Search Results: Repetitive Strain INjury

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Repetitive strain injury

Our assessment determines the cause of your repetitive strain injury (RSI). In addition to providing treatment to help tissues heal we take a comprehensive approach to look for undetected weakness, poor coordination and compensatory movement patterns which can cause RSI and/or prolong recovery.

Who will benefit?

Anyone who has injuries which are caused by repetitive tasks. We have experience in treating and preventing:

        Carpal tunnel syndrome

        Tennis elbow

        Golfers elbow



        Achilles strains

        Neck pain

        Low back pain

Service provided by:

Taylor Sipos, RPT            (Bio)

Tiffany Shi, RPT               (Bio)

Juliette Woodruff RMT (Bio)

Igal Untershats RMT (Bio)

John Gray Reg. Kinesiologist (Bio)

More information:

To Book an appointment call 416 925 4687 or email


Preventing Repetitive Strain Injury RSI


When you get hurt, and can’t identify the cause, the most common diagnosis is repetitive strain or RSI.  Although this diagnosis implies that you have strained your tissues by performing an activity too many times, in fact there can be several contributing factors to these types of injuries.  Understanding these factors is the first step in preventing repetitive strain injuries RSI and in curing them.

What causes RSI?

The mechanism of RSI is often compared to a car or a hinge which has been used too many times and is finally worn out however the human body is not a car or a hinge.  Unlike mechanical machinery we are capable of healing.  Prevention is through making better decisions and/or understanding what to change to reduce stress. The most common causes of repetitive strain are failure to allow adequate rest and working too hard.

Failure to allow adequate rest – My associate John Gray R. Kin., discussed the importance of rest in relation to exercise in a previous post.  We understand that people who work out too much get injured.  It is key to build in adequate time for recovery as repeating a task too soon causes the tissues to strain. Whether we get injured with typing or gripping activities at work, in sport or at home the same principles apply  Pain from these simple everyday activities indicate that we are pushing our tissues too hard in relation to the rest we are providing.  Giving yourself short breaks throughout the day goes a long way toward prevention.  Varying your activity is important i.e. if you are on the computer all day try to limit your keyboard time on weekends and evenings.

Working too Hard – Every day I see people make decisions that cause an activity to be harder.  Often countertops are too high for the “vertically challenged”.  To cut a sandwich they bring their shoulder up to their ear when a simpler solution would be to bend their elbow and lift their hand.  These client’s often come to me with pain in their shoulder and neck. My tall clients don’t fit into their chairs.  To adapt they tuck their feet under or stretch them out in front. Sitting on  a pillow or raising the height of the office chair would both be better solutions.  Sore knees and backs are common in these scenarios.

Tips to prevent injury

One thing I have learned over the years is that to be healthy we don’t need to do everything perfectly.  It helps to analyze whether something is more likely to cause an injury and change those things first.  Here are two of the filters I use to limit injury.

Don’t work as hard – When a task is heavy take a moment to ask whether you can make it easier i.e. heavy lifting, Simple changes can help you to prevent an injury such as:

  • Use a cart to bring in the garden soil or the heavy groceries.
  • Avoid lifting above shoulder height. Use a stool to put items on a shelf
  • Think before lifting heavy items off the floor. If it’s light you might get away with bending forward but as the weight increases you need to squat and keep your back straight.
  • Keep the weight close to your belly

Work smarter– Often we don’t think about our technique or our set-up when a task is repetitive or prolonged.  These activities seem easy however they frequently involve the smaller muscles in our hands and elbows.  These muscles tire more quickly. Straining these tissues is often unrelated to the volume of work but more often can be traced to how we do the activity.  When our set-up is poor (ergonomics) it causes us to work harder than we need to. The key to avoiding these injuries is to make better decisions.

Here are 5 simple and effective ways to limit injury.

  1. Don’t perch – sit!  Everyone tells you to sit up straight but it’s even more important to use the back of our chair.  Sitting on the edge of the chair increases the tension in our back muscles
  2. Blood doesn’t flow well uphill. Positioning your hands above the height of the elbows causes more work for our circulatory system.  Our arteries bring the nutrition needed to fuel activities and to repair strains. Hands should be positioned level or tilted slightly lower than the elbows.
  3. Nothing changes posture faster than vision.  If you can’t see the words on the screen most people will perch at the front of their chair or slouch forward to bring their eyes closer to the screen.  Moving your monitor forward is a better solution.
  4. Stay grounded. Feet dangling or resting on your toes are some of the most common bad habits I see in my practice. The problem is that these positions create too much strain on your back and leg muscles and cause fatigue.
  5. The problem with portable computers is they are portable  For over 4 decades we have been studying how to improve work ergonomics (relation of man to machine).  We finally have it right, understanding the height of your chair, monitor, desk etc., when suddenly many of us are no longer working at our desk.  If you are using portable devices try to use them better.  Work most of the time at a desk.  Hold your smart phone up towards your eyes rather than dropping your head. Remember that your head only weighs around 12 lb. when it is centered over your neck but the demand increases to 60 lb. when you drop it fully!

If you are injured these tips are also helpful in your recovery however it is also important to have your physiotherapist look for other issues.  Undetected weakness, poor coordination and compensatory movement patterns can all prolong your recovery from these debilitating and painful injuries. To book an appointment contact us at 416 925 4687 or email

The advice in this article is not meant to replace advice from your health care professional.

Shoulder Injury and Pain 101

The shoulder is a highly mobile joint. It is shaped like a ball and socket and has a very shallow contact where the arm bone and the shoulder blade intersect. This shape causes the joint to be heavily reliant on muscle support to allow for smooth and pain free movement.  It is also the cause of many shoulder injuries and pain.

Causes of shoulder pain

Pain in the shoulder can be caused by any of the structures surrounding the joint. There can be changes to the joint surface caused by wear and tear (osteoarthritis) or due to injury (traumatic arthritis). You can stress the ligaments causing a sprain, or strain the muscles and tendons causing tendonitis i.e. rotator cuff tendonitis. Further development in imaging has also made the medical community aware of symptoms caused by tears of the cartilage surrounding the socket (labrum). Sometimes the shoulder stiffens without any injury or warning and when this happens it is called frozen shoulder.

Shoulder Therapy 

At The Orthopaedic Therapy Clinic your therapist will partner with you to determine the best course of treatment for your injury. When you are having symptoms the most important first step is to understand what type of injury you have. Your therapist will provide a thorough assessment to determine whether your symptoms are caused by the joint, ligament, muscles or are referred from other structures such as the neck.

Stages of recovery

Once the injury is diagnosed the next step is to determine where you are in your recovery. Treatment is predominately determined by your stage of healing.

More acute injuries usually require a plan to reduce pain and inflammation.  Our physiotherapists use modalities i.e. acupuncture, ultrasound, etc,. as well as advise you on home treatments and strategies to help you heal.

As you continue to progress, the focus of your therapy shifts to the restoration of flexibility, rebuilding strength and re-establishing normal movement patterns. Both massage therapy and physiotherapy are helpful at this stage.

The final stage is to determine a strategy to help you return to full activity, sport and long-term prevention. Our therapeutic fitness team provides you with a program to complete this stage of recovery.

Shoulder Conditions we treat

Our therapists have extensive experience in the care of both the acute and chronic shoulder condition. We work with clients after surgical repair of tendons i.e. rotator cuff repair, and before or after total shoulder joint replacements. We provide therapy after joint fractures and shoulder dislocations both in non-operative and post-operative conditions.  We provide therapy for sports related injuries and prevention i.e. swimmers shoulder.

Contact us

Contact us at or call 416-925-4687 to book an appointment or to speak to a therapist directly.

Employee Programs

Therapeutic Massage

Therapeutic Massage

Therapeutic massage treatments are used to create structural change in the body. Using a variety of techniques it lengthens tissues, improves circulation and restores movement in fascia.  It can incorporate many treatment techniques including joint mobilization, deep tissue massage, Swedish massage etc. .  It is used to reduce the risk of repetitive strain injury, as well as reducing pain and inflammation associated with acute and chronic conditions and in cancer-care.

Therapeutic massage helps to facilitate healing and can decrease the time needed for healing through the use of deep tissue techniques, point-specific friction techniques and trigger point massage. The benefit of these approaches may be enhanced by the addition of hot and cold modalities to relax tissues and promote circulation.

Who will benefit?

Therapeutic Massage can help relieve the following symptoms:

  • Headaches/migraines
  • TMJ/tinnitus/vertigo
  • Neck pain
  • Back pain
  • Shoulder Pain
  • Movement dysfunction
  • Muscle and joint pain  

Service provided by: 

Juliette Woodruff RMT

 Igal Untershats RMT

More information:

For an appointment call 416 925 4687 or email:



Our digital technology helps us to get things done and to stay in touch however it also takes a toll on our physical health. Repetitive strain injury, tendinitis, neck and back pain are all caused by poor ergonomic habits and improper use of these devices.

