Search Results: mid back

Foam Roller Self-Treatment Techniques For Mid-Back Pain And Discomfort

Are you experiencing pain between your shoulder blades?  Does your mid-back ache at the end of a day at the computer?  If you experience this discomfort on a regular basis, these Mid-back pain self-treatment foam roller techniques will give you quick relief from stiff muscles. But before you get started its important to know which muscles to choose and how to apply pressure, as these tips can make the difference between finding instant relief or causing more discomfort.  

In my last blog I covered the principles of using the foam roller and other self-treatment techniques. Now it’s time to get rolling.  Helpful self-treatment strategies in this blog will focus on relieving the tension on the outer leg, front of the thigh, hip, mobilization of thoracic spine and releasing the chest. These techniques can be used in conjunction with your physiotherapy, kinesiology program or become part of your regular program at home. However if discomfort continues or progressively gets worse, then I recommend seeing your physiotherapist as it can be helpful to have an assessment to understand which specific muscles need to be targeted.

What causes mid-back pain?

Although it may seem unconnected, the pain in your mid-back area can be caused by general muscle tension even if the muscles that are tight, are even located in the mid-back. For example: tight hip flexor muscles (iliopsoas, rectus femoris, sartorius, TFL) pull your body forward, changing your posture and putting your body in a position that can cause strain on this area.

Other causes of mid-back pain include:

  • fracture
  • pressure on a spinal nerve
  • osteoarthritis
  • overuse
  • injury to the muscle, ligament and discs that support your spine

The pain you are feeling may be related to problems in the myofascial system. All structures in our bodies are wrapped in a thin membrane called fascia.  The pain is caused by an autonomic phenomena referred from an active trigger point.

Which muscles to target?

Although there are many muscle in the body that can contribute to mid-back pain, this blog focuses on the ones that I find often refer pain directly into the mid-back.  This group also has a big influence on your posture which is a major contributor to mid-back pain.

Some of the muscles I target are predicted by understanding that they are the opposites to the ones which you are having trouble connecting with.  This difficulty in being able to access muscles when you exercise can be caused by the opposite muscles being too tight. Using treatment tools allows these muscle to lengthen, allowing for a more efficient contraction. The foam roller aids in releasing muscles and fascia, allowing you to correct your posture, move better and gain more strength.

Before you get started take a moment to review the principles outlined in my previous blog.  This will help you to know what to expect and how to apply pressure safely and effectively as you get rolling with these self-help techniques.


Iliopsoas influences our posture by drawing the pelvis forward and changing our alignment. It connects our lower body and upper body and it gets tight as a result of weak core and buttock muscles.

This muscle is often held in shortened positions in our daily activities. For example: sitting for long periods of time, as many of us do because of our jobs, or sleeping with your knees to your chest. Anytime you hold your body in a posture for a prolonged period of time, the muscles shorten to that position and can develop areas of irritability within it (trigger points).

Symptoms: The referral pattern for trigger points in the iliopsoas muscle can be felt on the outer edge of the spine, tailbone (sacrum) and front of the thigh. If you find that you are unable to stand straight, if your legs feel heavy, if you feel tightness in your groin or even if you are having difficulty strengthening your butt, it may be because you have trigger points in this muscle.

Rolling Technique: If you have lower back discomfort, consult your physiotherapist prior to doing this stretch. Place a towel bolster to support the lower back area. Lie on the ground with the towel under the low back and hips. Place your buttock on the foam roller. Bring one knee to your chest and allow the other leg to relax and stretch. Hold until you feel the tissue lengthening or for at least one minute. When stretching, it should feel like a comfortable stretch however you should stop if you experience pain. I would not recommend this stretch for someone with a history of low back pain.



The chest area is often a big contributor to mid-back pain. When our chest muscles get tight, they pull our shoulders forward and bring our mid-back into a rounded position. Many of us find ourselves in this slumped body position on a daily basis. In addition to reducing muscle tightness, maintaining a healthy posture with muscle strengthening is also an important part of relieving mid-back pain and discomfort.

Symptoms: The pectoral muscles refer pain into the front of the shoulder, inner arm, inner aspect of the elbow and fingers.

Technique: To stretch your chest, lie on a foam roller lengthwise ensuring that your head is fully supported. Start with your arms at your side and gradually move your arms up to the place where you feel the first bit of a stretch and hang out until the stretch disappears or for 1 minute. Then gradually move your arms towards your head as you are lengthening the tissue. If you experience tingling in your arms, then ease off the stretch until it disappears. You can practice holding your arms for 1 min at varying degrees to stretch the different muscle fibers of the pectorals.



The rhomboids, along with the other shoulder girdle muscles, act to stabilize the shoulder. Typically the rhomboids are weakened and inhibited by the rounded shoulder posture that so commonly results from our computer work. Other activities that involve overhead work with the arms raised above the head or sleeping on one side can cause over activity in these muscles.

Symptoms: This muscle refers pain and discomfort to the inner border of the shoulder blade and spine.

Technique: Lie on your back or stand against a wall. Place the tennis ball between your shoulder blades and roll up and down on the rhomboids until you feel the spot you want to release. Hold the spot until you feel the softening of the tissue and the “good sore” sensation disappear.

Rectus Abdominus

The Rectus Abdominus muscle is the”six pack” we all admire.  It is one of four abdominal muscles that help to give us core support. It’s function is to bend the spine forward. 

Symptoms: This muscle can refer pain to a lot of areas. It refers pain into the mid-back area, and upper pelvic crest. In addition it can mimic numerous conditions such as:

  • heartburn
  • chronic diarrhea
  • Irritable Bowel Syndrome
  • gallbladder
  • genital pain
  • kidney symptoms

A surprising connection was found by Dr. Travell regarding other symptoms from abdominal trigger points which could take the form of nausea, chronic diarrhea, loss of appetite, projectile vomiting, and simple indigestion.

If the rectus abdominus is too tight or harbors trigger points we tend to lean forward and slouch. If you find you prefer to sleep curled up in bed it may be because your rectus abdominus is too tight.

Technique: Lie on your back with a pillow under your knees, place your fingers on your breastbone and walk your fingers down until you find the first soft spot. This area is the upper attachment of the rectus abdominis muscle.  It can help to activate the muscle to let you know you are on the right area.  Do a little abdominal crunch to feel the muscle contract and then gently walk your fingers up and down the muscle belly, locating the sore spots or referral points. Hang out with your fingers on the sore spots until they disappear or for up to two minutes.


Using self-treatment tools is not a cure for chronic pain, although it helps. Implementing trigger point release in conjunction with a stretching and strengthening program, will aid in a quicker results. It allows you to get relief at your own convenience at no cost.

If you have any questions or would like to know other strategies with self-treatment for different area’s of the body, please contact me, Juliette Woodruff at or call us to make an appointment 416-925-4687.


Travell, Janet, 1901 (copyright 1992) Volume 2 Myofascial Pain and Dysfunction-The Trigger Point Manual-The Lower Extremities


DIY! Self-Treatment Relieves Mid-Back Pain

When your mid-back begins to ache or the muscles between your shoulder blades spasm, you want immediate relief. However even when we are in pain our hectic lifestyles can make it difficult to find time for treatment. Often we leave it too long before we finally seek help. Self-treatment relieves mid-back pain and discomfort, and learning some simple do-it-yourself techniques can help until you find time to see your therapist.

In the previous article we discussed changing your posture throughout the day, diaphragmatic breathing, and strengthening your core to relieve mid-back pain.  All of  these strategies make an incredible difference but they take time to be effective. When you need immediate relief, direct treatment can help but the problem with the mid-back is that it is an awkward place to reach with your own hands.

Fortunately there are a variety of self-treatment tools on the market which can help you treat this area. Some are easy to transport, many are affordable and can be used anywhere.  For example many of my clients use the foam roller, tennis ball, Thera Cane/Shepherd’s Hook, lacrosse ball, as well as other devices. They find self-treatment between massage sessions helpful, but before you invest in these tools make sure that you know how to use them. Its also important to know which muscles need to be released as sometimes it’s not the muscle that is sore which needs treatment.

To help you get the most out of self-treatment here are some of the most common questions I find my clients ask about how to apply these do-it-yourself techniques.

1) Should I use Self-treatment before or after the workout?  

Although there has been some controversy on whether foam rollers are helpful or harmful, a recent literature review in the American College of Sports Medicine concluded that this self-treatment tool has a beneficial effect on range of motion, soreness, and fatigue after exercise.  In my practice I find that provided you use the foam roller properly after your workout, it can be very beneficial in relieving muscle soreness, improving circulation, flexibility, and increasing body awareness (biofeedback/proprioception).

2) Do foam-rollers work?

I have had clients ask me if the foam roller really works or is it just a torture device. Yes, it works. Foam rolling is a relatively new therapeutic approach. There is much more research needed to clarify the effects of foam rolling however the current evidence suggests it can help to improve flexibility, vertical jump, and reducing soreness.

3) How often should I self-treat?

When it comes to frequency, it is important to listen to your body. Treatment tools can be used everyday however I do not recommend treating several areas in the same muscle during the same session. Try releasing one area or trigger point and see how it feels before going onto another.

3) How long should I apply the pressure for?

Research shows that to produce change you need to hold the pressure on the muscle for a longer period of time.  This means that each area should be held for about 2 minutes.

When you find a sore spot, stay on the spot until it disappears or if the soreness does not diminish or change in quality after 2 minutes then stop, apply heat and gently stretch the muscle. If you feel okay than try it again over the next few days as the tissue can adapt to stronger pressures with a course of regular treatment.

3) Can I make the my pain worse using self-treatment?

Absolutely!  Rolling over the sore spots again and again will just aggravate the tissues.  The trigger points you are trying to release with these self-treatment tools are by definition an irritated area within the muscle tissue, so it is important to not irritate the tissue further.

4) How do I know if this treatment is right for me?

When your muscle is relatively healthy and strong, it should release quickly. Be careful if you stay on the spot for a long time and hardly notice a change as this indicates that the muscle is likely too weak for this treatment. When this happens, keep the rolling to a minimum until you restore the strength.

A failure to respond or increased irritation may also suggest that another muscle needs to be released first. If the muscle is not releasing relatively quickly, try working on one of the other tight muscles first.

5) How much pressure should I apply?

When it comes to determining the amount of pressure it is really important to listen to your body.   During the treatment you should experience a good soreness and not discomfort or pain. This treatment has a relieving, welcome quality, that feels better after the treatment.

If you find that the intensity is so much that you are clenching your teeth, then reduce the pressure as it is too strong. If the tissue is not releasing very well, or if you used too deep of pressure then you may end up feeling sore for the next day or two. A warm Epsom salts bath or any form of heat can be applied for twenty minutes,  This will help the circulation to that area and reduce the soreness.

6) How do self-treatment tools work? 

