This is a fracture that occurs at the attachment sites of both ligaments and bone pulls away from the attachment site of the soft tissue.

calcaneal avulsion fracture


  • Twisting or rotational injury of a joint.
  • Sports that involve high impact, jumping

Common avulsion fracture sites include

  • Rectus femoris muscle from the pelvis
  • Hamstring muscle from the pelvis
  • Lateral ligaments in the ankle
  • ACL in the knee
  • Peroneal tendon in the foot

Pain and Symptoms

Symptoms can include some or all of the following:

  • Pain is usually quite severe in and around the area of injury
  • Usually very tender over the area of injury
  • Often will have trouble weight bearing if it is a lower limb avulsion


Plain X-ray will usually show up the avulsion


This depends on the site of the injury and the nature of the fracture. It requires a medical opinion. Physiotherapy can ensure that recovery is optimised after fracture healing through an exercise program.

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Children’s bones are still growing, making them prone to overuse injuries at areas of the bone containing growth cartilage.  One of the most common examples of this type of injury is Osgood-Schlatters syndrome.  Other examples include Severs Syndrome which occurs at the attachment of the Achilles tendon.children

In the case of Osgood-Schlatters, a visible, painful lump appears below the knee.  Osgood-Schlatter disease tends to occur in children age 12 to 16 and is often associated with participation in sports that involve running, jumping, and sudden changes in direction (e.g. football, ballet, figure skating, basketball).  The condition is actually caused by an overstress to the growth plate, where the patellar tendon attaches to the tibia (shin bone).

The degree of pain associated with an Osgood-Schlatters can range from annoying and distracting during activity to constantly painful and mildly debilitating.  It’s common to state that Osgood-Schlatters disease and similar conditions will self-resolve in a number of years, but this is little comfort to the children.  Plus, parents, coaches, and young athletes can do more than wait.

Left unattended, these injuries may result in time off sport or even an aversion to formerly enjoyed athletics.  These injuries are suggestive of over-training, or unsuitable activities given a young athlete’s age and condition. A professional assessment is essential. Professional consultation can result in an individualized protection and improvement plan that may include targeted stretching, targeted exercises, equipment advice, and advice for training modifications.  Early diagnosis leads to good early treatment and can have a huge impact on the speed of recovery and may even prevent longer-term problems. Advanced Physiotherapy is involved with multiple sports organisations, so we prove adept at striking the right balance between protecting the health of the athlete while also encouraging fun, fitness, and athletic achievement.

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Research says yes! Various studies have shown that both exercise and manual therapy reduce the associated pain and disability of osteoarthritis and are recommended as first line treatments.(1-5) Dr. Alexis Wright and colleagues recently added to the body of research by completing a study that identifies five predictors of positive response to physiotherapy for hip osteoarthritis.


The five predictors are:

  • one-sided hip pain,
  • age 58 or younger,
  • pain of 6 or greater on a 10-point scale,
  • self-paced walk test of 40 meters in 25.9 seconds or less,
  • and duration of symptoms of less than one year.

The researchers found that the presence of just one of these suggests an average response to physiotherapy. If two predictors are present, this doubles the likelihood of a positive response. The presence of three predictors suggests a 99% likelihood of therapy success.

To conduct the study, researchers recruited 91 patients from doctors’ offices and from an orthopaedic center where patients had been referred for surgery assessment and consultation.  Patients were randomized into usual care from a doctor and other healthcare providers and three physiotherapy groups (manual therapy, exercise therapy, and combined therapy).  Patients received nine, one-hour therapy sessions.  Treatment success was defined as a three-point or greater improvement on an 11-point pain rating scale after one year.

In general, patients in the usual care arm only achieved important improvements in pain 2% of the time.  Patients in the physiotherapy arm achieved important improvements in pain after one year in 32% of cases. Advanced Physiotherapy has solutions for many types of arthritis pain and disability – especially osteoarthritis. Call us today and give physiotherapy a try if arthritis is holding you back.