In this article recently published in Investment Executive, Maureen Dwight provides information on identifying problems and how to manage injuries before they become serious.

The Orthopaedic Therapy Clinic is committed to improving your physical health.  Our therapists can help you to recognize the signs of carpal tunnel syndrome and other strains and sprains caused by technology.  We provide advice on ergonomic set-ups and will go onsite to your office to help you to optimize your set-up.

Tips for staying healthy in the workplace

Here are links to some of our past articles on staying healthy in the workplace

  • Take a Seat – Ergonomic Assessment of your Chair by Gareth Sneath,
  • Five Ways to get rid of Neck Pain by Juliette Woodruff,
  • Preventing Repetitive Strain injury by Maureen Dwight,

If you are already having symptoms you can click on “Where Does it Hurt” on our website, , to see all of the articles available on this area.

Contact us to set-up an appointment if you require treatment, diagnosis or ergonomic advice at 416-925-4687 or  If you are an employer requiring ergonomic onsite assessments or an education session for your employees please contact Maureen Dwight at:


Workplace Therapeutic Services

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Workplace Therapeutic Services

The Orthopaedic Therapy Clinic is a recognized leader in providing on-site workplace services for employers who are committed to creating a healthy work environment. Our approach is to work with you to develop a strategy to empower your employees to take control of their injury prevention and to participate in ergonomic awareness.

We work with you to determine your organization’s needs for workplace injury prevention and treatment. Our services can be fully customized or may include previously developed material depending on your requirements and your budget. We provide a wide-array of services including onsite treatment, lectures and involvement in employee health initiatives. Some of our services include:

On-site physiotherapy treatment

This service is suited to companies who take a preventative approach to employee health or have employees with chronic or recurrent repetitive strain injuries. We will work with you to maintain a healthy and productive work force as well as assisting you in managing your WSIB injuries. We have a proven track record in helping our corporate clients reduce the cost of work-related injuries and in improving your employee’s health and sense of well-being. We have provided services in the workplace for over 15 years. We are registered with the WSIB and can help you to manage these reporting requirements. We recognize that early intervention in injury treatment can limit lost time injures and the impact of these claims on your businesses NEER rating.

Many companies also include non-WSIB injuries in their employee health strategy, recognizing that early application of intervention strategies can help keep employees healthy and productive. This approach can also limit the likelihood that the work environment will contribute to these injuries – inadvertently changing a non-work related injury into a work-contributed claim. We work with you to develop strategies for job modification and management to help ensure that these non-work related injuries do not impact on your WSIB ratings.

Repetitive strain injury education

We frequently provide seminars and lectures on the causes and prevention of repetitive strain injury. These sessions focus on empowering the employee to take charge of their own injury prevention through an understanding of the factors contributing to these injuries. We work to create a partnership with management and employees in maintaining a healthy environment. Our educational sessions can be tailored to meet your specific needs and budget. Our standardized sessions can be presented in several formats such as a lunch-and-learn style or as a series of seminars. Our more in-depth programs can be customized to highlight the specific ergonomics of your worksite.

On-site ergonomic assessments

We can assist you in setting-up your employee’s ergonomic work stations. We provide your employees with specific tools that help to maintain these changes long after we have completed the training. We can also work with you to provide a train-the-trainer initiative helping your designated employee(s) be the first-line in managing your day-to-day ergonomic needs. We find that these ergonomic initiatives are even more effective when paired with our Repetitive Strain Injury Education. This program enhances your employee’s understanding of why these ergonomic changes will make a difference. These sessions help to consolidate your employee’s commitment and involvement in managing their own health.

Participation in health and safety initiatives

We are a collaborative partner for corporate health and safety teams who are looking to reduce their repetitive strain injury and enhance their strategies on prevention. We have a proven track record in injury reduction and minimizing lost time through empowering employees in prevention and early treatment initiatives. We are frequent participants in employee health fairs and health awareness initiatives.

Some of our corporate clients include:

  • The Toronto Star
  • Law Society of Upper Canada
  • Princess Margaret Hospital
  • Pfizer
  • Re:Sound Music Licensing Company
  • Sun Oil

Providing injury prevention & technical advice for the entertainment industry

We have frequently provided services to meet the unique needs of the entertainment industry. These services may be accessed at your site or at our clinic. We work with actors to help them to understand the impact of disability on the character they are portraying. We provide injury treatment for members of a cast and/or production team as well as helping you find prevention strategies for situations where you anticipate that injuries may occur.

Some of the productions we have provided services for include:

  • The Terry Fox Story
  • The Passion of Ayn Rand
  • Sweet Here After
  • Murder at 1600
  • Bless the Child, etc.

We have been on standby for injury support for Cirque du Soleil and treated performers from many of the major performance companies including:

  • Canadian Opera Company
  • The Toronto Symphony
  • Les Miserables
  • Lion King
  • Sunset Boulevard, etc.

If you would like further information or a quote on one of these services, please contact our clinic director, Maureen Dwight @ 416 925-4687 or

Massage Therapy

Registered Massage Therapy: how can it help me?

OTC_massageRegistered massage therapy is an integral part of recovery after injury. It can help to speed up tissue healing, restore mobility, reduce inflammation and reduce post-injury compensatory movement patterns.

We recommend massage therapy for relief of:

  • Discomfort from every day and occupational stresses
  • Muscle over-use and repetitive strains
  • Many chronic or acute pain syndromes
  • Reduction in muscle compensatory patterning
  • Post-injury and post-surgical swelling (lymphedema)
  • Reducing side-effects of Cancer-related treatments

Massage can speed recovery and is a powerful tool in the treatment of both chronic (long-term) and acute (brief and severe) soft tissue injuries.  It promotes an overal physical well-being and can be used to improve physical perfomance and body awareness.

Our experienced Registered Massage Therapists (RMTs) work with your body’s soft tissues, including muscles, skin and connective tissue, tendons, ligaments, nerves and membranes. If applied soon enough after accidents involving trauma or injury, Registered Massage Therapy can greatly reduce inflammation as well as the development of painful muscular compensatory patterns which are often a result of pain and injury i.e. piriformis syndrome, iliotibial band syndrome, etc.

Who will I see?

When you work with any of our Registered Massage Therapists, you’ll be dealing with a thoroughly trained professional. Each therapist is a graduate of a government-approved massage therapy school and has completed a minimum of 2,200 hours of anatomical, physiological and clinical studies, including intensive practical instruction. In addition our  therapists have extensive post-graduate education and are an integral part of our inter-disciplinary team working to provide a comprehensive approach to your recovery.

What techniques will my therapist use?

Our Registered Massage Therapists are schooled in an extensive variety of techniques. After completing your assessment they will discuss their approach and help you to determine which technique is appropriate for you. A treatment session may consist of several techniques depending on your specific needs.

  • Therapeutic Treatment Massage
  • Manual Lymph Drainage
  • Myofascial Release Therapy
  • Craniosacral Therapy
  • Scoliosis Therapy
  • Sports Massage
  • Pregnancy Massage
  • Positional release (Strain-Counterstrain)
  • Muscle Energy
  • Cupping
  • Acupuncture including:
    • Medical acupuncture
    • Dry needling
    • Electro-acupuncture
    • Fascial needling (Functional Fascia Therapeutics)

Therapeutic Massage:: Therapeutic massage is also known as deep tissue or Swedish massage.  It is used to reduce the risk of repetitive strain injury, as well as reducing pain and inflammation associated with acute and chronic conditions and in cancer-care. Therapeutic massage helps to facilitate healing and can decrease the time needed for healing through the use of deep tissue techniques, point-specific friction techniques and trigger point massage. The benefit of these approaches may be enhanced by the addition of hot and cold modalities to relax tissues and promote circulation.

Manual lymph drainage: Manual lymph drainage techniques can help improve healing after surgery or injury. These gentle techniques promote healing by enhancing circulation and reducing swelling. Manual lymph drainage techniques can also assist in the long-term management of lymphedema after surgical removal of lymph nodes. Our therapists have also completed post-graduate training in compression bandaging which can be a powerful adjunct in the management of the initial stages of lymphedema.

Myofascial Release:: can reduce adhesions and improve mobility. The application of a gentle stretch to restricted fascial tissues can help to restore movements. These treatments are beneficial if you are recovering from injury, surgery or cancer-related treatments i.e. radiation.