Our body has many subconscious, automatic controlling functions that work to help regulate tension.  Self-treatment tools rely on these functions.  Pressure on the muscle targets a structure called the muscle spindle and the Golgi tendon organ (proprioceptors). These structures are stimulated when we use pressure on a tight spot/trigger point. The application of tension creates a stretch reflex causing the muscle to send a signal to the brain.  This signal is received in the brain as a message to relax the muscle, making this an effective treatment tool in reducing tension. These structures are one of the reasons that massage therapy is so effective in relieving tension as your registered massage therapist is trained in how to maximize the effect of pressure on these organs.

Video explaining muscle spindle/golgi tendon organ

Feeling our best is important to having a pain free, healthy and happy lifestyle. When we are sore and in discomfort, pain effects our whole self, both physical and emotional. Empower yourself by using treatment tools to aid in your own relief of mid-back pain or any other part of the body, whenever and where ever you need it! Research has shown good effects with the foam roller, and as long as it is used safely, and can assist with your progression in rehab and in sport.

If you want to learn more about self-treatment techniques either book into to see me or come to my free seminar in June.  My next article and my seminar will cover the specific muscle techniques for applying the foam roller.




The effects of self-myofascial release using a foam roller or roller massager on joint range of motion, muscle recovery, and performance: a systematic review.

Cheatham SW, Kolber MJ, Cain M, Lee M. Int J Sports Phys Ther. 2015 Nov;10(6):827-38PMID:26618062


Is self-massage an effective joint range-of-motion strategy? A pilot study.

JBodywMovTher. 2017 Jan;21 (1):223-226


Do exercises with the foam roller have a short-term impact on the thoracolumbar fascia? – A randomized controlled trial.

J BodywMov Ther. 2017 Jan;21(1);186-193


The acute effects of deep tissue foam rolling and dynamic stretching on muscular strength, power, and flexibility in division I linemen

J strength cond Res. 2015 Jun 24.

Tips To Relieve Mid-Back Pain And Discomfort

Tips To Relieve Mid-Back Pain And Discomfort Have you ever experienced mid-back pain? Do you get a gnawing sense of discomfort between your shoulder blades? Or a knife-like stab under your shoulder blade? These pains can be caused by tight muscles, poor breathing habits or posture.   In my practice I have found that, in addition to massage, these tips can help you to relieve your own mid-back pain and discomfort.

TIP #1 – Change your posture throughout the day Mid-back pain and discomfort can be caused by changes to our posture.  This can affect anyone, but is more common in children and adolescent females.

Postural changes occur due to many factors such as:

  • sitting at a desk all day
  • a poorly fitted backpack putting pressure on our neck and shoulders
  • a lack of awareness of the position of our head while reading and writing
  • changes caused by hormones

One of the primary “jobs” of our muscles is managing our relationship with gravity. Postural changes affect how the forces of gravity are distributed thorough out the body. In turn, the balance between the muscle whose contraction moves us directly (agonist), and a muscle whose actions counteracts that of another specified muscle (antagonist) is altered and disrupted. Over time these changes cause repetitive stresses which result in injury. Posture has a larger effect on the body than many people realize. Often my clients are surprised to find that simple changes to everyday habits and posture makes a big difference in reducing their pain. The more you are aware of where your body is in space and the more you are able to correct your own posture, the better you will feel. Improving this awareness will not only help with correcting posture, it will also assist in preventing injury. Although it is important to realize that any change in habit takes time, awareness, and perseverance, you can begin to feel better with some simple changes.  Here are some simple changes that can help you improve your posture:

  • If you sit all day at work or school,  get up for a few minutes and move around or just get up and stretch.
  • When you have a major project or deadline, set a reminder on your smart phone to remember to move.
  • Try to be aware of your body and how you are sitting, standing or even walking.
  • When you are sitting, position yourself on your “sit bones”. This simple change off-loads the spine and make it much easier to have better sitting posture.

Take the time to adjust your work station.  If you need help check with your HR department as some companies offer ergonomic assessment for their employee’s work stations. If this service is not available the Orthopaedic Therapy Clinic therapists can come to your work site and/or begin a review of your ergonomics from photographs of your set-up.

TIP #2 – Practice Diaphragmatic breathing

Our diaphragm is an extremely important muscle.  It helps us to breathe, moves lymphatic fluid and plays a role in maintaining posture. This dome shaped muscle forms the floor of the thoracic cavity, while the lungs sit on top. When we inhale, the diaphragm contracts and is drawn downwards into the abdominal cavity. Other muscles lift the ribs like the handle of a bucket.  The thoracic cage becomes deeper and larger, drawing air from the atmosphere. This increase in air pressure provides support for the upper body. During exhalation, the rib cage drops to it’s resting position while the diaphragm relaxes and elevates to its dome shaped position in the thorax. Air within the lungs is forced out of the body as the size of the thoracic cavity decreases.  These constant pressure changes assist with the movement of lymphatic fluid which is not only important for regular fluid exchange but also for reducing swelling. The diaphragm also has an intimate relation with our core muscles (transverse abdominus/internal oblique). The finger-like extensions of the diaphragm connect into (inter-digitate) the transverse abdominus muscle.  This relationship assists with the  stability of the spine. If the diaphragm does not function properly this has a direct impact on the ability of transverse abdominus to work efficiently and to give stability.

TIP # 3 – Strengthen your core

Maintaining the strength in our postural muscles is critical to living without pain.  These muscles create the opposition for the gravitational forces constantly pulling on our bodies. A strong core lifts the spine, creating traction and allowing forces to be distributed through the body evenly, as well as reducing the risk of injury. Many of us have a tendency to carry our bodies in a slouched position. This forward position changes the gravitational pull on our bodies. In this position gravity has the advantage. Life can be hectic and often we have to choose where to allocate our precious time. Be kind to yourself and set some time aside to empower yourself and reduce pain and discomfort through strengthening exercises. Discuss with your physiotherapist to see if these strategies will help you manage your relationship with gravity:

  • Increase your abdominal stability – practice hollowing your abdomen by pulling your belly away from your pant-line.  You can work this into your day by practicing while sitting on the subway or waiting for the bus.
  • Strengthen your gluteal muscles – squeeze your butt often during the day.  This can be practiced when you are sitting or standing.
  • Strengthen your mid-back muscles – target the lower fibers of trapezius by bringing your shoulders down and back.  Practice this several times per day until it becomes a natural position for your shoulders.

If you are finding chronic tightness is limiting your ability to move well or if you have muscle soreness, book a massage therapy treatment with me to specifically address these areas and to learn which self release strategies you can use between treatments. My next blog will discuss self-release techniques using a tennis ball, foam roller, and the use of hydrotherapy for mid-back pain and discomfort.


  2. The Effects of Deep Abdominal Muscle Strengthening Exercises 

Juliette Woodruff is a registered massage therapist practicing in downtown Toronto at The Orthopaedic Therapy Clinic. Disclaimer-This information is not meant to replace medical/health advice. Contact your health professional to ensure the diagnosis and treatment are appropriate for your condition.

Safe Exercises for Back Pain 1A

Healthy Back On-Line Exercise Series – Safe exercises for your back

One of the challenges in this pandemic has been to stay fit, particularly when you have pain or injuries.  Your therapists at The Orthopaedic Therapy Clinic recognized how difficult this has been for our clients and have been working on a number of initiatives to help you to exercise safely.

(Watch the Video)

We know that many of you are selecting on-line programs.  Some of these programs are confusing and most are not back specific.  We would like our clients to exercise with people who understand how to get you stronger through exercise and to limit your risk for low back pain.

We are excited by your interest in our live Healthy Back online back series and decided to make some changes to allow more people to participate.  Beginning in mid- April, we are offering 2 new on-line classes each week for people who have experienced low back pain when they exercise.

Who should participate?

These classes will be suitable for most backs as each exercise will be completed in a spinal neutral posture.  If your back is a bit more particular about its directional preference, you can still participate as each exercise will also include a reminder of a modification for flexion or extension preference.

Who’s teaching?

Your classes will be led by one of The Orthopaedic Therapy Clinic’s exercise professionals.  Aniela Amio, Pilates/Yoga instructor and John Gray, Registered Kinesiologist both have extensive experience in helping people who have back pain to exercise safely.


Class format

Technique is critical to getting the most out of these classes with the least amount of discomfort.  To help this work for you we have enhanced our use of technology to allow us to provide more immediate feedback.  Now if anyone wants immediate feedback, just leave your video live and the instructor will correct any concerns with your technique.  We will not be recording the sessions.

Sessions will be limited to 8-10 participants.  A minimum of 8 is needed to host the class.

Which Safe Exercise class is right for you?

Healthy Back Basic Mat On-line Class for Low Back pain

If you are able to complete light exercises you should benefit from Aniela Amio’s, Pilates/Yoga Instructor, basic mat class for low back pain. (Watch the Video)

This series of 6 weekly sessions is gentle however it will help you to build your strength as exercises will be progressed throughout the series.

This Zoom group class starts on Thursday April 29th, from 5:30-6:10 PM.

  • CLASS 1: Thursday April 29, 2021 5:30 -6:10 PM – Click Here for class details
  • CLASS 2: Thursday May 6, 2021 5:30 -6:10 PM – Click Here for class details
  • CLASS 3: Thursday May 13, 2021 5:30 -6:10 PM – Click Here for class details
  • CLASS 4: Thursday May 20, 2021 5:30 -6:10 PM – Click Here for class details
  • CLASS 5: Thursday May 27, 2021 5:30 -6:10 PM- Click Here for class details
  • CLASS 6: Thursday June 3, 2021 5:30 -6:10 PM – Click Here for class details

Healthy Back Intermediate Strength On-line Class for Low back pain

If you need more challenge take John Gray’s, Registered Kinesiologist, intermediate-level strength class for backs.

Watch the Video

This series of 6 weekly sessions will build your strength as exercises will be progressed throughout the series.

This Zoom group class starts on Saturday April 24th, 2021 from 10:00-10:30 AM

  • CLASS 1 Saturday April 24, 2021 10:00-10:30 AM – Click Here for class details
  • CLASS 2 Saturday May 1, 2021 10:00-10:30 AM – Click Here for class details
  • CLASS 3 Saturday May 8, 2021 10:00-10:30 AM – Click Here for class details
  • CLASS 4 Saturday May 15, 2021 10:00-10:30 AM Click Here for class details
  •  There is no class  on May 22 of the Victoria Day weekend
  • CLASS 5 Saturday May 29 2021 10:00-10:30 AM – Click Here for class details
  • CLASS 6 Saturday June 5, 2021 10:00-10:30 AM – Click Here for class details


The  fee is $105 + HST for the entire 6 week session.  Individual sessions will be offered at $20 + HST per session only if there is room in the class one week before the session date.

Register at 416-925-4687

More information

If you have any questions about the program or would like more guidance on whether you should participate you can reach out to your therapist directly.  Or send an email to and this will be forwarded to the right person to assist you.

We are looking forward to helping you to stay fit and healthy.  Look for our other new programs coming soon!


