Sunday, December 20, 2015



Plantar fasciitis, one of the common causes of pain in heel, is due to irritation and inflammation of plantar fascia (a long thin band that connects heel to front of toes, and supports the arch of the foot).
The plantar fascia is designed to absorb the high stresses and strains we place on our feet. But, sometimes, too much pressure damages or tears the tissues. The body's natural response to injury is inflammation, which results in the heel pain and stiffness of plantar fascia.

Risk factors for plantar fasciitis include:

  •  Walking gait abnormalities, which place excessive stress on the heel bone, ligaments, and  nerves near the heel
  •  Running or jogging, especially on hard surfaces
  •   Poorly fitted or badly worn shoes, especially those lacking appropriate arch support
  •   Excess weight and obesity

Other risk factors associated with plantar fasciitis include:

  •  Increasing age, which decreases plantar fascia flexibility and thins the heel's protective fat pad
  •  Diabetes
  •  Spending most of the day on one's feet
  •  Frequent short bursts of physical activity
  •  Having flat feet or high arch feet.

Heel Spurs
Heel spurs are often associated with plantar fasciitis, though are not the cause of pain most of the times. One out of 10 people has heel spurs, but only 1 out of 20 people (5%) with heel spurs have foot pain. Because the spur is not the cause of plantar fasciitis, the pain can be treated without removing the spur.

The most common symptoms of plantar fasciitis include:
  • Pain on the bottom of the foot near the heel
  • Pain with the first few steps after getting out of bed in the morning, or after a long period of rest, such as after a long car ride. The pain subsides after a few minutes of walking
  • Greater pain after (not during) exercise or activity.


Examination would reveal,
  • A high arch or flat feet
  • An area of maximum tenderness on the bottom of your foot, just in front of your heel bone
  • Pain that gets worse when you flex your foot and the doctor pushes on the plantar fascia. The pain improves when you point your toes down
  • Limited "up" motion of your ankle.


Conservative: Conservatively patient can be managed with physiotherapy, which may include cold therapy, contrast bath or hot fermentation depending upon the pain, stretches (plantar fascia and calf), and myofascial release. Ultrasonic therapy and LASER have proved beneficial in the management of plantar fasciitis. Muscle stimulation can be implemented in cases of flat feet.

Home regime
It may include ice rolling for 15-20 minutes, avoiding activities that increase the pain, self stretch techniques several times in a day, strengthening the sole muscles, balance exercises as shown in the picture above.

Nonsteroidal anti-inflammatory medication: 
Drugs such as ibuprofen or naproxen reduce pain and inflammation.

Cortisone Injections: 
Cortisone, a type of steroid, is a powerful anti-inflammatory medication. It can be injected into the plantar fascia to reduce inflammation and pain.

Supportive shoes and orthotics:
Shoes with thick soles and extra cushioning can reduce pain with standing and walking. As you step and your heel strikes the ground, a significant amount of tension is placed on the fascia, which causes microtrauma (tiny tears in the tissue). A cushioned shoe or insert reduces this tension and the microtrauma that occurs with every step. Soft silicone heel pads are inexpensive and work by elevating and cushioning your heel. Pre-made or custom orthotics (shoe inserts) are also helpful.

Night splints:
 Most people sleep with their feet pointed down. This relaxes the plantar fascia and is one of the reasons for morning heel pain. A night splint stretches the plantar fascia while you sleep. Although it can be difficult to sleep with, a night splint is very effective and does not have to be used once the pain is gone.

Surgical treatment: 

we shall not discuss the surgical procedure.
Surgery is considered only after 12 months of aggressive nonsurgical treatment.

For any query or treatment for plantar fasciitis contact...

Pain Free Physiotherapy Clinic
31 A, DDA Flats, Pocket II, Behind sector 6 Market,
Dwarka, New Delhi 110075

Thursday, June 11, 2015

Carpal tunnel syndrome

Carpal tunnel syndrome occurs when the median nerve is compressed at the wrist. The median nerve originates from cervical  spinal nerves and controls movement and sensation to the palmer side of the hand, thumb, and fingers. The carpal tunnel, a narrow passageway in the wrist, is formed by bones on the bottom and sides and a ligament which composes the top of the tunnel. The tunnel also contains nine tendons that are connected to the bones and muscles of the hand. Under various circumstances these tendons may swell and enlarge causing compression of the median nerve against the ligamentous roof which results in the symptoms experienced in carpal tunnel syndrome.
Numbness and a “pins and needles” sensation are the most common symptoms. Most often the thumb, index, and middle fingers are involved. Symptoms are often worse upon waking or during activities that involve flexing and extending of the wrist. As the syndrome worsens, decreased grip strength makes it difficult to perform tasks with the involved hand.
Due to the fact that the median nerve emerges from the neck, it is important that the patient be thoroughly assessed to determine that the symptoms are not coming from a nerve entrapment (pinched nerve) in the neck, shoulder, or forearm.
Phalen's test helps diagnose the problem, with compression of dorsal aspects of hands the numbness and tingling sensation aggrevates. Other test would include tinel's sign, X-ray to rule out bony abnormalities and EMG and NCV to determine the extend and detrimental  effect of nerve compression.