Craniosacral Therapy:: a gentle, hands-on treatment. It is used to reduce tension and stress to improve the functioning of the body. It is particularly beneficial in chronic pain conditions and conditions where stress and tension are contributing to the restriction in healing.

Scoliosis Massage:: beneficial for individuals who have pain and are working to ensure maximum flexibility or to reduce movement imbalances. These techniques can be applied after surgery* to assist in healing as well as in non-operative conditions. At the Orthopaedic Therapy Clinic our scoliosis Massage Therapist applies a unique approach to address muscle imbalances. Our therapists are well-schooled in the over-all management of scoliosis in both the adult and the adolescent.
*Once your post-operative healing is stable.

Sports Massage:: a great technique for both serious athletes and the weekend warrior. Massage can be used as a preventive tool to avoid injury, as well as to decrease recovery time. It facilitates an increase in the range of motion in a muscle, enhancing performance and decreasing the risk for injury. It can also reduce spasms by decreasing hypertonic muscle tissue, increasing circulation and improving lymphatic return to assist in tissue healing.

Pregnancy Massage: beneficial throughout all three trimesters. Massage helps by reducing swelling, alleviating lower and upper back pain or discomfort, increasing circulation throughout the body and creating an overall feeling of relaxation and well-being.

Positional release (strain-counterstrain): a therapeutic technique that uses a position of comfort for the body, and its tissues to resolve physical restrictions and pain.

Muscle energy: a technique using the muscles own energy in the form of a gentle contraction to relax the muscles and lengthen the tissue

Cupping therapy: Cupping uses silicone or glass cups to create a vacuum which draws the circulation to the surface. When the cups are removed the circulation flushes creating the therapeutic effect.

Acupuncture including:

      • Medical acupuncture – is a therapeutic technique that involves inserting sterile fine needles into certain points on the body, encouraging the healing process and relieving pain. It is based on the points established along meridians (energy channels).
      • Dry needling (DN) or Intramuscular Stimulation (IMS)– this is a Western approach to acupuncture. In this technique thin needles are used to directly stimulate and release knots and trigger points in muscles. /
      • Electro-Acupuncture – is a technique that uses acupuncture needles to pass a pulsated current through the tissues to promote healing and/or reduce pain.  The current acts as a peripheral nerve stimulator for inhibited/weak muscles. It can increase the muscles activation/engagement and decrease pain.
      • Fascial needling –  (Functional Fascia Therapeutics) The technique is different from traditional acupuncture as the needles are inserted horizontally and more superficially. The technique targets the subcutaneous (below the skin) layer of tissue to stimulate change in connective tissues

What should I wear during a massage?

Depending on the technique or goals of treatment you may wear fitness clothing or we may ask you to remove all clothing except undergarments.  We recommend you bring shorts and a tank top.  Our therapists protect your privacy with draping to ensure that we only expose the part of your body that is being treated.

Do I need a doctor’s referral?

No, you do not need a doctor’s referral to be treated by a Massage Therapist in private practice. Some extended insurance plans require a doctor’s referral for you to be able to access your benefits. Be sure to check your benefits policy before you make your appointment or give us a call and we will be happy to help you sort out what’s needed.


How to shovel snow without injuring your back

types of snow shovels

Winter can be a tough season for back pain sufferers.  For many people shoveling snow is almost certain to cause low back pain.  Perhaps surprisingly, as a former back pain suffer, I look forward to this season. I enjoy being outside in winter weather and view snow shovelling as a great recreational alternative to going to the gym.  What better than a heavy shovel of snow to raise my pulse, tax my obliques and work on my glutes.  The fireplace and a rewarding glass of wine after can also be a great motivator.   Heres how to shovel snow without injuring your back:


Whether these demanding activities will improve your fitness and strengthen your core, or cause you to need an appointment with your favourite physiotherapist, is often determined by how you approach the activity.  Here are a few easy tips which can prevent low back pain which I find can be easily remembered by using the acronym TEC:  Technique, Ergonomics and Core.

T-Technique avoids snow shoveling back injuries

Technique relates to how you shovel.  Whenever activities are heavy or repetitive the technique you select becomes more important. Video 


Too often it’s our head space that causes our injuries.  We dive in full force, trying to get the job done quickly when our body is not at the same level of readiness as our head. 

When it comes to demanding activities, it is essential to prepare by warming-up if you want to shovel snow without injuring your back. 

Don’t confuse this recommendation with stretching.  Although these terms are frequently used interchangeably, warming-up really means you should raise your body temperature.  This is easily done by starting an activity slowly and avoiding the hard stuff until you feel your body is prepared to work.  You will know you are ready to work harder when you feel warmer and your breathing and heart rate start to increase.  Save the stretching for after the work-out, when your tight muscles need to relax. 

Take breaks

The second mistake we make is trying to get a heavy activity done as quickly as possible.  If an activity takes two hours to complete, doing it all at once is not the same as breaking it into two one-hour sessions.  Instead plan for a 15-minute break to allow your body to recover.  This reduces your risk of injury from fatigue. Always remember that the heavier the activity, the more breaks you need. 

Building strength, not injury

The third most common exercise mistake I see is repeating an activity before your body is ready.  Exercise only makes us stronger if we allow our body to rebuild from the strain. Hard work breaks our muscles down and during this period we are weaker than before we started the exercise.  No matter what type of exercise you do, make sure you build in post-exercise recovery. 

The need to recover is why we shouldn’t repeat the same demanding exercise two days in a row.  This allows sufficient time for our muscles to rebuild. Repeating heavy exercise before our muscles have had time to complete this physiological process raises our risk for injury.  

Ideally, we should exercise on alternate days but when it snows three or four days in a row you may not have a choice.  When this happens try to reduce the intensity by taking more breaks or lifting smaller loads.   Alternatively, perhaps the kid next door needs to earn a few extra dollars.…

To maximize recovery, take a page from the playbook of athletes and make sure you are well hydrated and consider your post-activity nutrition requirements.  In moderation foods that contain both sugar and protein provide your muscles with what they need for recovery i.e. low fat chocolate milk.

Learn the technique of lifting with your legs as the key on how to shovel snow without injuring your back

If you want to shovel snow without injuring your back you should “lift with your legs”.  Although I find that most people can recite this mantra they don’t actually execute it all that well. Rather than keeping their torso over their legs they lean forward.  When you are lifting in this posture it increases the difficulty of the task as you are now lifting the weight of the snow, the shovel as well as the weight of your upper body.  This can add 40 or 50 lb to a lift.   Keeping your shoulders over your hips reduces the strain on your back. 

This video shows a difficult snow shoveling task .  The area is bordered by a shoulder height barrier.  The shoveller is bending her knees and lifting smaller loads to reduce the strain of the task.

Use the right muscles

As you squat to lift the snow, pause for a moment and feel which muscles are working.  You should be using both your thigh (quadriceps) and buttocks (gluteus maximus) muscles.  Many people who are at risk for low back pain don’t use their buttocks and overuse their back muscles.  The high strain on the back  muscles causes spasms.  

Limit twisting 

Your spine is able to twist but twisting while you are lifting a heavy load is a quite another matter.  In snow shoveling, twisting can be avoided by pushing the snow forward rather than throwing it over your shoulder.  If you need to twist, keep the load lighter and take more breaks.     

types of snow shovels

E-The right Equipment avoids back injuries

Always take a moment to look at which tools you can use for the task.  A larger shovel will get the job done faster but it will also add to the strain.  A lighter, smaller shovel will take a little longer to complete the task however a few extra minutes is well spent in preventing an injury.  You can also consider one of the ergonomically designed, bent-handled snow shovels as they can make a substantial difference in the effort needed to push snow (see picture). 

C-Good Core avoids back injuries 

Despite following the best advice on technique and ergonomics some people will still get injured.  As a treating physiotherapist I have found this can often be traced back to mismatches between what you need to do the task and what strength your body has available.  Video

Before you start the snow season, make sure your abdominals, buttocks and thigh muscles are up to the task. If the snow arrives before you have gotten your core muscles working it is even more important that you focus on the T and E in TEC as this will limit the likelihood of injury.  On non-snow days work on targeted exercises to gain the lifelong support you need to prevent injury.

Next year start your pre-season fitness program in the fall, rather than waiting for the new Year.  Better yet keep the program going all year long as each season has its challenges and activity rewards.

Need more advice

If you need a fitness program our Kinesiologist, John Gray, or our Pilates/Yoga instructor, Aniela Amio can help you find your core.  They can also teach you the technique of how to snow shovel to without hurting your back.   If your back hurts even thinking about snow shoveling book to see one of our physiotherapists to get you on the right track.  Call us at 416-925-4687 or email to book an appointment.