Healthy Back On-line exercise program – Directional Preference

We are excited to announce our Healthy Back On-line exercise program.  We started this program as we recognized that many people were participating in on-line exercise programs however most of these programs are not specific for people who have injuries or have had back pain.  What makes our program unique is that it’s based on knowing your back’s directional preference and selecting exercises specific to your type of low back pain.    We use a Directional Preference System for low back pain to match your exercises to what your back needs.  This allows you to select an exercise class that is right for your back.

Click here for more information on registering in our back exercise classes.

Directional Preference and Back Pain Recovery

As we continue our War on low back pain and the back Attack/Acute pain finally subsides, most people begin to have periods where they have no pain.  At this stage in your recovery, you will find that some movements feel OK, or even make your back feel better, whereas other activities irritate.

When this happens, it is an indicator that you are ready to exercise.  What’s most important is to exercise using a program which respects your back’s Directional Preference.  This means your program should include exercises your back “prefers” and limit exercises which irritate.

The avoidance of irritation, combined with the benefits of exercising based on preferences, will help you to move forward to become stronger and return to a full and active lifestyle.

Knowing Your Back’s Directional Preference

Initially, most people will need their therapist or physician to help them understand the underlying pattern connecting these right and wrong movements. At first it may seem a bit random until the trained practitioner identifies the directionality.   However, once you understand the directionality, this knowledge will help you make better decisions on what to do or not do as you are recovering.  It will help you to choose exercises, safe cardio workouts and engage in everyday movements safely.

Directional Preference Designations

Most backs exhibit one of three Directional Preferences:

  1. Flexion preference – your back prefers forward bending
  2. Extension preference – your back prefers backward bending
  3. Neutral preference – your back is best if you keep it in neutral. It irritates if you go into more flexion or more extension.

Our New on-line Classes are for All Types of Back’s

We are launching our exercise series with videos and classes in  Mid April 2021. Click Here to learn  more about each class

These classes will be suitable for most backs as each exercise will be completed in a spinal neutral posture.  If your back is a bit more particular about its directional preference, you can still participate as each exercise will also include a reminder of a modification for flexion or extension preference.

Why use Directional Preference Rather than Diagnosis?

Our therapists, and many physicians, use the designation of Directional Preference to choose exercise programs.  This well-established format is used world-wide.  It is successful at helping people become more active because it respects the fact that even two people with the same diagnosis can have completely different directional preferences!

For  example, although most people with spinal stenosis will prefer flexion, there is a small group of people who will do better with extension.

A diagnosis of discogenic back pain gives limited insight into the type of exercise you need.  Some backs will need flexion whereas others will do better with extension.

These variabilities are why it is essential to know your Directional Preference to engage in safe exercise at this time in your recovery.

Key to your Success

The key to your success in this series is to:

  1. Respect your Directional Preference and use it throughout the series
  2. Commit to understanding the technique for each exercise.  Use the reference videos, or your therapist, to ensure you are getting the most out of the program.
  3. Apply the tips and activation strategies that work for your body to prevent/limit pain from exercise.  Recognize that not every tip works for every person.  This is why we provide you with several options on how to get the correct muscles working.  Once you learn what works for you, apply this throughout the exercise program.

We look forward to helping you get more active with safe exercise.  If you need further assistance, please call us at 416-925-4687 or contact your therapist at the following emails:

Safe Exercises for Back Pain – New On-line Exercise Classes

Healthy Back On-Line Exercise Series – Safe exercises for your back

One of the challenges in this pandemic has been to stay fit, particularly when you have pain or injuries.  Your therapists at The Orthopaedic Therapy Clinic recognized how difficult this has been for our clients and have been working on a number of initiatives to help you to exercise safely.  We are now ready to share the first in a series of new initiatives. (Watch the Video)

We know that many of you are selecting on-line programs.  Some of these programs are confusing and most are not back specific.  We would like our clients to exercise with people who understand how to get you stronger through exercise and to limit your risk for low back pain.

Beginning the last week in February, we are offering 2 on-line classes each week for people who have experienced low back pain when they exercise.  These classes are with Aniela Amio, Pilates/Yoga instructor and with John Gray, Registered Kinesiologist. These professionals have extensive experience in helping people who have back pain to exercise safely.

Please join us. Your 1st session for both classes is free of charge! 

Healthy Back On-line Exercise Class – Basic Mat Class for Flexion Preference Low Back pain

Aniela Amio, our Pilates/Yoga instructor, is providing a Basic mat flexion preference exercise session via Zoom.  This group class will be held on Thursday from 5:30-6:10 PM.

Maximum participation is 10 people.

CLASS ONE: Thursday Feb 25, 2021 5:30 -6:10 PM – Click Here for class details

CLASS TWO: Thursday March 4, 2021 5:30 -6:10 PM – Click Here for class details

CLASS THREE: Thursday March 11, 2021 5:30 -6:10 PM – Click Here for class details

CLASS FOUR: Thursday March 18, 2021 5:30 -6:10 PM – Click Here for class details

CLASS FIVE: Thursday March 25, 2021 5:30 -6:10 PM- Click Here for class details

CLASS SIX: Thursday April 1, 2021 5:30 -6:10 PM – Click Here for class details


Register by contacting us at 416 925 4687


Healthy Back On-line Exercise Class – Basic Strength Training for Flexion Preference Low Back pain

John Gray, Registered Kinesiologist will be offering a strength training session for people with flexion preference low back pain.  This group class will be held on Saturday from 10:00-10:40 AM

Class 1 Saturday Feb 27, 2021 10:00-10:40 AM Click Here for class details

Class 2 Saturday March 6, 2021 10:00-10:40 AM Click Here for class details

Class 3 Saturday March 13, 2021 10:00-10:40 AM Click Here for class details

Class 4 Saturday March 20, 2021 10:00-10:40 AM Click Here for class details

Class 5 Saturday March 27, 2021 10:00-10:40 AM Click Here for class details

Class 6 Saturday April 3, 2021 10:00-10:40 AM Click Here for class details

Maximum participation is 10 people.

Register by contacting us at 416 925 4687


Who should participate?

This class is targeted for people who have back pain with a diagnosis of  flexion directional preference.

If you have this diagnosis, your current physiotherapy program will likely include pelvic tilt positions and exercises.   If you are not sure if this is your diagnosis and wish to participate, please reach out to your therapist to determine if this is the right class for you.

What is the format?

Each class will last 30 minutes and there will be an additional 10 minutes at the end of the class for you to ask questions.

Each class will review:

  • finding your start position,
  • 3-5 strength and coordination exercises
  • 1-3 stretches and posture correction exercises

The emphasis will be on technique and helping you to know when you are doing the exercise correctly.

How much will it cost?

We are offering the 1st class free.

After that, the cost is $20.00 per session or you can sign up for the first 4 sessions in advance and get one class free at $60. The full price is $80 if sessions are bought individually.

How to register

Call our front desk team to register – 416-925-4687.  You will be sent a participation waiver and our Telehealth policy form.  Once these forms are completed, we will send you a Zoom link. These forms need to be received a minimum of one day in advance to ensure we can get the link to you in time.


The sessions will be provided using Zoom pro.

Each participant will be allowed into the session once their registration is verified.

All participants cameras and microphones will be blocked during the exercise session as each session will be recorded for later viewing.  During the question period you can unmute and use your camera as this section will not be recorded, however you will be observed by other participants.

More information

If you have any questions about the program or would like more guidance on whether you should participate you can reach out to your therapist directly.  Or send an email to and this will be forwarded to the right person to assist you.

What to do if these dates and times don’t work?

Please let us know if these times and dates don’t work for you as we are planning to offer more classes once these dates have been launched.  Contact and give them the dates and times that work better for you.

We are looking forward to helping you to stay fit and healthy.  Look for our other new programs coming soon!


Winning the WAR on Low Back Pain

One morning you wake up, get out of bed and find it difficult to straighten up.  Your back is stiff.  It’s hard to bend forward to put on your shoes.  You sit down and find that your leg suddenly won’t bend enough to reach your foot.  You take a hot shower and within an hour you begin to feel better and go to work.  You forget about it until the next day the same thing happens.   Whether you are 25 or 65 you may decide that this is just a sign of age when what it is telling me is that you are going to W.A.R. with your body.  These are the early signs of low back pain and unless you recognize them you may go onto a full back pain attack.

Stages of Low Back Pain

View Video, WAR on low back pain

W.A.R. is the acronym I chose to represent the struggle of the mind and body that is an integral part of this injury and because it is a helpful for understanding the 3 stages of recovery. Like with any war, there are stages of engagement.  Each stage has different characteristics and strategies.  Ultimately, winning this WAR will be determined by identifying which stage you are in and applying the treatments that work for that stage.

3 Stages of Low back pain:

  1. W- Warning
  2. A – Attack
  3. R – Resolution

Choosing your treatment

The most common mistake I see made in the recovery or prevention of low back pain is when the wrong treatment is selected for your stage of recovery.  Well-meaning friends, therapists or Dr. Google tells you about some amazing recovery from a certain type of treatment.  Maybe it’s exercise, manipulation or strong stretching techniques like ART.  Testimonials will encourage you to try it, but what is often unclear is whether it’s right for you.

While there is no doubt that each of these treatments can help reduce low back pain, if you want to win this WAR it’s critical to match the right treatment to where you are in your healing.  The wrong treatment at each stage can have a profound effect on both your speed and resilience of recovery.  The first step is to determine your stage of back pain recovery before you choose your treatment.

Stage 1 – Warning

Back pain often starts with subtle warnings. These warnings may go unrecognized or are ignored until suddenly you under Attack.  The result of missing these cues can be a full-blown episode of back pain which puts your entire life on hold for weeks or even months. To win this WAR your first goal should be to avoid the full-blown Attack.  This is best done by recognizing the Warnings and immediately making lifestyle changes.

Warning Symptoms:

Some of the most common symptoms of an impending back attack are:

  • Back stiffness in the morning
  • Back stiffness at the end of the day or after exercise
  • Back discomfort rising out of a chair
  • Back discomfort when standing. [1]
  • Muscle tightness in your hamstrings or calves when you haven’t worked-out

When you feel any of these symptoms, recognize that they are warning you that your back pain may escalate and seek some help in managing this stage.  Most people don’t need much treatment at this stage and prevention can be quite simple.  The focus of therapy should be to identify your risk factors and to understand which modifications can make a difference.

Correcting factors such as a sedentary lifestyle, tight muscles, poor core, etc. can go a long way to avoiding the Attack.  For many people preventing WAR can be as simple as reducing the length of time you are sitting and ensuring you are walking enough i.e. >8,000 steps per day. It can also be about ensuring you have a good ergonomic set-up for your computer and that you stop working on your laptop in bed or at the coffee table.


This is the stage that we all want to avoid however it is the one most people get to before they seek treatment.  It’s not surprising that this is what takes you in to your therapist, as the pain can be overwhelmingly intense.

