evidence is not definitive at this stage. Recent reviews have found FAI features on scans of athletes and non-athletes who have no symptoms.

If you have FAI, you will experience hip and groin pain and restricted range of hip motion. Symptom onset can be acute, after an injury, or gradual in onset. Pain often comes on with prolonged sitting, walking, crossing the legs or during and after sport or exercise, and is primarily felt deep in the groin at the front of the hip and more rarely it can be on the side of the hip or buttock.

Your physio will ask you about your symptoms, examine your hip movements and send you off for X-rays if appropriate. Once the diagnosis is confirmed your physio will aim to improve your hip strength, neuromuscular control, range of motion, balance and patterns of movement. Treatment may include a variety of techniques to stretch any tight structures, including the joint capsule or muscles in order to improve flexibility and length. You will also be prescribed strengthening exercises to improve the supporting hip muscles along with proprioception exercises (joint position sense) and functional control to improve dynamic control of your hip.

Groin pain can be of sudden or gradual onset and occur in sports such as football, hockey and long-distance running, but may also be felt when doing sit-ups. Groin pain is a common and complex condition caused by abnormal muscle forces acting on the joint at the front of the pelvis where several muscles attach. The condition can be classified according to the 5 muscle groups affected.

Groin pain is often complex and can be difficult to diagnose as there can be other causes of groin pain. Pain may be experienced on one or both sides of the groin, in the lower abdominals or at the front of the hips. Firmly touching the pubic bone at the front of the pelvis commonly makes the pain worse. You may also experience pain by crossing your legs, squeezing your knees together or when abducting the hip (moving the affected leg away from the midline of the body). Pain is often aggravated by exercise such as in running, kicking, performing sit-ups or activities involving change of direction.

Physiotherapy has been shown to be successful in treating groin pain and most people with the condition make a full recovery over time with appropriate management of the condition. This may include advising on sporting and work activities and prescribing exercises to strengthen the abdominal and hip muscles and to improve hip range of motion through stretching.

A Total hip replacement is a surgical procedure where the ball and socket of the hip joint are replaced with artificial material. The ball at the end of the femur (long leg bone) and the socket in the pelvis are replaced with a ball and cup made of metal, plastic, ceramic or a combination. The procedure is conducted by an orthopaedic surgeon in an operation that takes approximately 60-90 minutes and is conducted on individuals whose hip joints have been severely damaged, usually as a result of osteoarthritis, trauma or other joint disease.

Physio is an important part of rehabilitation after this surgery, initially by prescribing exercises while you are still in your hospital bed, and in sitting and standing to ensure your muscles around the hip and thigh are working properly. Your physio will then teach you how to get in and out of bed, how to walk with a frame or crutches and provide you with advice on how to be safe at home during your recovery phase. If you have stairs, you will be taught how to manage these.

You may be prescribed a home exercise program and referred for physiotherapy after you go home. You may also be referred to an exercise class or for hydrotherapy sessions. Alternatively, you may simply be instructed to continue with the exercises and to gradually increase your walking distance once you’re at home.

Patellofemoral pain, in other words “kneecap pain” is a condition where pain is felt at the front of the knee, around or behind the patella (kneecap). The pain is commonly felt with activities such as squatting, running, jumping and going up or down stairs, often limiting a person’s ability to participate in home, leisure or sports activities. The condition represents 25-40% of all knee presentations to a sports injury clinic and can affect people of any age, although studies have shown that up to one third of adolescents report PFP.

The patellofemoral joint is part of the knee joint, where the patella sits within its groove (trochlea) on the front of the thigh bone (femur). A smooth layer of joint cartilage covers the trochlea and the back of the patella to help the joint surfaces glide without friction. There are ligaments that help centre the patella on the trochlea and several muscles attach to the patella to assist its movement along the trochlea groove. The patellofemoral joint essentially functions as a pulley system that helps the quadriceps muscles straighten the knee efficiently.

PFP occurs due to a variety of reasons, sometimes seemingly without a particular trigger or injury. In others its onset is secondary to a change in knee loading such as a sudden increase in sporting activity, running more or running on hills or following a growth spurt. In others it can be secondary to an injury or surgery such as an ACL reconstruction.

