Piriformis syndrome vs S1 Nerve Root Compromise

Ms L presented to the clinic complaining pain mainly over her right buttock with sharp shooting pain radiating down on the side of her leg and foot. She was walking with limping gait, difficulty bending forward and reported severe sharp shooting pain when she first get up in the morning. On examination at initial session, there was pain over the piriformis muscle on palpation and reduced passive hip internal rotation compared to the left which was consistent with the clinical findings of piriformis syndrome. Treatments such as soft tissue massage, electrotherapy and piriformis stretching exercises were introduced in the first session. Upon the second session, the patient reported the pain was only getting slightly better and very mild low back pain was reported. Neurological examination was conducted which showed reduced sensation and reflex while the muscle function was intact. Since the neurological examination was positive with her severe leg pain that impacts her physical function, she was advised for a CT scan which demonstrates lumbar spondylosis with impingement on the descending S1 nerve root. On reassessment, the patient showed improvement in flexion after repeated lumbar flexion. The treatment approaches were adjusted according to the reassessment with a main focus on symptom-free and core stability exercises along with mobilisations. The patient is showing gradual improvement with reduced pain on walking and getting easier to bend forward. The following exercises were prescribed to reduce her symptoms and improve her physical function:

• Sustained lumbar rotation in left side-lying

• Straight leg raise nerve gliding exercise

• Posterior pelvic tilting exercise in supine

• Knee to chest repeated flexion in supine

• Postural correction to reduce excessive lumbar lordosis

Stenosing Flexor Tenosynovitis

Ms S was presented to the clinic with right ring finger pain especially during gripping activity. She reported feeling locked after her fingers were bent and had difficulty straightening them. A “popping” or “clicking” sensation would sometimes be heard if they are passively pulled out straight. Education, hand rehabilitation exercises and ultrasound were used to improve her situation. The patient is encouraged to modify her activity by reducing the frequency of carrying/gripping heavy objects to avoid overusing the tendon that bends the finger. Ultrasound was used to reduce her pain and swelling. Rehabilitation exercises such as passive finger stretching and tendon gliding were also introduced. The patient is showing gradual improvement and is able to move her finger more freely now.

Upper Crossed Syndrome

Ms Z was presented to the clinic with longstanding bilateral upper back pain. Pain was aggravated after sitting or standing for prolonged period of time. On observation, the patient demonstrated head forward posture, rounded shoulder and increased thoracic kyphosis. There was a diminished thoracic kyphosis during forward flexion and was improved after postural correction. Her pain in the upper back was associated with chest tightness and upper back weakness due to long-established poor posture. Exercises, soft tissue release and electrotherapy were used to reduce muscle tightness, improve muscle strength and reduce pain. The patient is demonstrating gradual improvement with physiotherapy interventions and proper postural correction. The following exercises were provided to improve posture in the long run:

• Pectoralis major stretches

• Resisted scapular retraction

• Upper trapezius and levator scapulae stretches

• Deep neck flexor activation

Rotator Cuff Tendinopathy

Mr S is a young man suffering from right shoulder pain due to repetitive lifting from his work. On examination, he showed signed for rotator cuff tendinopathy resulted from muscle overuse. His main complaint was having residual pain during overhead activities particularly at the end of range. He is receiving rehabilitation in our clinic receiving ultrasound, electrotherapy and exercise therapy to promote the healing of the tendon. The patient is following the home exercise program and is now gradually improving. Rehabilitation exercises provided include the following:

• Posterior rotator cuff muscles stretches

• Pectoralis major stretches

• Resisted scapular retraction

• Serratus anterior strengthening

• Resisted external rotation in neutral and 90 degree shoulder abduction

• Resisted shoulder flexion and abduction strengthening

Post Ankle ORIF Operation

Mr W is currently around 3 months post right ankle surgery after sustaining a distal tibiofibular fracture from falling off the rooftop during work. He was presented to the clinic with limping gait, reduced weight bearing on the right, reduced lower limb strength and balance. He is unable to work at the moment and is receiving rehabilitation in our clinic including ultrasound, joint mobilisation and exercise therapy. ROM, stretching, strengthening and balance exercises were given to the patient and he is educated to follow the home exercise program in order to improve his mobility. The patient is compliant to the exercise program prescribed and his gait, strength and balance are gradually improving to return to his work in a few weeks time. The exercises included for home exercises encompass the following:

• Knee to wall stretch

• Sidelying hip flexor, quadriceps and tibialis anterior stretch

• Sit to stand

• Step up and down

• Backward lunges

• Double leg calf raises

• Tandem/single leg balance

• Glute bridges

Hip Osteoarthritis

Ms W is presented with right hip pain started 1-2 years ago. Pain was aggravated with weightbearing activities such as walking and climbing stairs. Conservative treatment was chosen by the patient despite showing a moderately severe hip OA on xray. Ultrasound therapy, soft tissue release and mobilisation as well as rehabilitative exercises were provided to improve her hip pain. The patient now is able to walk with reduced pain and is compliant to the home exercise rehabilitation provided. Specific exercises focusing on core strengthening, postural orientation, lower limb resisted strengthening and functional strengthening are provided at different phases of recovery with the following examples:

• Glute bridges; active assisted hip and knee flexion with Swiss ball

• Forward, backward and sideway slide lunges

• Resisted hip and knee extension with theraband

• Sit to stand; Step up and down

Acute Low Back Pain

Ms P was presented to clinic with acute severe low back pain around 3 weeks ago. She reported severe pain during walking, prolonged positioning and in/out of bed. The pain is aggravated due to prolonged sitting at her workplace. Shockwave therapy was provided to increase the healing and recovery of the injured lower back muscles. The patient showed significant reduction in pain after the initial session and reported getting in/out of bed and walking more easily. The patient was also advised to incorporate regular daily physical activity and avoid prolonged sitting to improve her low back pain in the long term. She is now gradually returning back to work with reduced pain and improved function. To prevent recurrences in the long term, specific exercises will be provided to improve the flexibility of the back and core strength, including the following:

• Series of yoga stretches such as Cobra’s, Cats cows and child’s pose

• Core strengthening such as glute bridge, straight leg raise and dead bug

Rotator Cuff Tear/Subacromial Impingement

Ms S is presented right shoulder pain due to partial tear of her supraspinatus and sub-acromial bursitis, mainly due to age-related degeneration. She reported pain during activities such as reaching overhead and backwards. On examination, she had reduced postural control, shoulder range of motion and muscle weakness. She is currently improving gradually with the use of ultrasound to improve the healing of the torn tendon and appropriate exercise rehabilitation to improve her range and strength. The following exercises will be provided at different phases of recovery:

• Postural correction

• Scapular control

• Stretching of chest and posterior rotator cuff

• Active assisted and active shoulder range of motion

• Progressive upper limb strengthening

• Functional exercises

Shoulder Internal Impingement

Mr M is a young man suffering from shoulder internal impingement, reporting acute shoulder pain due to repetitive overhead activities from his construction work, gym practice and Thai boxing. He was presented with deep dull ache at the posterosuperior region of his shoulder, particularly positioning his arm in the throwing position. Pain was significantly improved with shockwave therapy, rotator cuff stretches and progressive strengthening exercises. He is now gradually returning to his work, sports and leisure activities with ease. Specific exercises were provided as follows:

• Shoulder internal rotation stretches

• Pectoralis major stretches

• Resisted scapular retraction

• Resisted shoulder internal rotation in neutral and in 90 degree shoulder abduction

• Serratus anterior strengthening

• Scapular stabilization exercises

Complete ACL Tear

Miss M is a young patient presented with complete ACL tear due to injury during her dancing. She was presented with swelling, pain and difficulty walking initially. She had also had consultation from specialist to receive surgery to repair her ACL and was referred for physiotherapy for prehabilitation. Standard ACL protocol was provided for this patient including the following:

• Pain and swelling control

• Passive and active assisted knee flexion in closed kinetic chain

• Isometric knee extension

• Gait retraining +/- assistive aid use

• Progressive strengthening in weightbearing position

• Balance training

During her rehabilitation in our clinic, ultrasound was used for pain and swelling control. Shockwave therapy was adopted to provide higher intensity ultrasound wave to promote blood flow, tissue healing and pain relief. ROM and strengthening exercises were prescribed in closed kinetic chain to avoid further shearing forces induced at the knee. The patient is having significant improvement in pain after the use of shockwave therapy. Her knee ROM and strength are also gradually improving which can help to optimize her function and independence after the surgery to assist her return to her sports.