The intensity of the pain may make this stage seem quite obvious however it is important to determine whether you are really in a full-blown Attack or already in the first stage of Resolution. Some people skip the full Attack stage or progress into the Recovery stage very quickly.  I find that these two stages are often confused and the treatment strategies are very different depending on where you are in your WAR.

Attack Symptoms:

The key characteristics of the full-blown Attack are:

  • Unrelenting pain. The pain may wax and wane but you are never pain free.
  • Short term relief may be felt from shifting positions but doesn’t last.

When you are in a full Attack the primary goal is to end it as quickly as possible.  Managing this stage is best addressed by never going to WAR in the first place, however if you find yourself in the middle of the Attack, the most important elements of treatment are management of the pain and avoidance of becoming mentally incarcerated as a prisoner of pain. This is when you should discuss medications with your physician, pain relieving strategies with your physiotherapist i.e. acupuncture, manual therapy and educate yourself on recovery strategies.

I find that the most common mistake made is over-exercising  during this stage. Knowing that core exercise is good you choose this moment to start your return to fitness.  Remember you need to move but you should also avoid substantial increases in pain.  My rule is that the pain should not increase for more than 20 minutes after movement or exercises.


Your final goal is to achieve full resolution. To do this you need a treatment plan which ensures your recovery is robust and resilient.  This is what will allow you to return to all your favourite activities and avoid future WAR’s.

The most common mistake I see at this stage is a failure to recognize the early signs of recovery. Many of us use pain as our guide, expecting to get active once the pain stops.  However pain doesn’t always shut off like a tap. The early signs of recoverycan be subtle.  There are changes in the quality, location and in what provokes the pain.  These changes tell me when you are ready to enter the final stage in the battle and really participate in therapy.

Signs of Resolution:

  1. Pain intensity lessening and/or becoming intermittent
  2. Pain localization (less leg or buttock pain)
  3. Pain improving with specific activities/directional preference i.e. walking or sitting
  4. Increasing function with no need to increase your medication

The second most frequent mistake I see is that we don’t focus enough on ensuring full resolution.  This is the stage when you should really start to exercise.  Restoring your core, re-establishing coordinated movements and strength is critical. You should be able to start weaning off medication and therapy shifts from pain relief to restoration of lifestyle.

Avoiding Future Wars

Depending on how well we manage the resolution stage determines whether we will keep going to WAR or whether our life returns to full and pain free.  Many people come out of the Attack stage only to have it replaced with constant low-grade discomfort and stiffness.  When you try to return to full activity or resume sports the Attack returns. You see numerous practitioners and no one can give you a clear answer why you can’t get rid of your pain.  MRI’s, X-rays and other tests all fail to explain your ongoing symptoms.  This reinforces the prisoner of pain.  You begin to worry that something permanent is wrong with your back – which no one can find!

If you are having repeated episodes of low back pain and all your tests are clear, this tells me that your back is structurally healthy.  If you are in the resolution stage you are ready to engage in therapy.  If there is no structural damage of significance i.e. herniated discs, stenosis, there are also no significant restrictions to recovery.  Even if you have structural changes your recovery can be good, it just takes a more thoughtful approach to planning your program.

The Recovery phase often requires the guidance of a knowledgeable spine therapist. Someone who understands which factors are challenging your recovery and can guide you into starting your exercise at the right level.  Remember if your pain has lasted longer than 3 months you are now out of shape.  You have also begun to lay down permanent motor memories which impact on your ability to recover.  A solid approach to fitness and restoring coordination are critical at this time.

Join me in the WAR on low back pain

I would like you to help win the W.A.R. on back pain.  Over the next series of articles, my goal is to help you become educated about recognizing what your body is telling you. This will help you to find the right therapist to guide you in your recovery.  It will also help you to know when it’s time to make a change in approach.  Winning this W.A.R. is also about helping you, your friends and even your children to avoid your first episode.

My next few blogs will explore each one of these stages more fully.  I will provide a more in-depth look at the symptoms and which treatments are likely to help. In the interim please contact us for more information or call 416-925-4687 to book an appointment if you need assistance in managing or preventing your own personal W.A.R. on back pain.


[1] This one is harder to recognize as may people mask this symptom by avoiding standing activities such as cocktail parties, museums, shopping or cooking

Causes of Low Back pain:  Does weight matter?

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

Often I am asked whether being overweight is one of the causes of low back pain. As a health professional it’s easy to say yes when confronted by a protruding belly or a heavy set body however the connection with low back pain is not as direct as we might expect.

When it comes to low back pain, recommendations for weight loss are almost as common as being told to strengthen your core,[1] however there is insufficient science to support this perspective. Having gone through a severe episode of sciatica most people are ready to commit to almost anything to not have this happen again.

Although I would endorse weight loss for a variety of reasons, if your goal is addressing the causes of low back pain my perspective is that it doesn’t really matter what you weigh.  What is key is having the strength to carry it. In my practice I have clients weighing 95 lb.who are suffering with back pain.  I also have clients weighing 300 lb. who are fully recovered.  The question I find more telling is whether you have gained weight recently and/or started on an intense new fitness program.  Answering yes to one or both of these questions provides me with more insight into the cause of your low back pain than simply calculating your body mass index[2].

Weight gain, sedentary lifestyle and intense exercise are causes of low back pain

A common history bringing you into my practice begins with a resolution to finally lose the 20+ lb. put on over the last 2-3 years.  Dieting is difficult, so often fitness becomes the method of choice.  Running, boot camp or cross fit seem to offer the most promise to kick start the loss.  Even if you have not exercised recently, many commit to 5-7 days per week.

The first few workouts go okay and then one day you wake up sore.  Your low back is aching.  From there it is downhill.  Within a few days the pain intensifies.  It starts to shoot down your leg.  Suffering from full blown sciatica erases any possibility of exercise and starts the perfect storm.  You begin to gain weight as not only can you not exercise, you now can barely walk.  Comfort food adds to the problem and instead of being 20 lb. overweight you are on you way to 30+.

Based on a study by Dr. Cholewicki[3], we know that even a modest increase in weight, particularly when gained quickly is sufficient to predict low back pain in athletes.  In this research study he followed Varsity level athletes, proving that every 1 kg. increase in weight, gained over a 3 year period increased the risk for low back pain by 3%.   Although I might quibble with his definition that 2.2 lb. gained within 3 years is rapid, I cannot disagree with the outcome. Recent weight gain compounded by an excessively intensive exercise program are key causes of low back pain.

Rapid Weight Gain is one of the Causes of Low Back Pain

Why a rapid increase in weight is more problematic than just being overweight can be best explained by how we build strength in the first place.

As children our body adjusts to weight gain by building both the muscle and the coordination[4] to heft this additional bulk around. As adults, changes in our body weight also needs to be paralleled with increases in both of these factors.

Based on Cholewicki’s study, even in highly trained athletes it takes time to make the needed adjustments to accommodate changes in body mass. Preventing injury requires enough strength for our body weight and the demands of our lifestyle

The second factor, excessive intensity of the fitness program, can compound the issue.  The longer we spend developing our careers, raising our kids and ignoring our bodies, the greater our deconditioning[5] and loss of muscle strength.  When you couple deconditioning with an additional 20 lbs. of body weight, engaging in a high-intensity fitness program can feel like 30 to 40 lb. to these mid-life weakened muscles.

Getting out of the vicious cycle

Once this vicious cycle of weight gain and inactivity sets in I find it takes a lot more effort to get on track than preventing issues in the first place.

Selecting a more modest exercise program combined with good eating habits would likely have given you the success you were looking for but now we need to start much slower.  The presence of sciatica and back pain predicts that the initial imbalances in your strength to weight ratio are now worse.  Instead of only battling weight gain and deconditioning, you now have post-injury compensatory patterning.  All three factors must be taken into account when planning your therapy program.

At this stage in your recovery I recommend seeing an experienced spine therapist who recognizes that pinched nerves complicate your return to exercise. Once there is involvement of the nerves (sciatica), these types of injury predict that some muscles will be weaker than others.   A failure to recognize and specifically target these imbalances is one of the key factors I find limiting your recovery.  It can often be the primary cause of pain whenever you try to get more active.  These compensatory patterns[6] need to be addressed before a general exercise program or returning to the activities you love becomes possible.

Compensatory patterns must be addressed before returning to a more active lifestyle

In our clinic we have learned to anticipate these patterns and address the changes as soon as they start to emerge. This is ideal, however even when that early opportunity has been missed, the chance for improvement is still good as most people can learn to restore these movement patterns even years after the initial injury.

The next topic:  How balance strategies 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.

[2] Height to weight ratio – BMI calculator app:
[4] This relationship is explored in the previous article on low back pain and core
[5] Loss of fitness
[6] Compensatory patterns and nerve involvement will be the subject of an upcoming blog.


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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.    

Massage therapy for prevention and treatment of swimmers shoulder

Swimming is a common sport and a pleasurable recreational past time. Whether you swim for
enjoyment or for competition the proper stroke mechanics of the shoulder are important for
prevention of shoulder pain and dysfunction.

One of the most commonly injured areas with swimmers is the shoulder with reports of
incidence of disabling shoulder pain in competitive swimmers ranging from 27% to 84%. When
aquatic athletes have pain located on the front and outer side of the shoulder and arm it can be
referred to as “swimmer’s shoulder. These injuries often result from intense training as many
swimmers in a single training session will average 3,000 to 6,000 meters. This intensity places
an enormous amount of strain on the shoulder.

The shoulder complex is designed to achieve the greatest range of motion with the most
degrees of freedom of any joint system in the body. The excessive mobility of the shoulder at
the glenohumeral and scapulothoracic joint is balanced by the stability of the acromioclavicularshoulder2

The shoulder is stabilized by a complex ligamentous system as well as an elaborate
muscular system. This support mechanism allows the shoulder to withstand large external
forces, while providing enough mobility for the upper extremity to accomplish complex
movement patterns.

The balance between shoulder mobility and stability occurs in many sports
that require overhead motions. Swimming requires several of these movement patterns,
involving continuous arm circumduction(1) clockwise and counter-clockwise directions.

It is important to understand that any complaint causing pain or contributing to abnormal
movement at the shoulder complex will disturb the balance of the stabilizing structures around
the joint. This leads to shoulder instability, the leading cause of shoulder pain in aquatic

The shoulder could be compromised due to:
· poor posture
· muscular imbalances (i.e. serratus anterior
· neuromuscular incoordination
· repetitive strain due to faulty training mechanics
· overuse and misuse

The common aliments include:

  • rotator cuff tendinopathies (i.e. supraspinatus)
  • impingements (long head of biceps)
  • glenoid labrum tear
  • shoulder bursitis
  • acromioclavicular joint dysfunction
  • The symptoms and presentation may differ depending on the dysfunction.