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Medial Collateral Ligament injuries occur when the knee is being stressed towards the inside – into a knock kneed position – either via non-contact (running/stepping resulting in the knee being twisted) or contact scenarios (an opponent in sport falling onto the outside of the knee). As a result of the extra force being placed through the tissue the ligament becomes overloaded resulting in damage to the tissue which can range from a small sprain to the ligament to a full rupture of the ligament.

Medial Collateral Ligament Injuries

Symptoms will generally be localised to the inside of the knee especially over the ligament. In moderate to larger tears there will be a large amount of swelling, diffuse pain through the knee and laxity within the ligament resulting in a knee that will feel quite unstable.

 The injury is graded on a scale of 1-3.

Grade 1 – A small sprain to the ligament resulting in a small amount of pain and small loss of function.

Grade 2 – A moderate sprain to the ligament resulting in a portion of the fibres being torn. Moderate to large swelling, unstable knee, loss of movement and limping..

Grade 3 – A full rupture or tear of the ligament resulting in loss of stability, large swelling, loss of mobility and a large amount of laxity within the knee. Frequently these injuries are associated with other damage to the knee including cruciate ligament tears.

Advanced Physio Treatment

Advanced Physio will provide different treatment options dependent on the grade of the injury. Treating a Grade 1 injury includes activity modification, ensuring that the patient avoids aggravating activities and starting a progressive strengthening program. Recovery for this level will take around 2-4 weeks. Treating a Grade 2 injury requires a period of immobilisation with the aid of a knee ranger brace. The position and the time the brace is used for is dependent on the level of the injury and the symptoms of the knee. Recovery for this level will take around 6-8 weeks A Grade 3 injury requires period of  immobilisation with the aid of a knee ranger brace. The position and the time the brace is used for is dependent on the level of the injury and the symptoms of the knee. Recovery for this level of injury will take up to 12 weeks. These grades will also require the development of a graded strengthening program. As a patient progresses through their rehabilitation, our skilled physiotherapists will be gradually return the patient to sport specific training, if required.

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There are several tendons in the thumb. Two of these (abductor pollicus longus, and the extensor pollicus brevis) sit within a common sleeve (known as a tendon sheath). Overuse of these tendons will create an inflammation of the tendon sheath via excessive friction where the tendons emerge from the sheath. The tendons are normal. This is common in activities which use the thumb e.g. pruning and sports such as racket sports and golf.


Pain and Symptoms

  • Pain will be through the outside of the wrist below the base of the thumb
  • Often there may be some swelling over the affected area
  • It is usually tender to touch the affected area


Diagnosis of this condition can usually be confirmed with clinical testing. Imaging such as x-ray, bone scan and ultrasound can also be used to confirm the diagnosis and exclude other injuries.


  •  Activity Modification/Rest – A period of activity modification is recommended to help rest.
  • Bracing – The wrist and thumb can be supported with a specially made brace to reduce movement
  • Medication – Is sometimes advised – prescribed by a doctor.
  • Cortisone – Cortisone may be suggested as a form of treatment to help settle the inflammation. This needs to be prescribed and administered by a Doctor
  • Strengthening – Long-standing cases can result in weakness to the rest of the hand and arm through disuse.


This is highly variable depending on the extent of the problem. Tendon problems often take several months to settle and resistant cases sometimes require a surgical opinion.

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Nerve Root Compression is a common condition that affects these nerves. It can affect any level of the spine but is more common in the lumbar and cervical spine. The compression is usually the direct result of an acute disc bulge or some bony overgrowth or both leading to a compression of the nerve near these foramina.

The irritation may be due to the direct mechanical compression of the disc on the nerve or due to the chemical irritation caused by disc.