Svetlana Marianer – Bio

SvetlanaMarianerSvetlana Marianer


Registered Physiotherapist, MSc. Pht

Svetlana Marianer graduated from McGill University with a Bachelor’s in Rehabilitation Science and a Master’s in Physiotherapy in 2012. Since completing her degree, she has taken various continuing education courses such as Manual Therapy, Mckenzie’s Cervical, Thoracic and Lumbar spine, Mulligan’s Lower Quadrant assessment and treatment, Blaise Dubois’s Prevention of running injuries and non-traumatic lower extremity injury, numerous courses from the Advanced Physical Therapy Education Institute (APTEI) and many more.

As a former ballet dancer and a present CrossFit athlete, Svetlana is particularly interested in orthopedic care, the prevention and treatment of sport injuries and the biomechanics of movement and all it encompasses. Moreover, although Svetlana’s nature is that of an athlete, she has a strong foundation in managing acute and chronic low back and neck pain, various repetitive strain injuries and a variety of musculoskeletal impairments resulting from every day and or recreational activity. Svetlana’s recent passion has been in women’s health which prompt her to get her training in pelvic floor therapy. Her focus is to create a comfortable environment where issues related to the  bowel, bladder and the sexual health are openly discussed and treated. Her skills allow her to treat clientele of all ages. Svetlana is fluent in four languages : English, French, Hebrew and Russian.

Dry Needling – A Western Approach to the Eastern Art of Acupuncture

Dry Needling is an acupuncture-­like treatment used in therapy. Also known as intramuscular stimulation (IMS), this treatment is used to reduce muscular and myofascial (1) pain, release trigger points, and restore movement.

It may be used to treat a chronic condition or an acute episode particularly when there is no obvious cause of injury, i.e. repetitive strain injuries (RSI). Every muscle in your body is comprised of numerous muscle fibers, which generally line-up in the same direction. This structure helps each of your muscles produce the greatest possible amount of power. To do this, the fibers need to glide and move freely. However, through a lack of mobility the fibers within the same muscle, or between different muscles located next to each other, can stick together and form what is felt as a thickening or knot.

These adhesions can also be felt as taut and tender spots in the connective tissue or in the fascia which surrounds muscles, resulting in myofascial knots and trigger points. These adhesions  can form when your muscles are held in a shortened position for a long period of time, such as sitting at a desk with poor ergonomic support. Trigger points can also result from contusions (bruises) or repetitive stress, such as the pain you may feel in your forearms due to typing.

Eastern vs. Western Acupuncture

Dry Needling is considered to be the Western approach to acupuncture. It focuses on the biomechanics of the body, emphasizing the importance of human body’s structures and movements; rather than the energy channels used in Traditional Chinese Medicine (TCM).

The practice of dry needling began in the 70’s when North American Physicians wondered what would happen if they stimulated trigger points in the muscles using only the needles, instead of injecting local anesthetics. The term dry needling was chosen because nothing was being injected through the needles.

Ever since its introduction a number of studies have shown there is as much benefit from dry needling in the treatment of musculoskeletal pain as there is with the injection of different substances, including corticosteroids and analgesics. 

These results prompted me to study dry needling as well as acupuncture to treat muscular and myofascial pain. Although I use both techniques, in my practice I have found dry needling helps my patients recover faster and I often use it in conjunction with manual therapy and other more traditional physiotherapy modalities.

What is the difference between acupuncture and dry needling? 

In TCM, besides the points established along meridians (energy channels), individual points (2) are frequently targeted to treat myofascial conditions. These points often resemble trigger points and/or motor points in the tissue. In contrast, dry needling directly targets localized trigger points regardless of their relation to meridians. Depending on your healthcare practitioner’s approach, Dry Needling and Acupuncture points may or may not be identical. However, even when the points are identical, the two techniques can be rather different. By inserting needles through the skin, fascia, and into tense muscle fibers, dry needling directly releases knots and trigger points. These fine needles are similar to – or often the same as – acupuncture needles. However, they are not left inserted in the muscles for an extended period of time. Instead, they are moved in and out of the trigger points to elicit a contraction, twitch or “popping” sensation in the muscle fibers.

How does Dry Needling work?

Dry needling restores your muscle fibers’ natural movements and reduces restrictions that impede mobility. It helps to restore muscle efficiency through contraction and relaxation of specific fibers. This technique can also release endorphins – the body’s naturally occurring morphine which reduces pain!

By inserting a needle into a tense muscle an involuntary contraction or twitch may occur. These local twitch responses (LTR) have been shown to improve treatment outcome (3). The quick contraction causes the adhesion in between muscle fiber to break down and improves the movement of the muscle.  As the fibers shorten and pull away from the trigger point the result is a release of tension and relaxation of the muscles.

Is Dry Needling painful?

Here at the Orthopaedic Therapy Clinic we commonly believe in a  “No Pain, More Gain!” model of treatment. However, Dry Needling is one of the few techniques in which some pain can result in more gain!

When inserted into a relaxed muscle at rest, needles face minimal resistance as they move through muscle fibers and there is little to no discomfort. However, the higher the tension, the more resistance there is to the needles entering the muscle. The result is that you may experience a quick cramp-like sensation with a local twitch response when trigger points are targeted directly. For this reason, some patients may find the application of dry needling more uncomfortable than traditional acupuncture. After a treatment you may feel a localized soreness for up to 48 hours after a dry needling treatment session. It is important to allow an adequate amount of time between dry needling treatment sessions to let your body’s natural healing process to take place after each treatment.  Treatments are typically scheduled once this localized soreness has resolved.

Who benefits from dry needling?

As a practitioner, I use both acupuncture and dry needling to treat acute as well as more persistent or chronic conditions. Considering that breaking down adhesion is not the primary focus of acupuncture, I find dry needling more effective when dealing with chronic tightness and cramps in muscles and fascia; particularly when there is a plateau in recovery with other treatment techniques. Dry needling is beneficial in combination with other physiotherapy treatments (strengthening muscles, manual therapy, soft tissue release, etc.). I recommend this technique for treatment of a number of conditions; including, but not limited to:

  • Conditions associated with poor posture (i.e. Postural dysfunction),
  • Tendonitis,
  • Headaches and neck pain,
  • Back pain,
  • Repetitive strain injuries,
  • Muscle strains,
  • Concussion related symptoms

If you experience knot-like pain in your muscles that does not settle with other types of therapy, restricted range of motion or functional limitations; or if you feel that you no longer get lasting relief from other types of treatment, contact Milad Bazaz at the Orthopaedic Therapy Clinic to set up an appointment for a thorough assessment and to discuss whether dry needling is a treatment option for you.

  1. Myofascia is a dense and thin layer of tissue that covers muscles and bones in the body.
  2. Called Ah shi points
  3. APTA (American Physical Therapy Association)


Take a seat! Ergonomic assessment of your chair.

Neck and back pain often result from too much sitting and computer use. Although we usually think of sitting as a “rest” activity this seemingly innocuous every day activity puts significant loads on our spine. While it may not appear strenuous, science has shown that sitting increases the pressure on low back discs and even more so if we slouch. When doing ergonomic assessments I frequently find people don’t take the time to adjust their chair.  I go into their office and find the tags still attached and the manufacturer’s plastic still covering the knobs.   Taking a few minutes to ensure you have a good ergonomic set-up of your work space and your chair will go a long way in relieving and preventing repetitive strain injuries and pain.

Sitting is the new cancer

Sitting has received some pretty bad press lately, even being referred to as the new cancer.   This perpetual inactivity can lead to a reduction in physical fitness levels and health. Before you try to combat this trend by changing jobs or switching to a treadmill desk there are a couple of simple things you can do to reduce the impact of sitting and promote better health and comfort.

  1. Improve the way you sit  (posture and how the chair “fits” you)
  2. Reduce the length of time you sit 

What to look for when buying a new chair 

 The longer you sit the more important it is that you have the right support.  The right chair encourages good posture to unload your spine. Your chair should “fit” you just like a good pair of shoes fits your feet. To help encourage a good fit when you are purchasing an office type chair look for adjustable, “ergonomic” features.  You should be able to adjust the chair to make sure it provides the support you need.  Look for a chair where you can: 

  • Adjust the height of the chair
  • Alter the depth of the seat pan
  • Raise or lower the arm rests
  • Angle or tilt the back of the chair
  • Increase or decrease the support for the back (lordosis)

Take the time to adjust your chair

An ergonomic assessment of your office work station, and in particular your chair, is becoming more recognized as an important element in injury prevention.  Having an ergonomic assessment when you are new to the job is a best practice in some of the companies where I provide onsite ergonomic consulting however not every business provides this for their employees, particularly if we work at home or are self-employed.  With a few simple tips many of us can learn how to improve our set up and reduce our risk for the injuries of stationary living.   Posture and comfort can be improved by using these guidelines to ensure your chair “fits” you. The diagram below shows how we should be positioned when sitting. We call it “neutral” as this position has minimal strain. The set up of the chair helps to give you the right support in “neutral”. Familiarize yourself with your chair’s features and adjust them to enable a neutral posture.