Irrespective of whether you are training for a triathlon, or competitions such as Nationals, or
swimming to get healthy you want your body to perform with healthy strong structures.
Athletic performance is predicated on neuromuscular integration, muscular strength, and
structural integrity. Over-use injuries are common if you are doing rigorous weight training
program as well as swimming, without allowing the body enough time to recover. Over-training
can occur when one tries to make up for months of lack of training in a short time period

Possible Symptoms related to Swimmer’s shoulder

  • Muscular fatigue
    Changes in the stroke mechanics (dropped elbow, wider hand entry, early hand exit)
    Pain in the shoulder on the front and outer-side of the shoulder and arm
    Lack of muscle strength
    Sharp pain with overhead movement
    Decreased range of motion

Massage Therapy For Shoulder Pain
A regular massage therapy regimen, in conjunction with your physical therapy, is beneficial in
addressing the tight musculature of the body and to re-balance the structures of the shoulder.
Manual therapy lengthens the tissues which enhances the proper mechanics of the shoulder
and facilitates better movement patterns, decreases pain, reduces scar tissue, improves
muscular strength, increases range of motion, restores the length of tissues allowing for a
decrease in postural holding patterns, and improves circulation to the surrounding tissue.
Massage therapy makes muscles more receptive to performance and more importantly,
recovery. If you are having an intense training cycle and have a big competition coming up,
massage therapy can assist you in having a faster recovery and increased flexibility. Speak to
your therapist to formulate an individualized treatment that meets your needs.

How Do I Treat and Prevent Swimmer’s Shoulder?
Swimmers should focus on prevention and early treatment. A proper analysis will lead to the
most appropriate treatment plan for recovery. A good treatment plan includes:
· The best prevention tool is analyzing training methods, stroke mechanics (discuss with
your swimming coach how to improve your stroke mechanics)
· Avoid using hand paddles as this increases stress on the shoulder
· Reducing the inflammation and apply ice to the shoulder for 15-20 minutes after
training. Discuss with your doctor the use of anti-inflammatory medication however it is
not recommended to cover up the pain with drugs to continue to swim

· Depending on severity, rest or modify how many meters during a training session

· Passive care by a registered physiotherapist that may include ultrasound, interferential
current, joint mobilizations, kinesio taping
· Registered massage therapy for cross frictions to break down scar tissue, myofascial
release, trigger point therapy, strain counter strain, positional release, etc.
· Rehabilitation exercises to strengthen the weak musculature, and restore proper
biomechanics and movement patterns of the shoulder
· Self massage using a tennis ball to release trigger points in the rotator cuff muscles
· Self stretching to muscles such as pectorals either with dynamic contract relax
techniques or passive stretching
· Foam roller for lengthening tight muscles both in the upper and lower extremity and
mobilizing the mid back

If pain in the shoulder continues and increases in discomfort or the presentation changes with
diffuse pain or sharp shooting pain throughout the shoulder and upper extremity see your
physician or your physiotherapist.
Disclaimer – 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

What to expect from your Rotator Cuff and Shoulder Pain Assessment

This is a follow up to my previous article  where I described the anatomy of the rotator cuff (FIGURE 1) and how it may become injured. If a rotator cuff injury, such as a tendinitis or a partial tear, does occur it is important to have this assessed by a trained health professional. A competent examination will help you find a diagnosis and will determine the contributing factors to your injury. This will guide your therapist in developing an effective treatment plan, tailored to your individual needs.

Let me take you through the essential components of an assessment for a suspected rotator cuff injury.







(FIGURE 1: The rotator cuff is made up of 4 muscles which work to stabilize the shoulder)

Subjective Assessment

At the Orthopaedic Therapy Clinic, the examination is provided one-on-one with a registered physical therapist.  It begins with a subjective assessment. Your physical therapist will ask evidence-based questions to rule a rotator cuff injury in or out. Some of the topics covered will include:

  • Age and gender
  • Location and nature of pain
  • Presence of other symptoms such as numbness, tingling, clicking, stiffness, etc.
  • Activities that make the pain worse/Activities that make the pain better
  • Past Medical History
  • Previous injury in shoulder
  • Occupation and physical demands of job
  • Activity preferences
  • X-ray, ultrasound or MRI results

In addition to these topics, other factors that may be explored include: History of anxiety/depression, expectations for recovery, degree of social support systems, beliefs about pain, and pain behaviours such as avoidance of movement. All of these factors are important and have been associated with prognosis in shoulder pain recovery1. Finally, your physical therapist will help you to set a goal, so that you can work towards a specific task to determine degree of recovery.

Physical Examination

After the completion of the interview, your physical therapist will take you through a physical examination. The goal of this examination is to determine your shoulder mobility and strength and the structural integrity of relevant structures.

To begin, your physical therapist will observe your posture. This will include the positioning of your shoulder and shoulder blade as well as the curvature of your neck and mid-back. Next your physical therapist will have you complete various movements such as overhead reaching and rotations to determine your range of motion as well as the presence of any pain with these movements. Additionally, your physical therapist may try to alter the painful movements by changing the posture of the shoulder or shoulder blade to determine if your aggravating activity may be modified.

Next, your physical therapist will test the strength of your shoulder in various positions. As muscles weakness is a common feature in rotator cuff pathology, this will be a helpful test to allow your physical therapist to rule in or out a cuff problem. This may also help the therapist guide exercise prescription, as they may choose to prescribe exercises to strengthen the muscles involved with the weakened movements.

Your physical therapist may also choose to perform certain tests (FIGURE 2) to determine which specific structures may be involved. These tests will help determine which of the 4 rotator cuff muscles are involved, and if a cuff pathology truly exists. Finally, your physical therapist may choose to palpate structures around the shoulder to determine which of them may be painful or tight.

(FIGURE 2: The Hawkins-Kennedy test is a popular manoeuvre to determine presence of rotator cuff injury)


A strong physical examination combined with a thorough history involving the above topics will allow your physical therapist to determine an accurate diagnosis for your shoulder pain. These diagnoses may include rotator cuff pathology, labral tear, frozen shoulder, shoulder osteoarthritis or shoulder pain referred from the neck. If the diagnosis is indeed a rotator cuff injury, there are many effective treatments that may be employed. This will be discussed in the part 3 of my rotator cuff series!

I encourage you to reflect on the contents of this article if you are currently experiencing shoulder pain. Try to determine what the contributing factors to your pain are and what movements/positions are aggravating. If you need assistance with these things I suggest you contact a health professional for a full assessment.

To complete an assessment for a suspected rotator cuff injury or other shoulder pain, contact Taylor Sipos, Registered Physiotherapist, by calling the Orthopaedic Therapy Clinic at (416) 925-4687 or emailing


[1] Chester, R., Jerosch-Herold, C., Lewis, J., & Shepstone, L. (2018). Psychological factors are associated with the outcome of physiotherapy for people with shoulder pain: a multicentre longitudinal cohort study. British journal of sports medicine52(4), 269-275.

Figure 1:

Figure 2:

Taylor Sipos Bio

Taylor Sipos,

Registered Physiotherapist, MPT, BKin,



Taylor completed his Master of Physical Therapy degree from Western University after earning his Bachelor’s degree in Kinesiology from McMaster University. Taylor’s passion for physical therapy developed as he grew up participating in competitive sports. Watch Taylor’s video here
Since graduation, Taylor has taken continuing education courses to enhance his skills and advance his professional development. These courses include:

• Mulligan Concept Lower Quadrant course
• Soft Tissue Release
• Level I Acupuncture through Acupuncture Canada
• Temoporomandibular Management: Modern Manual Therapy
• Temporomandibular Management: Advanced Physical Therapy Education Institute (APTEI)
• The Hip Complex: Breaking down barriers to better outcomes

In addition, Taylor currently has his Level I certification within the Orthopaedic division of the Canadian Physiotherapy Association’s manual therapy levels and intends to complete all 5 levels to become a fellow of the Canadian Academy of Manipulative Physiotherapy (CAMPT). Furthermore, he has received training in concussion and vestibular rehab. Taylor is also interested in pursuing courses in dry needling, McKenzie low back management and treatment for running injuries.

Taylor’s treatment strategy always revolves around the functional goals of his patients. One of the first questions he asks upon working with a new client, is “What would you like to get back to doing?”. Once a goal has been established, Taylor works in collaboration with his clients to achieve these goals. Taylor delivers treatment with a great deal of empathy and compassion for his clients. He strives to provide evidence-based therapy with a strong focus on exercise and education. He believes in motivating his clients in taking an active approach in their rehabilitation to meet their individual goals. In addition to his emphasis on self-management, Taylor utilizes his skills in manual therapy and acupuncture as an adjunct therapy to help his patients return to what they love participating in.

Taylor has always been passionate about sport and in his youth he competed in hockey, lacrosse and cross country running. Now in his spare time, Taylor participates in mid and long-distance running and as such, he has a keen interest in the rehabilitation of running-related injuries. In addition to running, he also enjoys weight lifting, playing hockey and cycling.

Improving your Results with the New Exercise Tracker

The therapists at the Orthopaedic Therapy Clinic (OTC) are always looking to improve how you can achieve your goals.  Recently we have been working in partnership with our exercise software provider to improve your experience.  They are piloting an exercise tracker and we are on-board to try this upgrade with our clients.

What does this mean to you and your recovery?  View the video here.

How often are you doing your exercises?

You can now record your consistency in your exercise tracker.  The tracker allows you to mark off each exercise on a calendar.  This can help you to stay motivated as well as showing your therapist your consistency to your program.

How long does it take to do your exercises?

You can now time your sessions. The program has a built-in timer.  Just click on the stopwatch feature and it will time how long your program takes.

Get interrupted in mid-program?  No problem! Hit the pause button and then resume when you are back on track.

Why do we care how long it takes to do your exercises?

We know that as you improve the exercises are completed more quickly.  This can be a good measure of progress.

We also don’t want you to spend too long on your program.  Our goal is to provide an efficient and effective program.  This data  assists in creating a good dialogue on what is enough and what is too much in your recovery program.

Pain tracking

There is an option to record your pain during each exercise.  This helps us to know if an exercise appears to be irritating and to see if it is getting better or worse over time.  Remember that we don’t like pain increases to last more than a short duration (under 30 minutes) and that it should not be substantial increase i.e. more than 2 points from your baseline pain.

Ready to participate?

Next time you are in the clinic ask your therapist to show you how to use tracker function.  There are some features that are customizable.  For example if pain is a concern this feature needs to be enabled by your therapist for each exercise that you want to track.

If you are managing well and want to update your exercises or just learn to use the tracker – book into our see our kinesiologist John Gray.  If you need modifications in your exercises to manage your injury or pain then book into to see your physiotherapist and he/she can show you the tracker as part of your appointment.  Call us at 416-925-4687 or email to book an appointment.

Remember this is a pilot so there may be a few glitches.  Let us know what you encounter and we will feed it back to the software company for improvements.