Physiotherapy treatment would comprise of modalities that includes US and IFT, stretching of median nerve (this also reduces the chances of double crush syndrome). Exercises would include reverse phalen's maneuver ( i.e namaste pose, with elbow and wrist at 90-90 position and shoulders resting by the sides) and strengthening of musculatures around the wrist. Tendon gliding exercises are also very helpful in increasing the mobility of tendons in the tunnel.

Sunday, January 4, 2015

Rheumatoid Arthritis (Patient Education and Physiotherapy)


(I Shall be discussing only the articular features)

RA is a chronic inflammatory disease. The cells lining the synovial membrane are activated by some process not yet understood, triggers the immunological response. These cells proliferates, resulting in thickening and inflammation of the synovial membrane. These cells are invasive, fibroblast like cell mass (called PANNUS), which is capable of eroding cartilage and bone. The synovial fluid accumulates, and the joint swells, distending the capsule, pulling on its periosteal attachment and causing pain and potential rupture. The ligaments and muscles around the joint are also subjected to weakness and potential rupture.

Factors which may (suspected) evoke the immunological reactions are Climate, Race, Diet, Psychosomatic disorders, trauma, Endocrinal dysfunction, Hereditary, disturbance in autoimmune system and infections.

Diagnosis ( Criteria given by American Rheumatoid Association)

Detection of abnormal protein, known as Rheumatoid serum factor (Rh. Factor)
(There are also sero negative variants of arthritis presenting similar feature)

Other abnormal findings,
Raised ESR, serum fibrinogen and immunoglobulins
Reduced albumin

Synovial Fluid examination reveals yellowish/greenish in colour, cloudy in clarity, low viscosity and neutrophills (75%) predominantly.

Clinical Findings
Onset between 35-55 years of age
male:female- 3:1
Severe pain
raised temperature
morning stiffness
phebitis (extruded synovial fluid may irritate the soft tissue around)
contractures, , fibrous/ bony ankylosis
secondary osteoarthritic changes
Deformities- wrist, small joints of hand, knee, elbow, shoulder, hip most commonly affected.

common deformities
Hand - ulnar drift of the hand, Boutonniere deformity, Swan neck deformity
Foot - Hallux Valgus, Hammer Toe

Rheumatoid Arthritis also includes non articular affection ( systemic illness, blood disorders, vascular, cardiac, respiratory, reticulo-endothelial, skin




1. No destructive changes on X- ray,
2. X- ray evidence of osteoporosis may be present.


1. X-ray evidence of osteoporosis, with/without slight subchondral bone destruction; slight cartilage       damage may be present,
2. No joint deformity, although limitation of joint range of motion (ROM),
3. Adjacent muscle atrophy,
4. Extra-articular soft tissue lesions, such as nodules and tenosynovitis may be present.


1. X-ray evidence of cartilage and bone destruction in addition to osteoporosis,
2. Joint deformity such as subluxation, ulnar deviation or hyper-extension without fibrous or bony           ankylosis,
3. Extensive muscle atrophy,
4. Extra articular soft tissue lesions such as nodules and tenosynovitis may be present.


1. Fibrous or bony ankylosis,
2. criteria's of stage III.


Completely able to perform usual activities of daily living (self care, vocational and avocational)

Able to perform usual self care activities and vocational activities but limited in avocational activities

Able to perform usual self care activities, but, limited in vocational and avocational activities

Limited in ability to perform usual self care, vocational and avocational activities.
Usual self care activities include dressing, bathing, grooming and toileting.
Avocational includes recreational and leisure activities.
Vocational includes work, school, homemaking etc (age and sex specific)


1] Acute phase/ Active phase
2] Chronic phase

- There may be exacerbations and remissions during the course of the disease.


1. Relief of pain and inflammation
2. Restoration and maintenance of joint range of motion
3. Improvement of muscle strength and endurance
4. Prevention of deformity
5. Correction of deformity
6. Optimization of functional level
7. Management of re-occurrence. 