  • Note the upright position of the spine with hips at the back of the chair.
  • Eyes level with the top of the monitor
  • Elbows at a right angle, arms by your side
  • Wrists in line with the forearms
  • Hips and knees at a right angle or slightly downward sloping
  • Feet flat on the floor or foot stool

How to improve your current ergonomic set-up

Even if you don’t have the perfect chair,  simple adjustments can improve many set-ups.  Here are a few suggestions to improve your current work set up:

  • Use a pillow or back support if your chair is too deep or if it leans back too far.
  • Use a foot stool if the chair is too high or sit on a cushion if it’s too low.
  • Purchase an external keyboard for your portable.  This allows you to raise the computer screen without lifting your hands too high.

Finally, remember that even when you have an optimal chair set- up it is still important to stand and move around.  Try to move about 5 minutes for every 40-60 minutes of sitting.  Walk or climb stairs on your longer breaks to give your body some much needed activity.

Onsite assessment and resources

An ergonomic assessment provides a practical way of keeping employees healthy. As an employer or manager if members of your team are having symptoms or have lost time from work due to aches and pains related to their chair or work station, consider having an ergonomic assessment completed. This can be conveniently done on site, adjustments made where possible and recommendations discussed. Alternatively be pro-active and improve your employee’s work station before they get symptoms.  To discuss or arrange onsite ergonomic services contact Gareth Sneath at, 416-925-4687.

Looking for more advice?

Check out the September 2016 article posted by Juliette Woodruff, RMT “Tips to relieve mid back pain and discomfort”.

The Ontario Ministry of Labor has an excellent web site on the other ergonomic factors to consider for your work station


This advice is not intended to replace the advice of your professional or to replace an ergonomic assessment.  Contact your professional if you are having pain or require further advice.    

Reducing Stress With Exercise – It’s All In Your Core

If you need one more reason to exercise your core this recently published article may provide the scientific basis that will help to motivate you http://www.theatl. At times it’s a bit technical but the key message is that there are newly discovered pathways connecting the motor cortex – the part of your brain which produces movement,  to your adrenal glands – the organs which produce chemicals related to stress. In other words:

We are hardwired to use exercise to reduce stress.

Reducing stress with exercise

Up until now the reduction in stress from exercise has often been attributed to the psychological impact of relaxation.  Beginning in the 1950’s Dr. Hans Selye showed that body chemistry changed in relation to stress.  More recently Dr. Jon Kabat Zinn gained strong scientific support for Mindful Meditation, showing changes in blood chemistry resulted from performing his techniques. This more recent article shows that the relationship of exercise is much more than psychological. The existence of physical pathways means our nerves are direct connections which regulate the relationship between the movement center of our brain and our organs. Doing radical research, in what at times reads like a biological sci-fi thriller, this neuroscientist used the rabies neurotoxic virus to follow the pathways between these two systems.

The upshot is that strengthening your core is not only good physically, it also may have a greater effect on reducing stress than other types of exercise such as cardio or weightlifting.

This conclusion is based on the number of connections between the core muscles represented in your brain and these glands.  This larger network of nerves suggests that there should be more to gain in relation to lowering your stress hormones by exercising these specific muscles. The key take away from this article:

Short of time? Focus on exercising your core to achieve stress relief. 

Getting on track

If your goal is to use exercise to reduce stress or if you are trying to get back to fitness after an injury our team can help you get on track.

  • Physiotherapy: Seeing one of our physiotherapists can be a helpful first step in avoiding injuries which can be caused by an over-enthusiastic start to a new program or unaddressed imbalances. An assessment will help you to determine which muscles to target and/or what to treat prior to beginning your fitness program.
  • Kinesiology: Once you are ready to get started on your fitness our Registered Kinesiologist, John Gray, can design a customized fitness program specific to your needs and goals. Focusing on your core will help you to build strength, reduce risk for re-injury, improve balance as well as helping you to manage the effects of stress.
  • Chiropractic: Need a gentle start? Our chiropractor Dr. Adonis Makris is a Master in Medical Qigong.

Maureen Dwight is a registered physiotherapist working in downtown Toronto.  The Orthopaedic Therapy clinic frequently provides onsite and offsite workplace therapy and ergonomics.  Please contact us if your company would like to explore our education, treatment and/or ergonomic services or if you have or want to prevent repetitive strain injuries.

The advice in this article is not meant to replace advice from your health care professional.

When Hamstrings Attack


Each spring, many frustrated clients arrive at the clinic with tight and painful hamstrings.  Despite their best efforts to stretch, massage, or roll them into submission, they have made no progress.  For some it only made things worse, causing sudden attacks of pain and cramps in the hamstrings, low back and even the calves.

Common wisdom tells us that to relieve tightness in a muscle, just stretch it.  It’s true that in many cases, a tight muscle is just a tight muscle, and stretching can help in recovery and relief.   However, when we’ve tried an approach that doesn’t seem to be helping, it often ends up that the pain is not where the problem is.

Getting to the source of the problem

When stretching doesn’t help it is usually because we are treating the symptom, not the problem.  From the clinical perspective, we refer to hamstring tightness as a compensation strategy.  The tightness is your body’s way of supporting other muscles, as well as changing posture and movement.  However, tightness also comes with changes in the way that deeper muscles work, creating an imbalance in the muscles that coordinate to maintain stability and mobility.  And this is not good.

Many leading clinicians believe that compensation strategies arise from a strain, sustained posture or repetitive movement that created physical pain at some point in one’s past.  When hamstrings compensate and tighten up, they stop your pelvis from naturally tilting forward.  This increases the effort needed to walk, run, climb and step, and can also flatten or round your low back.  These changes put more stress on the low back and leg muscles which can add up and get worse over time.

This discovery has led to the use of the phrase –  “using high load strategy for a low load task”.  This means that you are using additional muscular effort for normal daily activities that should be relatively effortless.  Some clients describe these compensatory strategies as a sensation of heaviness in the legs, muscles that fatigue quickly, or of a feeling as if you are “driving with the parking brake on.”

How to get better

Depending on the cause, rest and anti-inflammatory drugs often help temporarily relieve symptoms, but often do not help in the long run.  Even when the pain subsides, muscles may not automatically reset themselves and return to normal,1 increasing the risk that the lingering imbalance could resurface as a bigger problem in the future.  Research2 suggests this may explain why so many people suffer recurrences of the same problem after their initial injury.

The key to getting better is to first identify and then retrain those deeper muscles whose response has been decreased by pain.  This is done with slow, specific movements that focus on your ability to control the activity of the deeper muscles.  This treatment approach proceeds from easier, non-functional movements, to dynamic, functional, movements so that muscles progressively rebalance their activity to share the load efficiently.  Rushing ahead with strength training too early will not let us retrain a “low load strategy for a “low load task”, since over-active, tight muscles would reinforce a “high load strategy” for all movements.

Identifying the affected muscles requires a thorough evaluation by a qualified musculoskeletal health professional.  Fortunately, our treatment for such a complex problem often won’t even ask you to break a sweat.  At the Orthopaedic Therapy Clinic, we routinely prescribe only 3 or 4 simple exercises that can be done in under 12 minutes and requires no equipment.   These exercises improve the deeper muscles’ contribution to joint stability so that over-active muscles don’t have to compensate for this loss.  Tightness and stiffness naturally recede as muscles work more efficiently in the balance between movement and stability.

I hope this short article has helped clarify that not all muscle stiffness is created equal.  If you suffer from unrelenting hamstring tightness, it could be a sign of more serious issues that should be addressed before larger injuries possibly occur.  If you would like more information on this subject, or to book an appointment, please call us at 416-925-4687 or email me at

This information is for educational purposes only and does not constitute medical advice for any condition.  Reasonable and appropriate care should always be performed by a qualified health professional after a comprehensive evaluation to identify treatment goals.


  1. Hides JA, Richardson CA, Jull GA. (1996).  Multifidus muscle recovery is not automatic after resolution of acute, first-episode low back pain.  Spine, Dec 1;21(23):2763-9.
  2. Comerford, M & Mottram, S (2012). Kinetic Control: The management of uncontrolled movement.  Churchill Livingstone.