  •  More commonly associated with degenerative change that occurs in the disc over time
  • Acute disc injury from lifting or twisting movement
  • Osteophytes or bony overgrowth
  • Spondylolithesis or forward movement of one vertebrae on another

Clinical Features

  • Pain is usually severe and will refer down the peripheral limb i.e. leg or arm.
  • Can often be associated with weakness, pins and needles, numbness and loss of reflexes.
  • Tender over affected region with associated muscle spasm.
  • Significant loss of active movements
  • Pain is usually aggravated by sitting, bending, lifting and often sneezing.


MRI or CT scan will help provide a direct diagnosis along with clinical findings. Once the condition is diagnosed then a decision on the appropriate course of management can be established.


Conservative management will usually include:

  • Activity Modification – A period of activity modification will be required to help allow the area to settle. Safe activity is important to make sure the spine stays mobile.
  • Bracing – A short period of bracing early in the rehabilitation may assist with settling the pain.
  • Pain Medication – Early on appropriate pain medication prescribed by your GP may be appropriate in helping to control symptoms.
  • Range of Motion Exercises – These are designed to safely restore the active movement in your spine to help with return to functional activities and settle symptoms.
  • Strengthening – A strengthening program will be developed to help restore full function, and help with return to daily activities and work.
  • Ergonomic and manual handling training – if necessary will be integrated in your program.
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Bone is a metabolically active tissue that undergoes continuous resorption and renewal. Stress on the bone accelerates this process. When the process of renewal is not able to keep up with the process of bone resorption a stress fracture can form.

Stress fracture

There are 2 types of stress fractures:

A fatigue fracture occurs when abnormal stress is applied to normal bone. This is common in athletes. An insufficiency fracture occurs when normal stress is applied to bone with diminished elastic resistance.

The usual one seen in the lumbar spine is a fatigue fracture. It occurs in the area of the vertebrae called the pars interarticularis and is generally related to hyperextension, rotation and compression. It is most common on one side of the body but can occur on both sides. It is common in sports people and is seen frequently in cricket fast bowlers, throwing athletes, weightlifters, soccer players, gymnasts, dancers and Australian Rules footballers.

It is essential that it is diagnosed early as these do not always heal completely (especially those on both sides) and can lead to a permanent defect in the bone and potential for longer term low back problems.

Risk Factors

Training Volume and Insufficient Rest – Overtraining is common. Too much or the wrong type of training or sudden increases in activity and insufficient rest can overwhelm the repair process eventually leading to bone injury.

Hormonal – Overtraining or low body weight has the potential to cause lowering of oestrogen and subsequently lower bone density, or a negative calcium balance.

Other endocrine factors that have the potential to influence bone health and therefore stress fracture risk are glucocorticoids, growth hormone and thyroxin.

Nutritional Factors – Either secondary to abnormal eating behaviours or poor diet can increase the risk of stress fractures and need to be addressed in management.

Calcium balance can be affected by other dietary factors such as a high intake of salt, phosphorus, fibre, protein, caffeine and alcohol. It is not clear whether dietary supplementation with calcium or inadequate calcium in the diet is a factor in stress fractures but it is clear that restrictive or abnormal eating behaviours are a risk. Other nutrients such as potassium, iron, zinc magnesium and various vitamins are probably necessary.

Psychological Issues can result in overtraining or an eating disorder.

Muscle Fatigue – Muscles exert a protective effect on bone and muscle fatigue has been associated with increased bone fatigue.

Type of activity – certain activities especially those involving rotation, hyperextension or compression are more prone to this problem

Technique – the body position adopted in several sporting activities can lead to stress fractures. This can often be modified without detriment to performance.

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This is a stress injury to the bony attachment of the patellar tendon (see fig 1). It is caused by repeated stress on the growth plate of the bone from activities such as running, jumping and kicking. It usually occurs in active adolescents between the ages of 11 and 15 years and presents with pain and swelling over the front of the knee fig 2 below the knee cap, at the top of the tibia.

Osgood Schlatters Disease 1

Osgood Schlaters disease 2



Is likely to consist of:

Activity Modification – This is designed to help unload and rest the affected area. Except in extreme cases complete rest is not usually required and a reduction in the volume or intensity of activity is all that is needed. In rare circumstances where the symptoms are severe a short period of immobilisation is required.