Joint Protection/ Patient Education to Prevent Deformity (in Acute Stage)

1. Monitor the activities and stop when discomfort or fatigue begins to develop.
2. Use frequent but short episodes of exercise
3. Decrease level of activity or omit provoking activities if joint pain develops and persist for more         than 1 hour.
4. Balance work and rest to avoid muscular and total body fatigue.
5. Increase rest during flare of the disease.
6. Avoid Deforming positions

  • properly supported positioning of the involved joints and correct bed postures are important
  • the use of firm mattress minimizes the effect of mal-positioning thereby preserves the                 integrity of the joints.
7. Avoid prolong static positioning; change positions during the day every 20-30 mins.

8. Use appropriate adaptive devices

Ref- J. Maheswari, hall n broody.

Wednesday, November 26, 2014



Pain over the lateral aspect of the hip and thigh may be due to local trauma or overuse, resulting in inflammation of the trochanteric bursa which lies deep to the tensor fascia lata. There is local tenderness and sometimes crepitus on flexing and extending the hip. Swelling is unusual but post-traumatic bleeding can produce a bursal haematoma.

X-ray may show evidence of a previous fracture or a protruding metal implant or trochanteric wires dating from some former operation. There may also be calcification or shadows suggesting swelling of the soft tissue. It is important to exclude underlying disorders such as Gout, Rheumatoid Arthritis and infections (including Tuberculosis)           

Other causes of pain and tenderness over the greater trochanter are stress fracture (in athletes and elderly patients), slipped epiphysis (in adolescents) and bone infections (in children). The common cause of misdiagnosis is referred pain from the lumbar spine.
The usual treatment is rest, Physiotherapy, NSAIDs, and injection of local anaesthetic and corticosteriod (provided infection is excluded). If a haematoma is present should be drained.

In Physiotherapy, cold compression, ultrasonic therapy and TENS can help reduce pain and swelling.


Acute tendinitis may cause pain and localized tenderness just behind the greater trochanter. This is seen particularly in dancers and athletes. The clinic finding and X-ray features are similar to those of trocanteric bursitis, andthe deferential diagnosis is the same. Treatment protocol is also almost the same.


This overuse injury is often seen in footballers and athletes. The patients complains of pain in the groin and tenderness can be localized to the adductor longus origin, close to pubis. Swelling below this site may signify an adductor longus tear. 
Acute strains are treated with rest and heat., while chronic strains may need prolonged PHYSIOTHERAPY.


Pain in the groin and anterior thigh may be due to an iliopsoas bursitis. The site of tenderness is difficult to define and there be guarding of the mussels overlying the lesser trochanter. Hip movements are sometimes restricted; indeed, the condition may arise from synovitis of the hip joint since there is often potential communication between the bursa and joint.

The most typical feature is a sharp pain on adduction and internal rotation of the hip. Pain is also elicited by testing psoas contraction against resistance.
The differential diagnosis of anterior hip pain includes lymphadenopathy, hernia, a psoas abscess, fracture of the lesser trochanter, slipped epiphysis, local infection and arthritis.


Snapping hip is a disorder in which the patient  (usually women) complains of hip ‘jumping out of place, or catching’, during walking. The snapping is caused by a thickened band in the gluteus maximus aponeurosis flipping over the greater trochanter. In the swing phase of walking the band moves anteriorly; then, in the stance phase, as the gluteus maximus contracts and pull the hip in extension, the band slips back across the trochanter causing an audible snap. This is usually painless but can be quite distressing, especially if the hip gives way. Sometimes there is tenderness around the hip, and it may be possible to reproduce the peculiar sensation by flexing and extending the hip while the patient contracts the abductors.

Treatment of the snapping tendon is usually unnecessary, the patient merely needs an explanation and reassurance. Occasionally, though if discomfort is marked, the band can be either divided or lengthened by Z- plasty.

mendmeshop pics

for any assistance for pain around hip,
31 A, DDA Flats, Pocket 2, Behind Sec 6
Dwarka, New Delhi 110075

Friday, July 11, 2014

Ankle sprain or twisted ankle

A sprained ankle or twisted ankle is a common cause of ankle pain.  
More common is an inversion sprain (or lateral collateral ligament sprain) where the ankle turns over so the sole of the foot faces inwards, damaging the ligaments on the outside of the ankle.

A medial ligament sprain is rare but can occur particularly with a fracture. This happens when the ankle rolls the other way, so the sole of the foot faces outwards, damaging the ligaments on the inside of the ankle. 

The lateral collateral ligament comprises of 3 bands connecting the fibula anteriorly and posteriorly with the talus and with a 3rd band on the sides with the calcaneum. Severe the injury more the no. of bands injured.