Regardless of individual contributing factors, there is strong evidence for the most common reasons, including:

• weakness of the front of thigh (quadriceps) muscles – which can cause the patella to not glide centrally within its groove, leading to areas of increased pressure or friction in the patellofemoral joint
• weakness in the hip/buttock (gluteal) muscles – which can contribute to poor alignment of the leg and knee, or excessive tightness of other thigh muscles, both of which place extra stress on the joint
• variations in bony anatomy – which could be a patella that sits high or wide (laterally) in its groove, a trochlea groove that is relatively shallow, or variations in the shape of the hip and thigh bone that cause the knee to turn inwards with walking
• in some people additional factors may include flat feet, weak calf muscles, stiffness in the ankle, hip or knee joints, or tightness of soft tissues on the outer thigh

Though not classically PFP, there are two other conditions affecting the patellofemoral joint that cause pain in the same area and lead to similar functional limitations:

• patellofemoral osteoarthritis (OA) - is as common as tibiofemoral OA (OA in the larger part of the knee joint)
• patellar instability - commonly results from dislocations of the patella leading to pain and ongoing instability which varies in severity, at the extreme end requiring the attention of an orthopaedic surgeon but for most people managed effectively with physiotherapy

If you have PFP you are likely experiencing grinding sensations from the patellofemoral joint when bending your knee, mild knee swelling, pain at the front of your knee while sitting, getting out of a chair or on straightening your knee after prolonged sitting. During your physiotherapy assessment there will be tenderness to the back of the kneecap during examination of your knee which will help your physio confirm the diagnosis. Scans such as X-rays and MRI are not required to diagnose PFP.

One of the most important parts of managing PFP is to first have an accurate diagnosis of your knee symptoms which your physio is able to do after excluding other possible conditions. Once the diagnosis is clear your physio will manage your PFP in the following ways:

• education on contributing factors in order to have realistic expectations of rehabilitation, to manage physical activities appropriately, and to be an active participant in your treatment program
• individually tailored treatment that may include a home exercise program, patellofemoral taping and bracing, building activity gradually and retraining (eg running) if required

There are two types of cartilage inside the knee and both can be injured in different ways. Both the lateral and medial menisci function as washers, helping with shock absorption and aiding in joint stability. They are C-shaped and made of tough, rubbery fibrocartilage, in contrast to the solid layer of articular cartilage between the tibia and femur and between the kneecap and its groove on the femur. This articular cartilage provides a shiny, smooth, friction-free surface to assist with gliding of the joint.

Injuries to the menisci generally fall into two categories:

• acute injuries (sudden onset) that mainly occur with sudden movement such as rotation, generally while the foot is in contact with the ground, as happens in sporting activities (the force can cause an acute tear, often involving a knee ligament injury, with the size and location of tears determining severity
• degenerative injuries (gradual onset) are the result of gradual thinning of the meniscal cartilage which makes the meniscus less robust and more vulnerable to tearing with a minor twisting movement

Injuries to the articular cartilage also occur in several ways:

• trauma or acute injury – after sustaining a high force injury (eg a fall from a height or a heavy awkward landing while playing sport) which can result in chipping of the articular cartilage or a cartilage compression injury
• patellar dislocation – where a piece of articular cartilage on the surface of the patella is chipped or fractured
• osteochondritis dissecans (OCD) – mainly found in adolescents and young adults, and where a small patch of bone develops a lesion under the cartilage, causing the cartilage and bone to weaken, occasionally separating from the underlying bone and resulting in locking and clicking of the knee if the joint is not unloaded to allow the lesion to heal
• wear and tear (OA) – commonly arises as a result of cumulative injury throughout a person’s life, but can also occur in younger people with a history of traumatic knee injury, or in those who work in highly physical jobs or have movement patterns that place stress on areas of the cartilage
• apophysitis – is related to growth and load, where injury occurs to the area of cartilage where it transitions to bone at the location of a tendon insertion involving both the bone and tendon (eg Osgood-Schlatters Disease)