Low Back Pain and Core Strength

I DON’T HAVE TIME FOR THIS!  Second in a series on causes of low back pain.

You got to have core!

Maureen Dwight, Registered Physiotherapist, Clinical Musculoskeletal Specialist, Advanced Spinal Practitioner ISAEC

The role of a strong core is almost undisputed when it comes to winning the battle against low back pain.  No matter how fit you are or how flat your belly, the most common recommendation is to get a better core.  For most people this recommendation translates to strength exercises.  More sit-ups or Pilates-type leg lifts. Often bird dog, Superman’s and planks enter your daily therapy routine but as the research in this area expands we need to know whether doing exercises will give us what we need.  Not only do we want to recover from our current episode of low back pain but we also want to limit future occurrences. Ultimately we need to know whether we should put our time and energy on low back pain and core strength exercises or whether other strategies such as sleep habits[1] make the bigger difference in recovery and causing low back pain in the first place.

What is core?

Although the need for muscle support for a healthy spine is undoubted, the experts have yet to agree which muscles constitute “core” or what aspects of these muscles’ support is critical to your recovery.  Some experts limit their definition of core to the abdominals whereas others include the buttock and back muscles.  When it comes to determining the relationship of low back pain and core I find that I generally need to look for deficits in several muscles but typically one of the first groups I check are the ab’s.

Low back pain inhibits core functioning

There are several compelling studies outlining the role of the abdominal muscles in low back pain.  For example in 1998 Dr. Paul Hodges[2] literally revolutionized our perspective on a relatively ignored abdominal muscle. As a result of this seminal study Transversus Abdominis went from relative anatomical obscurity to becoming almost a household name in the lexicon of back pain.  Dr. Hodges showed us that a change in function of this muscle could be predicted strictly by experiencing back pain.  In other words there was no need for injury or damage to the back, simply feeling pain was enough to change the muscle’s function.

Low back pain prevention and coordination of abdominal and core muscle response

Another factor causing low back pain is the speed at which your abdominal muscles react to unanticipated events. To prove this theory Dr. J. Cholewicki[3], a pre-eminent biomechanist, recruited Varsity athletes with no previous history of low back pain.  Each participant sat on a bench with their chest leaning into a support until a magnetic force released the support without warning. The subject suddenly and unexpectedly needed to establish independent posture. Electrodes  were used to measure how quickly the abdominal muscles reacted to create more support.  The results showed that if these muscles were delayed by as little as the time it takes you to blink your eye (>14 milliseconds) that this was enough to predict future problems.  Although there were no injuries from the testing over the next three years they found that this delay predicted the likelihood of the athlete experiencing their first episode of low back pain. To further understand Dr. Cholewicki’s study it might help to imagine  the post you are leaning against suddenly and unexpectedly gives way. How quickly your muscles sense this change will determine whether you will fall however back pain is typically more insidious than this more predictable injury.  Instead think about how your muscles react to every turn in the road or every shift in the bus. Your muscles need to absorb these forces to keep you upright, otherwise all of us would still need to be strapped into an infant’s car seat.  Failure to support our spine sufficiently against these and other small repetitive irritants means that repetitive strains are being transmitted to our back.  Over time these irritants accumulate and cause injuries.  This is why many of us can never fully identify the factor hurting our back – the forces are too small and too repetitive for us to take notice of. The key message I take from these studies is that our body is protected by a quick response in the muscle system which limits our risk for injury.  If that response is slow or insufficient then the repetitive strains can cause injuries.

  • The role of our muscles is to prevent injury and the faster and the more comprehensively they react the less likely we are to get hurt
  • The delay in the abdominal muscles reacting to an unanticipated event is predictive of a future episode of low back pain

Symptoms of poor core support

  • Low back pain
  • Back stiffness
  • Poor sport or recreational performance
  • Poor balance

Tests to see if your low back pain caused by poor core

Unfortunately for most clinicians the equipment needed to test these muscles is too elaborate and too expensive to allow for wide availability however there are some simpler tests[4] which I have found helpful in determining if abdominal stabilization is a problem.  Try these simple tests to determine if you should seek out a therapist to try to prevent future episodes of low back pain.

  1. Single leg lifts: Lie on your back with your knees bent.  Place your fingers on the bumps on the front of your pelvic bones (ASIS).  As you lift one leg check to see whether the bones stay still or feel like they rock or tip under your fingertips.  If everything holds steady it is likely that your abdominal muscles are stabilizing your spine against the force of moving your leg. If you feel movement it is likely that you need to improve your stabilization.
  2. Lying arm reach: Lie on your back with your knees bent. Bend your elbows and tuck them into your sides.  Lead with your fingertips as you reach your arms straight to the ceiling.  You should feel a sensation of deep hollowing as the Transversus tightens and your abdominal muscles pull inward toward your back bone.  This test shows whether your core is providing support for the simple motion of moving your arms.  I find this test particularly important for back pain in computer workers and students as the support for the arms should come from the abdomen, not the back or the neck muscles.

 When to seek therapy 

You may benefit from seeing a spine therapist if during the leg lifting self-test you:

  • Felt your hip bones tip or rock
  • Felt a gripping in your ribs and/or tension in your back or neck
  • Felt your back arches or your head lifts off the mat
  • Felt your “six-pack” (rectus abdominis) and/or abdominals next to the pelvic bumps (internal oblique) pop outward.

You may also benefit from an assessment if during the arm lifting self-test:

  • You did not feel your abdominals react[5] at all.
  • You felt your “six-pack” (rectus abdominis) and/or abdominals next to the pelvic bumps (internal obliques) pop outward.
  • You felt a gripping in your ribs and/or tension in your back or neck

When deciding where to put your time and energy to prevent low back pain I would recommend that if you failed any of these tests or have experienced low back pain you should consider seeing a registered physiotherapist or registered kinesiologist whose perspective goes beyond looking at the relationship of low back pain to core strength.  Their examination should include tests to look at muscle activation and coordination.  If you passed all of these tests than your low back pain may not lie in the activation or the coordination of the abdominal muscles.  Perhaps it lies in the sleep deprivation[6] we previously looked at, other “core” muscles and/or the second factor in Dr. Cholewicki’s study which we have yet to have a look at, body weight.

The next topic: How weight changes cause low back pain. 

Maureen Dwight is a registered physiotherapist practicing in downtown Toronto at the Orthopaedic Therapy Clinic.  For more information on treatment options for prevention and alleviation of low back pain please contact us at or drop by our Toronto Clinic. The advice in this article is not meant to replace advice from your health care professional.   [1] [2] [3] Biomechanics is the study of physics applied to the human body. [4] Tests based on the movement patterns described by Dr. Hodges [5] Most people have difficulty feeling reaction on the leg lift test but it is quite apparent with the arm reach [6]  

What You Need to Know to Prevent and Treat Shoulder Pain Caused By Swimming

Swimmers shoulder is a soft-tissue condition caused by inflammation and is the most common injury in swimmers. If misdiagnosed or mal-treated, it can become chronic and very painful. Someone experiencing swimmer’s shoulder might ask the following questions:

  1. Why does my shoulder hurt when I swim?
  2. I train a lot and my shoulders are strong, why does swimming still hurt?
  3. What can I do to treat my shoulder so that I can return to swimming?
  4. I heard swimming injures the rotator cuff. Is swimming safe for my shoulders?

This article delves further into shoulder anatomy and the causes and resolutions of swimming-related shoulder injuries. It will answer the most important injury-related questions and provide insights to help avoid recurring injuries in swimmers and for other causes of shoulder pain.

Shoulder Anatomy

The shoulder is the most mobile joint in the human body however it’s biomechanical structure sacrifices stability for mobility. This design disadvantage can be visualized as a golf ball sitting on a tee. The large humeral head (the top of the arm) sits on a tiny scooped out glenoid cavity (part of the shoulder blade) and together, they form the shoulder joint. Unlike the golf ball which is meant to be launched from the tee, the head of the humerus must remain centered and stable yet allowing for a large range of motion.

An important muscular system called the rotator cuff stabilizes this “ball” and prevents it from sliding off the socket. The rotator cuff has the largest effect on joint stability and is comprised of four muscles; supraspinatus, infraspinatus, subscapularis and teres minor. These muscles and their tendons run around, over and under the joint and are protected from the rough surfaces of the bone by a cushioning fluid filled layer called the “bursa”. In a healthy shoulder, the tendons are protected by the bursa and glide underneath the bony structures without being harmed when the arm is moved. However, when it comes to competitive swimmers where each shoulder averages roughly 4000 strokes in a single workout, the biomechanics start to change.