In addition to the ligament damage there may also be damage to tendons, bone and other joint tissues, that is why it is important to get a professional to diagnose your ankle sprain.

                                          Grades of Severity for Sprained Ankles:

Sprained ankles, as with all ligaments sprains, are divided into grades.

Grade 1 sprain:

  • Some stretching or perhaps minor tearing of the lateral ankle ligaments.
  • Little or no joint instability. 
  • Mild pain.
  • There may be mild swelling around the bone on the outside of the ankle.
  • Some joint stiffness or difficulty walking or running.

Grade 2 sprain:

  • Moderate tearing of the ligament fibres.
  • Some instability of the joint.
  • Moderate to severe pain and difficulty walking.
  • Swelling and stiffness in the ankle joint.
  • Minor bruising may be evident.

Grade 3 sprain:

  • Total rupture of a ligament.
  • Gross instability of the joint.
  • Severe pain initially followed later by no pain.
  • Severe swelling.


                                                         Treatment of a Sprained Ankle

Immediate First Aid for a sprained ankle:
Aim to reduce the swelling by PRICE as soon as possible.

P is for PROTECTION. The injured ankle should be protected with utmost care to prevent any further injury.

R is for REST. It is important to rest the injury to reduce pain and prevent further damage. Use crutches it necessary. Many therapists advocate partial weight bearing as soon as pain will allow. This is thought to accelerate rehabilitation.

I is for ICE or cold therapy. Applying ice and compression can ease the pain, reduce swelling, reduce bleeding (initially) and encourage blood flow (when used later). Apply an ice pack or similar immediately following injury for 15 minutes. Repeat this every 2 hours.

C is for COMPRESSION - This reduces bleeding and helps reduce swelling.

E is for ELEVATION - Uses of gravity to reduce bleeding and swelling by allowing fluids to move away from the site of injury.

Further treatment

In cases of severely injured ankle (grade 2 and 3) cast can be applied for 3-6 week as per the orthopaedics decision. At times surgical intervention may be needed.

Following the initial painful stage in grade 1 treated with PRICE and after removal of cast in severe cases, physiotherapy treatment can help the ankle return to normal as soon as possible.

Physiotherapeutic modalities like LASER therapy, Ultrasonic therapy and TENS can help reduce pain further and promote healing. Hot fomentation can increase the circulation of the area which further promote healing and increase the pliability of the tissues. Wax bath instead of hot fermentation can be used in cases where cast was applied. 

To strengthen the soft tissues around the ankle start with gentle isometric (tension building without movement) exercises, followed by range of motion exercises within the painfree limits. As for e.g.. writing the alphabets A-Z with the great toe on the floor, heal raises in sitting etc. Approach your physiotherapist to learn more.

Strength can be further developed though resisted exercises with the help of therabands.

The techniques like cross frictional massage and ligament stretching can be implemented to prevent adhession formation and to maintain the flexibility of the ligaments. This helps to reduce the chances of recurrent ankle sprain problems.

The calf muscles often tighten up to protect the joint following a sprained ankle, and so gently stretching the calf muscles can also help to maintain movement at the joint.

A wobble balance board is an important part of rehabilitation of ankle sprains to improve the proprioception (joint sense) which generally gets hampered after any injury.

Contact Pain Free Physiotherapy Clinic for Physiotherapy treatment of ankle sprain.

Dr. Roshan Jha (PT)
Sr. Physiotherapist 
Pain Free Physiotherapy Clinic
31 A, DDA Flats, Pocket 2, Sector 6, Dwarka
Ph. No. 8800299652

Tuesday, July 8, 2014


                    KNEE JOINT

The knee is a hinge-joint formed between the tibia (lower bone) and femur (upper bone), also called Tibiofemoral joint, which is dived into medial and lateral compartment. The patella glides over the front of femoral condyles to form a patellofemoral joint. In addition, there is superior tibiofibular joint between the tibia and the head of fibula(outer leg bone).
                                                                                                                                                                         The knee joint is particularly susceptible to traumatic injury because it depends more on the ligaments due to less musculature around it for its strength and stability.  

The space between the tibia and femur is partially filled by two menisci (inner and outer sides) that are attached to add congruency. They aid in lubrication and nutrition of the joint and act as shock absorbers.

The functions of different ligaments of the knee are:

Medial Collateral (inner side ligament)

Prevents medial (inner side) opening up

Lateral Collateral (outer side ligament)
Prevents lateral (outer side) opening up

Anterior Cruciate (within joint on the front side)
Prevents anterior (front) translation of the tibia on the femur

Posterior Cruciate (within joint on the back side)
Prevents posterior (back) translation of the tibia on the femur.
It must also be remembered that the lumbar spine (lower back), hip, and ankle may refer pain to the knee, and these joints must be assessed if it appears that joints other than the knee may be involved.