The general recommendation is that if the child has pain and limping that they discontinue their activities for the day. If they have pain and limping for 3 or more days they are to cease their athletic activity for a month and perform only stretching exercises.

Stretching Exercises – These are often recommended and are best prescribed by a Physiotherapist Technique Modification – Improving jumping or running technique can reduce stress through the patellar tendon and the apophysis Supportive Straps or Tape – Can reduce stress through the apophysis This varies. Most will control their symptoms over a 6 – 12 week period. In some the symptoms can last 12 months or so. It is important to realise that these symptoms will always resolve as the growth plate mature

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This injury results in the patella (knee cap) moving outside of its natural groove in the joint and dislocating to the outside of the knee. The injury can either be traumatic with a history of trauma, or non-traumatic or spontaneous occurring in individuals whose ligaments are hypermobile.

Patella dislocation

What Structures can be Injured?

  • Patella and femur joint surfaces
  • Medial retinaculum, medial patella-femoral ligament

Factors that Predispose to Dislocation

  • Shape of patella and femoral groove
  •  Weak connective tissue
  • Poor lower limb strength/control
  • Poor lower limb biomechanics
  • Previous dislocation or history of subluxation
  • Age and gender. This is particularly common in teenage girls

Pain and Symptoms

  • With the traumatic injuries there is often quite a large effusion (swelling).
  • Feeling of something going out of place
  • Obvious dislocation of the patella sitting laterally Pain


Often a dislocation can be confirmed with history and clinical examination. An x-ray is usually performed to rule out any fracture or other injury. MRI is frequently used to further assess the knee


Surgery is usually only required if there is a history of recurrent dislocation with the role of the surgery to stabilise the patella femoral joint.

 Recovery Time

Compliance with your rehabilitation program is essential in achieving a good result following this injury. It can take 3 – 6 months to regain normal function


Treatment regime for patella dislocation for the first time will usually consist of a Physiotherapy prescribed and supervised exercise program. If a recurrent dislocation has occurred then a review with an orthopaedic surgeon is advised.

Physiotherapy would usually involve the following:

  • Activity Modification – To help protect the knee and allow the un-injured tissues of the knee to settle. Appropriate cross training can be implemented to maintain fitness levels.
  • Exercise – A thorough graded lower limb strengthening program will be developed by your physiotherapist to help restore your full function and assist with return to pre-injury activity. The program should also include a balance and proprioceptive component and finally an injury prevention component.
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Sprains to the lateral ligaments of the ankle are the most common sporting injury and account for about 10 percent of all sporting injuries. Not surprisingly this has been well researched and there are well over 100 published papers on preventing ankle injuries.

Over 95 % of these sprains occur to the lateral ligaments of the ankle and are caused by twisting the foot in or inverting the foot. These sprains range from a mild grade one (microscopic damage) to amore severe grade 3 (full rupture) and with more serious grades can even result in damage to the joint or fracture.

ankle sprain

If you injure the ankle follow the following steps.

Follow the RICER rules

  • Rest – cease the sport and if the ankle is painful get onto crutches
  • Ice – 15-20 minutes every hour for the first 24 hours
  • Compression – use a compressive bandage or sock
  • Elevation – where practical elevate the ankle so it is above the knee
  • Referral to Physiotherapy – Don’t self diagnose, these injuries are not always simple and sometimes result in fractures or other significant injuries

In summary this research has shown that Physiotherapy rehabilitation which focuses on a short period of rest and protection of the injured ankle followed by a professionally designed rehabilitation program is

  1. By far the treatment of choice and will promote faster and better recovery than either surgery or no rehabilitation
  2. Effective at preventing further injury

A typical rehabilitation will take between 2-6 weeks depending on the severity of the injury.

Returning to play may require either bracing or taping. If there are correctly prescribed or applied they will help reduce the chances of a re-injury without affecting performance.

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