Cupping Therapy Relieves Pain

Many athletes and artists use cupping treatments to relieve pain and enhance recovery.  The awareness of this treatment increased dramatically at the Barcelona Olympics

when Michael Thorpe launched the ancient treatment of cupping into the limelight.  Many people wondered what the bruises or “hickeys” seen all over his body were and what might be the purpose of these treatments?  

Although it may seem new, the knowledge that cupping therapy relieves pain has been known for centuries in China and is commonly used as an effective part of their medical treatments.  Watch Igal Untershat’s video explaining the benefits and use of cupping- click here.

What is cupping?

Cupping is used to improve circulation.  The mechanism of effect is not fully known however theories base results on activating the body’s natural mechanisms.  The rush of circulation mimics an injury response and the tissue mobilizes a response to get “healed, renewed”.

In medicine we typically use silicone or glass cups.  They create a vacuum (negative pressure) which draws the circulation to the surface. When the cups are removed the circulation flushes creating the therapeutic effect.

Who benefits from cupping?

Cupping is recommended for many types of musculoskeletal conditions or injuries as it stimulates the fascia (coating on the muscle), increases blood flow and affects myofascial trigger points.  It is a great compliment to manual therapies, such as massage, as it enhances the effects of physical manipulation of the soft tissue.

What can you expect after a cupping treatment?

 In addition to feeling relief of tension and improvement in your pain you will also notice a change in the skin where the treatment was applied.  These changes mimic an injury and the tissue can look irritated, however this is what the treatment is supposed to do.  You will typically notice the following changes that will last a few days to a little longer than a week:

  • Redness in the tissue.  This results from extra circulation in the area/bringing blood to the surface.
  • Round bruises may appear.  These may occur in areas when cupping was done for longer than a few min.  It results from collapsed superficial blood vessels in the skin.  They will resolve on their own, typically in less than a week.
  • Increased sensitivity in the area where the tissues were treated.  You may experience more sensitivity to touch or feel a bit bruised when you lie on the area.  This increased sensitivity typically lasts for a few hours post treatment.
  • Mild irritation or itching during the treatment.  This results from the effect on the circulation and nerves.  It may last for a few hours post-treatment.

When not to use cupping:

Cupping is a safe modality when used by a trained healthcare professional.  However there are sometimes when it should not be used.  Your professional will screen you for these conditions prior to applying the treatment.  Always let the practitioner know if you

  • Bruise easily
  • Take blood thinners
  • Have sensitive or thin skin
  • Are allergic to plastic or silicone (the cups are typically comprised of these materials)
  • Have an open sore
  • Have a bruise or mark from an unknown cause
  • Have a skin disease/condition i.e. psoriasis, eczema

The research on cupping

In health care one of the most important types of studies are systematic reviews.  This is where many articles are reviewed for quality and the researchers evaluate and conclude on the overall strength of the evidence.  These types of reviews give us more confidence in ensuring our practices are based on the best evidence available.  In addition to the great results I have seen from my practice, I was pleased to find this systematic review supported it’s use in managing pain

In summary the research supports cupping is particularly effective in managing:

  • neck pain
  • low back pain
  • shingles-related nerve pain

The results were even better when combined with acupuncture and manual therapy, all of which I have found useful in my practice.   I also find it useful to manage tight muscles, particularly after work-outs or in injury management, which might be why Michael Thorpe uses it too!

If you would like to try this technique and are having back pain, neck pain or muscle tightness, please contact me at 416-925-4687 or by email at


Neck pain – it’s time for a new pillow!

In my last blog I looked at helping you to choose the right mattress for you to avoid or reduce back pain In this blog we will look at how to avoid neck pain by choosing the right pillow.  If  you are having any of the following symptoms you should look to replace your pillow sooner than later:

  • Awakening with neck pain that gets better as the day goes on
  • Neck stiffness particularly in the morning.
  • Your hands go numb at night

Tingling or numbness in the hands at night can often be a sign of poor support or awkward sleeping positions.  It can be caused by straining your neck and this affects the nerves that go into your hands.

Where to start? ( Watch Video –   how to choose a pillow )

Companies that sell beds often recommend when you buy a new mattress that you consider your whole sleep system.  I agree that you need to make sure your mattress, pillow and mattress topper are all working together to give you the support you need.  If you need to replace your entire sleep system, then I usually recommend you buy the mattress first.  Add a topper if the mattress is a bit too firm and then finish with finding the perfect pillow.  Your neck and back will both thank you for the effort you put into the support. Most importantly make sure the retailer allows you to return these items if they don’t work.  A pillow can set you back over $100 and I just finished pricing mattress toppers for the cottage and they are $200+ for one that provides enough support.

Consider how you sleep

Which pillow you will choose is largely determined by your sleep habits.  Pillows need to support, as well as mold to you. This can be difficult to achieve, particularly if you don’t always sleep in the same position.  If you sleep on both your back and side it’s much more of a challenge to get the pillow just right as we need more support when we are on our side than when we are on our back.  The key to having a restful sleep and pain free sleep is to keep your neck in line with your body .

Here’s a guide on what to look for depending on what type of sleeper you are: (Watch Video –  Choosing a pillow for how you sleep )

Pillow for the Side sleeper

Most people’s pillows need to be thicker when you sleep on your side vs. on your back.  When choosing a pillow it needs to be thick enough to fill the gap between your shoulder and the side of your head.  The broader your shoulders, the wider the pillow.

My rule for getting it just right is to imagine a straight line is drawn down the length of your nose.  Then imagine another line is drawn up the middle of your breast bone.  The two lines should meet in a straight line.  This ensures you don’t have a kink in your neck and wake up stiff or in pain.  If you have too little support your head and neck will drop down. Too much support and you will bend your head and neck upward.

Pillow for the Back sleeper

For most people your pillow will be thinner if you are a back sleeper. The pillow needs to be thick enough to fill the distance between the back of your head and your upper back.

If your upper back is more rounded then you may need to use a thicker pillow until you improve your posture.  Some people prefer to sleep on their back without a pillow but I find this habit is often too flat for most people.  Either too high or two low of a pillow can cause pain.

You can tell if your pillow is too high as your head and neck will be bent down and not in line with your torso.  If it’s too low your chin will poke up toward the ceiling and you may find you are looking slightly backwards.

Pillow for the Stomach sleeper

Although manufacturers sell a pillow for sleeping on your stomach, my recommendation is to break this habit.  Neither your neck nor your back will feel good with this posture over the long term.

This is not an easy habit to break, as many people have used this position for most of their life.  I recommend to begin the transition by lying on your side and placing a large pillow against your belly.  Roll forward until you are ¾ of the way onto your stomach with your torso against the pillow.  This will give you the sense of comfort most people crave. Contact with the abdomen appears to be what most people are seeking.   Providing you don’t roll too far forward you won’t twist your neck.  Consider a longer torso pillow to allow you to bend your top leg and rest it on the pillow.  Alternatively, two pillows can create the same benefit but are more awkward if you change positions a lot.

Pillow for if you flip all night

It’s good to change positions at night and many people sleep on both their side and back.  However, sleeping on both your back and side can be more challenging for getting the pillow right.  If this is your norm its more important to choose a pillow that is made of a more adaptable material (see below) and you will likely benefit from a thicker mattress topper.

Start by choosing the right thickness of pillow for when you lie on your back. Then make sure you have enough mattress topping to allow your shoulders to sink in a couple of inches when you are on your side.  Ensure that the material in the pillow molds to you and adjusts as you change position. Unless your neck is very stiff, this should provide enough support for both positions.  If your neck is very stiff, restoring more movement through treatment and exercise will help you to be able to sleep more comfortably.

Pillows for watching TV or reading in bed

The most common mistake I see is not related to sleeping. How we watch TV or read in bed has a big impact on neck pain.  Many people use too high of a pillow.  Instead of propping your head up, try to position your pillows like a ramp, to create a gentle incline.

How adaptable is your pillow

I have to confess, I don’t like shaped pillows.  These “bumps” on the end of the pillow often don’t fit.  Each of us has our own shape and size to our neck and unless you are fortunate enough to fit the manufacturers specs, their support can be too much or too little.  Instead I prefer to use a non-shaped pillow made out of an adaptable material that will nestle into your neck.  If that’s not enough support, we can roll up a towel or a piece of foam until we find the exact right thickness for you.

Choosing the right material

There are 4 common materials that I recommend for pillows.  There are many reasons to choose one over another, however the most important feature of each one of these types is that they adapt.

  1. Memory foam – I tend to favour these types of pillows as they are very adaptable. A good memory foam pillow will let you shift positions from back to side with much less concern about the mattress topper. They also tend to last for several years.  The down side is that they are expensive, often $100+. Some people find the foam retains heat. Be careful if you are scent sensitive as some foams off-gas and I see a lot of complaints in the reviews.
  1. Water-based pillows – This was the first type of pillow that had a high-quality research study which demonstrated improvement in people’s neck pain. It was the one that I used until I moved to a memory foam.  In most designs there is a central water bladder surrounded by outside fiber fill.  If this is the pillow you decide on, make sure that you can add or remove water.  This allows you to customize the support and is really useful as you can add a bit more water when the fiber damps down.

The downside of these pillows is their weight.  Watch your back when you change the pillow case.  Slide it over and keep the pillow in tight to your body when you lift it.  If you are very sensitive to noise at night, this may not be the pillow for you.  Some people can hear water sloshing as they turn over.  Often this can be improved by working the air bubble out before closing the valve.  If you travel with this pillow I would recommend draining the water and refilling when you arrive.

  1. Buckwheat – This is an inexpensive, adaptable pillow. The type I prefer has a zipper and comes with extra cereal.  This feature allows you to customize the support by adding or subtracting what you need.

The cons of this pillow is that it doesn’t last as long as I find the heat of the body fuses the buckwheat together.  If you are a sensitive sleeper there can be a rustling noise as you roll over.  I don’t know of any fixes which get rid of the sound.

  1. Feather and down – Most feather pillows are all down or all feather. The pillow I like best is a combination of down and feather.  A core of feather provides support and the softness of the down surrounding the core allows the material to adapt to your shape.  Feather can be fluffed up and can be cleaned to reduce the matting of the material and restore support.

The downside of this pillow is allergies to feather, expensive, hard to find and sometimes it’s a square shape which requires different bed linen.

When do you need to treat your neck?

Your pillow can’t completely correct your neck pain.  If your neck is stiff, if you are having numbness or if you need further advice on finding the right sleep system, the therapists at the Orthopaedic Therapy clinic can help you sort out how to start getting a good night’s sleep.

Should I use hot or cold for my injury?

woman applying cold pack on her arm

Should I use hot or cold? This is one of the most frequent questions I am asked when someone gets injured. It’s no wonder it’s so confusing when one professional tells you hot and the next is recommending cold. Choosing ice or heat is important and making the right choice depends on the stage of healing of your injury and on what you are trying to achieve.

How do I know whether to apply hot or cold for my injury?