1. Why does my shoulder hurt when I swim?

Swimmer’s shoulder injuries occur primarily due to excessive repetitive overhead motion. This movement narrows the subacromial space, a tunnel like opening located between the acromion (the front part of the shoulder blade) and the humerus. As this narrows, the space for the tissues becomes restricted. This results in the bone applying direct pressure to both the tendons and bursa, inflaming and irritating the soft tissues. This can lead to conditions such as impingement, bursitis or tendonitis.

2. I train a lot and my shoulders are strong, why does swimming still hurt?

Swimming long distances, excessive training, poor stroke mechanics and lack of rest can all demand more from the shoulder muscles than they have to give. It’s sometimes easy to forget that overworking our muscles and overtraining can interfere with what we are trying to achieve and instead lead to regression, poor performance and detrimental changes. When the rotator cuff is overworked it weakens and fails to stabilize the shoulder; often leading to subluxation of the joint.

3. What can I do to treat my shoulder so that I can return to swimming?

It is important to keep in mind that swimming demands much more than just the isolated function of the shoulder. We use our shoulder blades, back, trunk and legs to stabilize the body and help with the pulling motions. Overall, shoulder injuries can be prevented by adding in dry land exercises that are designed to strengthen these muscles.

At the Orthopedic Therapy Clinic, our physiotherapists determine the source of your shoulder injury by assessing your shoulder strength, range of motion and posture. We look for signs of glenohumeral instability, altered scapulohumeral   and poor neuromuscular control.

  1. Shoulder dislocation :
  2. Scapulo-humeral rhythm
  3. Poor neuromuscular control:

Each of these alterations can lead to training errors and restrictions which can cause and prolong the recovery from a painful swimmer’s shoulder.

Whether your shoulder pain is due to swimming or other causes, once the source of injury has been determined, our physiotherapists guide you through a comprehensive rehabilitation program that includes these five important steps:

Step 1: Injury Protection: The aim in this step is to decrease pain and inflammation and provide active rest from pain-provoking movement. Treatment includes modalities such as ultrasound, TENS, Interferential current, acupuncture, massage, heat/ice, rest and anti-inflammatory tips. In this step, we want to avoid painful movements while making sure the shoulder keeps moving in order to prevent other complications such as frozen shoulder.

       Also at this stage we want to keep the body moving and work on restoring the core as well as strengthen the areas that haven’t been affected. It is crucial to keep in shape and keep          active without straining the injured shoulder.

Step 2: Regain full shoulder range of motion: In this step, the goal is to help regain healthy, pain-free shoulder mobility. Our physiotherapists focus on stretching, myofascial release, joint mobilization and active/active assistive exercises. This is accomplished by lengthening shortened muscles, manually working on the joint and prescribing light strengthening exercises. Massage therapy can also be helpful in regaining motion and lengthening tissues.

Step 3: Restore scapulo-humeral movement: The shoulder is highly dependent on the scapula (shoulder blade) and its ability to control normal movement. An improper ratio of motion of the shoulder blade to the shoulder joint is a major cause of rotator cuff impingement and chronic shoulder pain. This step aims to correct this altered scapulohumeral rhythm and promote exercises to strengthen the shoulder blade and upper back muscles. This is an essential component for successful rehabilitation.

Step 4: Restore rotator cuff strength: In this step, our physiotherapists prescribe an exercise routine designed to regain the full strength of the rotator cuff muscles. Each exercise is individually tailored, progressing the athlete’s strength and endurance through the rehabilitation.

Step 5: Return to swimming: In this step, physiotherapists may suggest the professional coaching of a kinesiologist or work with your swim coach. This close interface will help to customize a training program designed to progressively increase speed, power, and agility. Athletes should work to perfect their technique as they slowly return to a full load.

4. Is swimming safe for my shoulders?

At the Orthopedic Therapy Clinic, we believe that prevention is the best medicine. We strongly suggest that all athletes undergo a screening evaluation prior to the start of their swimming season. Our physiotherapists focus on prevention and early treatment, identifying and addressing impairments prior to injury and evaluating our swimmers’ training methods and mechanics to ensure they are best suited for their goals. The screening evaluation of an uninjured athlete is as extensive and detailed as the one used for a swimmer with symptoms and in both cases, the goal is to determine if restrictions exist and then a plan is provided to prevent shoulder pain. The best prevention remains through specifically tailored exercises, good stroke mechanics and gradual increases in workload.

Svetlana’s background

In my practice I have had the privilege of working with many water based athletes as well as expanding my knowledge by completing a number of courses related to the shoulder and the rotator cuff muscles. In my experience, the prognosis for recovery is very good as long as the problem is caught in the early stage of injury and if all the steps of healing are successfully completed.

Swimming is an excellent sport that I encourage for many people. I am motivated to help those suffering from injuries so that they can get back in the water as soon as possible. If you are experiencing a swimming shoulder injury, a rotator cuff injury, or any shoulder pain and want to get it resolved, please contact me, Svetlana Marianer Registered Physiotherapist, at the Orthopedic Therapy Clinic in downtown Toronto.

This information is not meant to replace medical/health advice. Contact your health professional to ensure the diagnosis and treatment options are appropriate for your condition.

Reference :

Abelew T. Kinesiology of the shoulder. In: Tovin BJ .Evaluation and treatment of the shoulder: an integration of the guide to physical therapist practice, 2001. 

Becker, T. Components of a Dry land Exercise Program for Injury Prevention, A Scientific Approach To The Sport of Swimming, 1983.

Bell, K. Motivation, A Scientific Approach To The Sport of Swimming, 1983.

Ciullo, J. Swimmer’s Shoulder, Clinics in Sports Medicine, 1986.

Lewis, J.S., Green, A, Wright, C. Subacromial impingement syndrome: The role of posture and muscle imbalance, 2005.

Murphy TC. Shoulder injuries in swimming. In: Andrews JR, Wilk KE (eds). The Athlete’s Shoulder, 1994.

Richardson, A. The Shoulder in Swimming, A scientific approach to the sport of swimming 1983.

Seitz, A.L., McClure, P.W., Finucane, S., et al., Mechanisms of rotator cuff tendinopathy, Clinical Biomechanics, 2011.

Shapiro C. Swimming. In Shamus E, Shamus J (eds). Sports injury prevention and rehabilitation, 2001.


Ankle and Foot 101

Ankle and Foot

It is truly remarkable that the ankle and foot function as well as they do when you think about how small they are and how they are able to support our entire body weight. Maintaining proper alignment, good foot wear and dynamic balance are critical elements in maintaining the health of these joints.


The ankle is a very stable joint comprised of three bones. The lower end of the tibia (shin bone) and the strut-like outer bone (fibula) form the curve that fits the talus (upper foot bone). This design is very stable and is often described as a mortar and pestle. The ankle’s bony stability means it is at low risk for arthritis however sprains to the ligaments are quite common as is over-stressing muscles and tendons.

Ankle Injuries

When you are standing still the ankle bones fit quite snugly together meaning that there is a low risk of injury in this position. However if you jump and land with your toes pointed down, the stability is compromised making you more at risk of spraining your ligaments. The most common injury is to the ligaments at the outer aspect of the ankle (fibular), such as when you roll over on your ankle, however depending on how you land you can also sprain the inner ligaments (deltoid).

Before you sprain your ligaments the muscles around the ankle should react to prevent the injury. This can strain the muscles known as the stirrups (tibialis anterior and posterior) however these strains are more common with low-level repetitive movements that are poorly executed i.e. pronation during walking or poor foot wear. Achilles tendon strains and tears are another common cause of ankle pain.

The Foot

The foot is comprised of 7 bones in the rear and mid-foot and 19 bones in the front of the foot and toes. There are ligaments spanning between each bone and muscles that may traverse only a short distance or begin just below the knee and extend to the end of our toes.

The stability of the foot is highly dependent on its shape. Anatomists borrow the architectural term “keystone” to describe the shape and to help to explain the stability of the foot. This shape is considered one of the most stable in architectural design.

Injuries can occur to any structure however some of the most common conditions are over-stressing the big toe to cause a bunion, plantar fasciitis from over-pronation or stress fractures to the bones in the front of the foot from repetitive over-straining.


At The Orthopaedic Therapy Clinic your therapist will partner with you to determine the best course of treatment for your injury. When you are having symptoms the most important first step is to understand what you have. Our therapists provide a thorough assessment to determine whether your symptoms are caused by the joint, ligament, muscles or are referred from other structures such as the low back.