     Chondromalacia patella (also called patellofemoral syndrome): Irritation of the cartilage on the underside of the kneecap (patella), causing knee pain. This is a common cause of knee pain in young people.

§        Knee osteoarthritis: Osteoarthritis is the most common form of arthritis, and often affects the knees. Caused by aging and wear and tear of cartilage, osteoarthritis symptoms may include knee pain, stiffness, and swelling.

Knee effusion: Fluid buildup inside the knee, usually from inflammation. Any form of arthritis or injury may cause a knee effusion.

§      Meniscal tear: Damage to a meniscus, the cartilage that cushions the knee, often occurs with twisting the knee. Large tears may cause the knee to lock.

§       ACL (anterior cruciate ligament) strain or tear: The ACL is responsible for a large part of the knee’s stability. An ACL tear often leads to the knee “giving out,” and may require surgical repair.

§   PCL (posterior cruciate ligament) strain or tear: PCL tears can cause pain, swelling, and knee instability. These injuries are less common than ACL tears, and physical therapy (rather than surgery) is usually the best option.

§      MCL (medial collateral ligament) strain or tear: This injury may cause pain and possible instability to the inner side of the knee.

Patellar subluxation: The kneecap slides abnormally or dislocates along the thigh bone during activity. Knee pain around the kneecap results.

§     Patellar tendonitis: Inflammation of the tendon connecting the kneecap (patella) to the shin bone. This occurs mostly in athletes from repeated jumping.

Sharp catching pain
Mechanical defect (trauma)
Aching type pain with morning stiffness which eases with movements but gets worst with exertion
Degenerative changes
Night pain
Degenerative changes, lateral cystic cartilage, Meniscal tear
Pain on weight bearing
Mechanical or arthritic lesion
Pain while climbing up or down the steps or rising from chair
Patellofemoral origin
Pain on twisting
Meniscal origin
Pain over bony eminence below knee in young adults
Osgood Schlatter’s disease

                                           Physiotherapy & Exercise


We all know that your physiotherapist is an expert in the prescription of exercise appropriate to you and your injury or fitness level. As a part of their physiotherapy training, your physiotherapist not only is educated in injury diagnosis but also in exercise physiology or the science of exercise. This enables your physiotherapist to not only assess and diagnose your injury but also to prescribe injury, fitness or age-appropriate exercises targeted to you at that point in time.

What Exercises Should You Do?

It is important that your exercises should not be painful. While some personal trainers believe that the more painful the better, this is not the best for your body or injury. 
In fact, research does inform us that pain inhibits muscles from performing to their optimum. This argues the case that painful exercise is actually counter-productive.
You'll find that your physiotherapist will thoroughly examine you and prescribe a series of exercises suitable for you in quantities that will not injure you further. Please seek an exercise expert, such as your physiotherapist, when you are planning your rehabilitation.

What Happens When You Stop Exercises?

Without some simple exercises, we know that certain muscles can become weak. When these supporting muscles are weak, your injured structures are inadequately supported and predispose you to lingering symptoms or further injury. You can also over-activate adjacent muscles that may lead to further injury.

It is also important to understand that even if you are "in good shape," you may have weak localised or stability muscles.
When you have an injury, you should perform specific exercises that specifically strengthen the muscles around your injury and the adjacent joints. Your physiotherapist will assess your muscle function and prescribe the right exercises specific for your needs.

The exercises prescribed will usually be relatively simple, and do not require any special weights equipment, and can be performed safely at home.

Would You Stop Your Daily Prescribed Drugs?

When your physiotherapist prescribes your individualised dose or exercises, they are using their professional expertise to optimise your exercise dose. 

Would you just stop taking your regular blood pressure medication because you were too busy or didn't think it was working?  I would hope not!

Exercise when prescribed by an expert such as your physiotherapist should be treated as your mandatory dose as prescribed by your physiotherapist. Just like when you don;t take your blood pressure medication, you can't expect the drugs to work of you don't take it as prescribed by your health professional!
So, next time you skip your "exercise dose" just remember that you are not putting your health first.

If you have any questions, please contact PAIN FREE PHYSIOTHERAPY CLINIC.

BPT, DCPT, Mulligan Practitioner
31-A, DDA Flats,Pkt II, Sector 6, Dwarka, New Delhi 110075
Ph. no. - 011-45020554, +918800299652