Research shows these treatments [1] can be beneficial at any stage of healing. I generally recommend the application of hot, cold, or contrast therapy depending on where you are in your recovery.

Acute Stage – This stage typically lasts between 1 and 3 days.

This is the stage when you are feeling pain. The tissues are warm to touch, there is swelling, tissue discoloration and muscle spasm. During this stage the tissues are breaking down and preventing further injury is the main goal of treatment.

Preventing further injury is the main goal of treatment

Preventing further injury is the main reason to cool the tissues. Some literature supports the use of cold application to slow your tissue’s demands for nutrition and circulation. The benefit of cool is seen in near drownings. Cooler water means that delicate tissues, like the brain, are less injured. When tissues are cool you can go longer without providing new oxygen as the consumption of what’s in your body is slowed.

Slowing consumption can also be important in the acute stage of a soft tissue injury, particularly with more severe injuries as healing raises the demands on the metabolic process and swelling often slows the delivery. Cooling the tissues reduces the likelihood of running out of metabolic substance and not having the nutrition you need to repair the injury.

Sub-acute Stage – This stage follows right after the initial injury, from day 4 to 3 weeks.

During this phase the initial swelling is decreasing and bruising is changing from purple to yellow in color. Muscle spasm changes to tightness and discomfort replaces sharp pain. This is the repair phase when we can start to do more therapy. In addition to massage, stretching and exercises I often find heat is best to help you get moving but recommend cool if you over-do the activity.

Recovery Stage – This final stage can last from 3 weeks to 3 months.

Recovery follows the sub-acute stage. The bruising has resolved, there is no heat however you have muscle tightness. This is the remodeling phase when therapy is the most important. Deep tissue massage and more demanding exercises help the tissues to remodel stronger. I find heat is the best during this stage unless you over-do it

Why apply hot or cold?

The benefits of hydrotherapy treatments include:

  • dramatically increasing the elimination of waste and assisting in detoxification
  • loosening tense, tight muscles and encouraging circulation
  • increasing the metabolic rate and digestion activity (heat)
  • hydrating the cells, improving skin and muscle tone
  • boosting the immune system, allowing it to function more efficiently
  • improving the function of the internal organs by stimulating their blood supply
  • reducing inflammation (cold)
  • reducing lymphedema (contrast)

How to apply Cold

Cold hydrotherapy is used to reduce pain and decrease blood flow, minimize pain and swelling after an injury. At home, cold can be applied using ice or gel-filled ice packs, ice baths or cold, wet towels. Cold is applied for 10-15 minutes, depending on the part of the body being iced.  You should wait a minimum of twenty minutes between applications. I recommend to my clients to use a warm wet towel around the ice. It’s not as threatening on first application.

How to apply Contrast treatments

Contrast hydrotherapy is an application of heat followed by an application of cold. This increases blood flow to and from the area, which can speed healing. Research shows both short and long-term benefits for[2] distal blood flow and claudication in people with significant peripheral arterial disease. This research supports that contrast hydrotherapy may be a preventative treatment for lymphedema -which is a common type of swelling after traumatic injuries. I prefer contrast for lymphedema however it can be challenging to find access to facilities with tubs/pools for the legs. I find my clients like it for their forearms, hands and feet with arthritis and when minimal swelling is left and ice no longer feels good to apply.

Contrasts are usually started with very minimal differences in temperature. A general guideline for the timing of heat and cold applications is three minutes of heat followed by one minute of cold. This can be repeated for up to thirty minutes. A simple application is a rule of threes: three minutes heat, thirty seconds of cold, three times.

There are a number of ways to apply contrast hydrotherapy at home. You can alternate hot and cold packs depending on the body part being treated. For hands and forearms, I often recommend filling a two-sided kitchen sink with hot water on one side and cold on the other and alternating between the two.

How to apply heat

Heat can be used to make muscles softer and more flexible, increase circulation, reduce pain and provide relaxation. It often comes in handy for relief of tight, achy muscles which are often present inmore chronic conditions. At home, basic heat hydrotherapy can take the form of a hot bath, an electric heating pad or a microwaveable cloth bag. Heat is applied for up to 10-30 minutes at a time, and the temperature should never be uncomfortably hot.

Some precautions to consider when I use hot or cold for my injury treatment

Heat is not used when swelling or bleeding are present, as it can increase blood flow. Don’t use heat over an area with an infection, if you have a burn or a circulatory conditions, such as high blood pressure, then specific hydrotherapy applications may be required. If you use an electric heating pad – put a timer on to make sure you don’t fall asleep and get a burn. Cold is  not advised if you have poor circulation or if you have extreme cold sensitivity. Be careful with both heat and ice if you skin sensitivity is diminished in the area you are applying the treatment.

If you are finding chronic tightness is limiting your ability to move well or if you have muscle soreness, book a massage therapy treatment with me to specifically address these areas and to learn application of hydrotherapy and self-release strategies you can use between treatments. 


[1] Scientific Evidence-Based Effects of Hydrotherapy on Various Systems of the Body

[2] [PDF]Is there a role for contrast hydrotherapy? – Journal of Lymphoedema


Juliette Woodruff is a registered massage therapist practicing in downtown Toronto at The Orthopaedic Therapy Clinic. Disclaimer-This information is not meant to replace medical/health advice. Contact your health professional to ensure the diagnosis and treatment are appropriate for your condition.

Are Your Knees Bringing You To… Your Knees?

Managing or preventing knee pain can very confusing because advice is often contradictory.  Exercise approaches promoting functional movements are a favourite amongst fitness and health professionals, yet many people gravitate to exercise machines that are specialized for targeting problem areas.  In this article, I hope to provide some clarity to help you make the best decision for your individual needs and goals.

Functional training has become the most popular method rehabilitation and fitness professionals use to return clients to sports, as well as improve performance and reduce injury risk.  This is because performing exercises that look like sports movements is believed to be significantly better than strengthening using machines that focus only on a single muscle or muscle group.

But that’s not all.  Some research studies caution that the use of exercise machines may cause potentially-damaging forces in both ligaments and cartilage that could lead to osteoarthritis of the knees.  Of these, the seated knee extension is recognized to be the most dangerous.  The most important arguments against exercise machines for the knees are:

  • Research has shown that knee strain when using machines can be much higher for the same muscular effort than during functional exercises like squats or lunges with even very heavy weights.
  • Exposing your knees to high forces may lead to progressive problems including arthritis and surgery to reduce pain.  This can have a significant impact on activity level in the long term, especially for anyone who has had a knee injury in the past.
  • Exercise machines often focus on a single muscle, or localized area of the body.  However, the opinion of many experts is that lower body strengthening should condition more muscles than just the quads, such as the muscles of the hips, which are used in many sports movements. 

Low pad position on knee extension machine. Raise on shin to help decrease strain on knee ligamentsSeated Knee Extension Machine

Despite such clear warnings that people may be training their thighs at the expense of their knees, gyms continue to fill their spaces with these machines because of their popularity with members.  They have not only been touted by famous bodybuilders for building a muscular physique, but they are also easy to perform without detailed instruction.  Additionally, there are several relevant points that suggests that research may not have all the answers.  These include:

  • Biomechanical analysis that estimates forces and injury risk does not agree with the clinical research studies. In other words, the laboratory and the clinic don’t seem to agree.  For example, injuries almost always happen during functional movements such as lunging or landing on one’s feet, and there are no medical reports of this injury happening when performing a knee extension exercise.
  • Medical research also shows that quadriceps strength is the most important factor in avoiding future injury.  However, additional research has also shown that functional exercises, such as squats and lunges, alone may not sufficiently strengthen the quads.  This unfortunately places the person in a difficult position, because expert advice may not be best for their long-term recovery.

Given the strong points on both sides of this discussion, can we actually say that it is possible to safely use exercise machines for strengthening that will also not increase the risk of future injuries to the knees?  Yes of course!  But only as part of your whole program, because you have to consider your individual needs.  Here are some guidelines to help you do it safely and effectively:

  • Make sure the equipment is set up properly (Here is a great video with tips on how to perform this exercise correctly.) And always do the following:
    • Make sure your knee lines up with the point of rotation of the machine.
    • Instead of placing the pad just above the ankle joint (as seen in the picture), adjust it to about mid-shin level as this has been shown to help decrease stresses on the knee ligaments (Escamilla et al, 2012).
    • If you have knee pain or a previous injury, make sure you use an exercise machine that allows you to adjust the starting angle and range to a safe amount, or at bare minimum, stay within your pain-free range of motion.
  • Don’t use heavy weights! Even if it’s possible to select hundreds of pounds on the machine, there is a clear trend for increased knee ligament strain with increased knee extension force.  And by itself, the seated position used on this exercise means you won’t improve your athletic ability, either.  Keep these stresses and strains in check by aiming for moderate resistance that lets you perform around 10-15 repetitions with *perfect technique*. 
  • Another strategy to increasing resistance in an exercise is to try going very slowly up and down (counting to between 5 and 10 in each direction), experiment with static holds at full extension, or reduce your rest period between sets to between 30 and 60 seconds. This increases both muscle activity and limits additional stresses in the knee joint structures, and lastly:
  • Pay close attention to how your knees feel during and after your workout, and never let your knee pain increase during a set of exercise. Signs of swelling, redness, heat may indicate an irritation to the joint that could turn into bigger problems in the future.  If pain or swelling does not return to normal after one-to-two days, consider seeing a musculoskeletal health professional for help.

In general, people who are trying to prevent knee pain, or who are back playing sports pain-free, will likely benefit from including exercise machines for the legs because the forces are not likely to be greater than when doing squatting or lunging movements.  This also includes people with mild knee osteoarthritis.  However, those following a knee rehab program should focus on body weight exercises that restore normal movement in the knees, hips and ankles.  Knowing how much of each type of exercise to use not only depends on your stage of recovery, but also your particular medical and activity history, individual physical characteristics, and goals.  So it pays in the long term to have a specialist see where you need the most attention first, and work with you to plan a return to the activities you love the most.

The advice in this article is not meant to replace professional advice from a therapist or trainer.  If you would like to find out how you can safely prevent or manage knee pain, or to schedule an appointment, please feel free to contact John Gray at, or call us at The Orthopaedic Therapy Clinic at 416-925-4687.



OTC Social Media Platforms

We have been working hard to develop content that helps you to manage your injuries and pain by making better choices on exercises, products and even how you manage your therapy type i.e. Telehealth. You can keep in touch with us on the following platforms:

Fee changes due to COVID

Please note that effective August 18, 2020 the fees will be increased by $10 per 1/2 hour appointment or $20 per 1 hour appointment. This reflects the increased costs of COVID control. You can read about our process here

If you have any concerns about the fee change, please contact Maureen Dwight directly at

Functional Fascia Therapeutics (FFT)

In 1996 Zhonghua Fu, PhD, invented a technique which inserts needles under the skin into the fascia.  The technique is different from traditional acupuncture as the needles are inserted horizontally and more superficially.  Only one needle is inserted at a time and the therapist provides the treatment by gently moving (swaying) the needle. The technique is relatively pain free.