Once the injury is diagnosed the next step is to determine where you are in the recovery sequence. Treatment is predominately determined by your stage of healing as more acute injuries usually require a plan to reduce pain and inflammation. Some ankles will benefit from bracing and when required we will help you to determine the best type of support to protect the injury as you recover. As you continue to heal the focus of your therapy shifts to the restoration of flexibility, rebuilding strength and re-establishing normal movement patterns. The final stage is to determine a strategy to help you return to full activity, sport and long-term prevention of re-injury.

Conditions we treat

Our therapists have extensive experience in the care of both acute and chronic ankle and foot condition. We work with clients after surgical repair of tendons i.e. Achilles tendon repair or removal of bunions. We provide therapy after sprains, fractures and dislocations both in non-operative and post-operative conditions.

Wrist and Hand 101

Wrist and Hand
The wrist and hand are incredibly sophisticated joints. Our bi-pedalism means we do not need these structures for support and we are freed up for the intricate activities which so often contribute to our high-level of creativity. Whether we are painting, cooking or playing a musical instrument it is our hands that allow us to participate in these past times. However our high dependence on our hands makes it a challenge to prevent the over-use of these joints and to maintain healthy, pain free functioning.
The wrist is comprised of three bones. The lower end of the radius (bone in line with the thumb) and the ulna (in line with the 5th finger) form the curve that fits a series of 4 bones called the first row of the carpus. This design allows for a high degree of movement however it is not very stable. The wrist’s lack of bony stability means it is at a higher risk for arthritis however sprains to the ligaments and over-stressing muscles and tendons are also common causes of pain.
The bones of the wrist can be fractured when you fall. As we fall it is natural to reach out to brace ourself, causing this injury to be one of the most common on an icy winter day.
Although there is not much actual muscle support around the wrist joint there are quite a few tendons on both the front and back of the joint and these tendons can be strained from over-use. The ligaments extending from the lower aspect of the forearm to the upper carpal bones can also be a source of pain if over-strained.
The Hand
The hand is comprised of 8 bones in the two rows of the carpus as well as 14 bones in the fingers. There are ligaments spanning between each bone and muscles that may traverse only a short distance or begin above the elbow and extend to the end of our fingertips.
The stability of the hand is highly dependent on its shape. Anatomists borrow the architectural term “keystone” to describe the shape and to help to explain its stability. This shape is considered one of the most stable in architectural design.
Injuries can occur to any structure however some of the most common conditions are over-stressing the thumb joint to cause arthritis or injuring a tendon to cause De Quervain’s tendonitis. Pain can be caused by a strain to the muscles in the hand or to any of the ligaments between each of the bones.
At The Orthopaedic Therapy Clinic your therapist will partner with you to determine the best course of treatment for your injury. When you are having symptoms the most important first step is to understand what you have. Your therapist will provide a thorough assessment to determine whether your symptoms are caused by the joint, ligament, muscles or are referred from other structures such as the neck.
Once the injury is diagnosed the next step is to determine where you are in the recovery sequence. Treatment is predominately determined by your stage of healing as more acute injuries usually require a plan to reduce pain and inflammation. Sometimes braces are needed to let the area rest at night or for support while at work. When required we will help you to determine the best type of support to protect the injury as you recover.
As you continue to heal then focus of your therapy shifts to the restoration of flexibility, rebuilding strength and re-establishing normal, coordinated movement patterns. The final stage is to determine a strategy to help you return to full activity and sport. An analysis of your ergonomic set-up can be an important part of your long-term prevention strategy.
Our therapists are experienced in the treatment of both acute and chronic wrist and hand condition. We have extensive experience in the treatment and prevention of repetitive strain injuries. We work with clients after surgical repair of fractures i.e. Colles fracture. We provide therapy after tendon repairs and joint dislocations both in non-operative and post-operative conditions.


Physiotherapy: how can it help me?

OTC_DynamicExerciseAt the Orthopaedic Therapy Clinic our extensively trained Registered Physiotherapists use a targeted, individualized approach to promote movement and speed recovery from joint, muscle and nerve-related pain and injury.

We recommend physiotherapy for:

  • Injuries or imbalances of the soft tissues or joints that cause pain, restrict everyday activities or change your posture
  • Prevention of injury or repetitive strain recurrence
  • Cancer-related pain, limitations of function and post-surgical rehabilitation

We work with you to help relieve pain, regain motion and restore your function. Our expertise in rehabilitation helps us to find solutions for your musculoskeletal pain whether it is from an accident, a repetitive strain or even when the cause is hard to identify. Although addressing an injury early is ideal, we have the experience to work with you whether your condition is chronic, recurrent or of recent onset. Our extensive experience allows us to find solutions when your recovery is complicated by pre-existing issues or co-existing health concerns i.e. neurological conditions, spinal surgery, etc.

Who will I see?

When you work with any of our Registered Physiotherapists you’ll be dealing with a highly educated professional who has extensive post-graduate experience. Each therapist is a graduate of a Canadian or Internationally recognized school of physiotherapy. All of our therapists have high-level certifications in areas of expertise such as manual therapy or cancer care.

What can I expect at my appointment?

The initial assessment is scheduled for one hour to allow sufficient time to thoroughly understand your concerns. Your appointment begins with a discussion of the key factors in your medical history and a lifestyle analysis to pinpoint the cause of the problem and any factors that may influence your healing.

We will assess the area you’re having trouble with and use our expertise to determine if we need to look beyond the local issue and examine other areas that might be contributing to the problem.

We’ll share the results with you and partner with you to design a treatment program specifically tailored to meet your needs and goals. We will help to determine which treatments are beneficial at your stage of recovery and continue to re-evaluate your needs as you move through the continuum towards better health. Follow-up appointments are scheduled for 30 minutes and all sessions are provided in a private, one-on-one setting.

What techniques do you use?

Our treatments may include the more traditional approaches such as ultrasound or interferential therapy as well as state-of-the art approaches such as surface EMG, force dynamometer strength testing and advanced hands-on therapeutic skills.

Manual Therapy

Manual therapy refers to techniques where a therapist skillfully applies his/her hands to move joints and tissues. These techniques are an integral part of orthopaedic physiotherapy and often compliment exercise in a treatment plan.

The goal of Manual Therapy is to alleviate pain and improve movement and function. These techniques can be extremely gentle or vigorous depending on the stiffness, pain and the stage of healing. Manual therapy can be used to improve movement in both the spine and in the peripheral joints.

The Physiotherapists at the Orthopaedic Therapy Clinic have extensive undergraduate and post-graduate training in Manual Therapy. They are trained by Canadian and International institutions, recognized by the International Federation of Manipulative Physiotherapists (IFOMPT).


Ultra-sound is a treatment modality that applies sound waves to enhance the healing of injured tissues. It is typically used to help calm irritated tissue when the pain intensity is high and inflammation is present however it can also be used later in your treatment to create deep heat. Once you start to improve and your movement becomes easier, ultrasound is usually discontinued and your program becomes more active to encourage a complete and full recovery.

TENS and Interferential Current

Transcutaneous Electrical Nerve Stimulation (TENS) is a treatment that uses electrical current to help manage your pain. TENS can be used to help manage your pain after an acute injury and can also be effective for chronic pain. Interferential Current is a form of TENS that is used for pain control typically after an acute injury.

Force dynamometer strength testing

This testing consists of a hand held device that measures the maximum force generated during a specific movement. Research has verified expected measures for several movements and we use this information to evaluate your strength based on norms for your gender, age and body weight. This information can be used to set goals, further refine your treatment program and/or to determine your progress over time.

Movement retraining 

Injury can cause you to begin to move with compensatory patterns. These patterns allow you to continue to move while you are healing however they are less efficient than normal movement. Most people will use compensatory movements when they experience pain, weakness or suffer an injury to a nerve i.e. pinched nerve, sciatica.

The problem with compensation is that the longer you rely on it the more ingrained these movements become, making it harder to return to more efficient pre-injury motions. In our practice we try to avoid the establishment of compensation by retraining movement early on. As the pain lessens we look to restore your flexibility, help you regain your strength and then evaluate the impact of your injury on your movement. We find that this approach is fundamental to  the long-term prevention of re-injury and for helping you to reduce your risk for other injuries.

Individualized Exercises

In our practice we find that our clients benefit most from very specific exercises which are selected based on the findings in your assessment.  We use this information to prescribe targeted exercises that help you to regain strength, mobility and more coordinated motion.  Our approach is to not only help you to understand why you are doing an exercise but also to make sure you understand the technique.  We find that using this approach results in the best outcomes in the shortest amount of time.

Do I need a doctor’s referral?

No, you do not need a doctor’s referral to be treated by a Physiotherapist in private practice. Some health insurance plans require a doctor’s referral for you to be able to access your benefits. Be sure to check your benefits policy before you make your appointment, or give us a call and we will be happy to help you sort out what’s needed.