Your physio, doctor or surgeon can examine your knee to accurately diagnose your knee symptoms, and may refer you for X-ray, ultrasound or MRI. Your symptoms will likely include:

• In the case of meniscal injuries – if acute you will usually feel a sharp pain followed by an inability to continue with activity. However, in both acute and degenerative, and depending on the severity of the meniscal tear, you will have moderate swelling, localised sharp knee joint pain when walking, twisting and turning, an inability to fully bend or straighten the knee (known as locking), sensations of clicking or catching which may or may not be painful and your knee may or may not be painful at night.
• If you have an articular cartilage injury – your symptoms will depend on the nature and severity of your injury and the area within the knee joint that has been affected. If your injury is secondary to trauma you will feel significant pain especially when trying to weight-bear and in certain knee joint positions. Your knee will also be swollen and be restricted in its range of movement. If secondary to osteoarthritis you will have experienced a more gradual onset of symptoms with swelling and pain after long periods of activity, and your knee may ache at night or be stiff after periods of rest.
• If you have knee joint OA which is more advanced, the shape of your knee may be different (eg “bow leg”, or “knock knee” depending on the side most affected).

Physiotherapy plays an important part in the management of knee cartilage injuries with treatment varying according to the type of cartilage injury you have. Commonly, your physio will prescribe exercises to optimise knee bending and straightening, to improve muscle strength and co-ordination, and they will advise you on pain management.

During the acute phase of a meniscal injury, when your knee is inflamed, your physio can help you settle your knee symptoms using ice, activity reduction and gentle stretches while doing simple pain-free strength exercises to prevent muscle weakness. Once your knee is more settled your physio will guide you through a rehabilitation program of exercises and progressive return to full activity.

In the case of injury to the articular surface of the kneecap and its groove, physio will generally include exercises to strengthen the muscles around the knee, hip and lower leg, and improve co-ordination, but if you have sustained a traumatic knee joint articular cartilage injury, you will likely need the opinion of a knee surgeon in which case your physio treatment will be more important post-operatively.

There are a number of causes for pain in the big toe and all can impact on your ability to walk. These conditions include the following:

Turf Toe is the name given to a sprain of the joint at the base of the first toe that is caused by an injury such as hyperextension (excessive upward bending) or stubbing of the big toe. This leads to pain and swelling around the big toe joint. In severe cases there may be tearing of the plantar plate that stabilises the joint on the underside of the foot. Playing on artificial turf and wearing soft footwear may increase the risk.

Hallux limitus is the term for stiffness at the first metatarsophalangeal joint at the base of the toe. The condition causes pain and limited movement of this toe and is usually the result of past acute trauma such as a turf toe or other sporting injury. Progressive stiffness can lead to arthritis and the development of small bone spurs that limit joint movement. As the condition progresses it can reach a stage of hallux rigidus (big toe stiffness) which will impact on walking ability where the big toe plays an important role in the push-off phase of the walking cycle.

Hallux valgus (bunions) where the first toe progressively deviates towards the second toe and sometimes overlaps the second toe. The feature of this condition is a painful bony prominence at the inside of the first toe joint, and potentially limited joint movement that causes problems with walking. The condition is up to 10 times more prevalent in women and has been associated with wearing pointed or narrow footwear such as high heels. It is however, also associated with a congenital deformity (birth defect) or laxity of the big toe joint and an excessively flat (pronated) foot.

Gout is a recurrent inflammatory arthritis condition that leads to joint pain, swelling and redness but tends to affect one joint at a time when the condition flares (an “attack of gout”). The condition is not usually preceded by injury.

Your physio will be able to diagnose the cause of your big toe pain, assessing movement at your big toe and around the foot. If a fracture or other disease is suspected (eg gout or arthritis) they may refer you to your GP for investigation and treatment.

With your physio’s training and experience you can confidently embark on a treatment and management program. They can advise on all of the above conditions but if you have gout you will be referred to another practitioner as physiotherapy is not a first-line treatment for gout.