The technique is used to reduce tightness in the myofascial system.  Its effect can be an immediate increase in mobility.

The theory behind the response is that the collagen tissues are most abundant in the subcutaneous layer of the body.  As the technique targets this layer of tissue it stimulates more change in connective tissues.

At the Orthopaedic Therapy Clinic we find that this technique is most effective when paired with soft tissue treatments that assist your full myofascial system to lengthen i.e. massage, soft tissue manipulation.  This technique, coupled with therapeutic exercises and posture change awareness creates a comprehensive catalyst for recovery from persistent musculoskeletal restriction.

Igal Untershats therapist at Orthopaedic Therapy Clinic in TorontoIgal Untershats is trained in Functional Fascia Therapeutics. To arrange an appointment please call 416 925 4687 or email:



Welcome to our new Registered Physiotherapists!

Please join us in welcoming Taylor Sipos,  Tiffany Shi to the team at The Orthopaedic Therapy Clinic. 

Taylor Sipos Registered Physiotherapist MPT, BKin

Taylor completed his Master of Physical Therapy degree from Western University after earning his Bachelor’s degree in Kinesiology from McMaster University. His passion for physical therapy developed as he grew up participating in competitive sports.

Since graduation, Taylor has taken numerous courses to improve his skills and advance his professional development. These courses include the Mulligan Concept Lower Quadrant course, Soft Tissue Release and Acupuncture. He plans to complete his manual therapy levels through the Orthopaedic division of the Canadian Physiotherapy Association.

Taylor delivers treatment with a great deal of empathy and compassion for his clients. He strives to provide evidence-based therapy with a strong focus on exercise and education. He believes in motivating his clients in taking an active approach in their rehabilitation to meet their individual goals.

In his spare time, Taylor participates in mid and long-distance running and as such, he has a keen interest in the rehabilitation of running-related injuries. In addition to running, he also enjoys weightlifting, playing hockey and cycling.

For an appointment please call The Orthopaedic Therapy Clinic at 416 925 4687 or contact Taylor at





Tiffany Shi Registered Physiotherapist, MSc.PT, BSc

Tiffany graduated from the University of Toronto with a Master of Science in Physical Therapy in 2019. Prior to pursuing a career in Physiotherapy, Tiffany obtained a Bachelor of Science degree in Honors Biochemistry from McMaster University in 2017.

Tiffany is passionate about helping people recover from their conditions and return to the activities they love. She loos to obtain a thorough history and a holistic physical examination of patients to identify the root cause of the condition. Tiffany’s treatment approach includes manual therapy and evidence-based exercise prescription tailored to the different goals of each client.

Tiffany is a strong believer in life-long learning. She is interested in continuing education in areas of manual therapy, acupuncture/dry needling, concussion rehabilitation, and pelvic health. She has recently received her certification in level 1 orthopaedic manual and manipulative physiotherapy.

In her spare time, Tiffany is busy practicing in sabre fencing and refereeing at competitions. She also enjoys photography, sewing, life drawing, and reading. Tiffany is bilingual, she is happy to provide service in Mandarin if needed.

For an appointment please call The Orthopaedic Therapy Clinic at 416 925 4687 or contact Tiffany at

Announcing:  Aniela Amio – Pilates and Yoga Instructor, Reiki practitioner

We are excited to announce Aniela Amio is joining our team at the Orthopaedic Therapy Clinic. Aniela brings extensive experience in injury rehabilitation through Yoga and Pilates. She is certified in Pilates, Yoga and Reiki. Her focus is on spinal health and injury recovery as well as pre and post-natal care. Aniela will be an integral part of the team, along with our registered kinesiologist, John Gray, in helping you to advance your recovery to return to fitness while reducing your risk of injury.

Aniela’s passion is to empower people of all ages and abilities to improve how they to move and help them to take care for their own bodies.  She is interested in and continues to expand her studies with workshops on the mind body connection, chronic pain, scoliosis, fascia, pre and postnatal health and recovery as well as working with the aging population.  Aniela has had the opportunity to work with professional athletes, dancers, chronic pain suffers and those recovering from spinal injuries and surgeries.

Call us  at 416 925 4687 to book an appointment or chat with your therapist to determine when you are ready to benefit from working with her.

Scoliosis Presentation

Maureen Dwight presented a paper on scoliosis at the National Orthopaedic Division Conference held  in London Ontario.  This will represent her third presentation to treatment professionals on managing and treating scoliosis.  These engagements have been based on the paper she  co-authored on scoliosis treatment.  Although primarily written for treating professionals, it is available on our website at These efforts are helping to raise the awareness of treatment professionals on evidence-based treatments for scoliosis.  Maureen also attended the International scoliosis conference (SOSORT ) in Dubrovnik Croatia.

Functional Medicine: A Proactive Approach for Long-Term Health

By Dr. Adonis Makris D.C.

About 16 years ago I discovered Functional Medicine and began studying[1] this ground-breaking method of patient care. This holistic approach to treating patients incorporates the latest genetic science, systems biology, and insights into how environmental and lifestyle factors trigger the emergence and progression of disease. As a medical professional this approach to health care is an important part of my toolkit for treating patients.

holistic medicine

What is Functional Medicine

Functional Medicine is truly holistic—it views all the components of the human biological system as a functioning whole. The body is seen as a single, integrated system rather than a bunch of organs and body parts “owned” by different medical specialties. It treats the whole person by looking at how a patient’s complete bio-system interacts dynamically with their environment to produce patterns and effects that change over time.

Bringing the practice of medicine into the 21st century

Conventional medicine today is focused on the diagnosis and treatment of trauma or acute illnesses that require urgent care—for example, pneumonia or appendicitis or a bone fracture. Physicians treat patients with drugs or surgery to try and fix the immediate problem or symptom.

This acute-care approach to medicine, however, is not designed to prevent and treat the complex, chronic diseases that are running rampant in modern Western society. This means that people who have a general sense of not feeling well and those without any confirmed disease often “fall through the cracks” in terms of conventional diagnosis, but can benefit from the principles of Functional Medicine.

The underlying causes of conditions like diabetes, heart disease, osteoporosis, reflux, mental illness, and autoimmune disorders such as fibromyalgia and Sjogren’s syndrome are often missed when the approach is limited to managing the symptoms. Most medical training does not look at preventing chronic illnesses through nutrition, diet, and exercise.  Although the research and information around managing disease is increasing, time  is needed to implement new practices in more traditional professions. Nonetheless, the changes are steadily presenting themselves in the field of medicine.

Heading off chronic disease at the pass

You don’t need to have a chronic disease to benefit from Functional Medicine. The approach addresses the underlying causes of disease even before it has a chance to take root. It engages both patient and practitioner in a therapeutic partnership to support long-term health.

Often one of the early symptoms which is addressed by Functional Medicine is a general sense of feeling unwell.  This may be the start of something that could lead to a disease. Functional Medicine can give you a chance to nip conditions in the bud before they blossom into a disease

The major influences that contribute to chronic disease include:

  • Poor nutrition
  • Sedentary lifestyles
  • Chronic stress
  • Poverty[2]
  • Environmental toxicity
  • Fragmented social networks[3]
  • Chronic infections[4]
  • Aging

How does Functional Medicine Help?

Functional Medicine integrates a patient’s signs, symptoms, and common pathways of disease with seven biological systems where core clinical imbalances are found. These core clinical imbalances bring together the mechanisms of disease with the manifestations and diagnoses of disease:

  1. Assimilation: digestion, absorption, microbiota/GI, respiration
  2. Defense and repair: immune, inflammation, infection/microbiota
  3. Energy: energy regulation, mitochondrial function
  4. Biotransformation and elimination: toxicity, detoxification
  5. Transport: cardiovascular and lymphatic systems
  6. Communication: endocrine, neurotransmitters, immune messengers
  7. Structural integrity: sub-cellular membranes to musculoskeletal integrity

In this way we can see that one disease/condition may have multiple causes (that is, multiple clinical imbalances), just as one fundamental imbalance may cause many seemingly different conditions.

For example, obesity is a condition that can result from numerous imbalances—hormones, mood disorders, diet and exercise, genetics, inflammation. But also a single imbalance, such as inflammation, can cause many conditions (diabetes, heart disease, depression, arthritis, cancer). Functional Medicine seeks to restore balance in the patient’s environmental inputs and in the body’s fundamental physiological processes because balance is the key to restoring health.

Functional medicine, nutrition and science

Scientific research around the therapeutic effects of nutrition give credibility to the Functional Medicine approach. A large and rapidly expanding evidence base about the benefits of clean eating, and the clinical use of vitamins, minerals, and other nutrients such as fish oils, support the treatment method. 

This also applies to Mother Nature’s botanicals (organic fruits, veggies, herbal medicine); exercise (aerobics, strength training, flexibility); stress management; detoxification; acupuncture; manual medicine (massage, manipulation); and mind/body techniques such as meditation. We also use guided imagery and biofeedback. All these alternative tools and practices are gaining more credibility within the medical community based on the growing body of research to support their value.

Because chronic disease is a food and lifestyle-driven, environment and genetics-influenced phenomenon, we need an approach to healthcare that integrates all these elements within the scope of each patient’s personal journey. With Functional Medicine we have a proactive approach to solving the modern epidemic of chronic disease that is creating a global health crisis.

My Approach

As a Functional Medicine practitioner I spend time with patients, listening to their histories and asking questions to uncover the interactions among genetic, environmental, and lifestyle factors. With science, clinical wisdom, and innovative tools, we can identify many of the underlying causes of chronic disease and intervene to correct the clinical imbalances, even before actual disease is present. Even for people who feel relatively healthy but may have a few complaints Functional Medicine optimizes your health and gives you strategies to prevent disease before it takes root. For example this approach can benefit you if you have any of the following concerns:

  • fatigue
  • poor sleep patterns
  • injuries
  • stress

For my patients, it begins with getting a complete history of your illnesses and injuries (about an hour-long interview), answering a series of in-depth health appraisal forms and questionnaires about food intake, plus a commitment to keeping a daily food diary to track eating habits. There’s also a physical examination that involves tests (blood pressure, pulse, respiratory rate, neurological screening) and blood work done with a chemistry lab to assess hormonal balances and metabolic function.

Ultimately, your health is your biggest asset. To get an in-depth understanding of how Functional Medicine can work for you, an initial consultation with a Functional Medicine practitioner is a great investment in preserving that asset for years to come. Contact Dr. Adonis Makris at the Orthopaedic Therapy Clinic to set up an appointment for a thorough assessment and to discuss whether Functional Medicine is a treatment option for you., 416-925-4687.

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.

[1] (Currently Dr. Adonis Makris is a post-graduate Doctorate candidate at Functional Medicine University.

[2] Fear of financial stability is the No. 1 cause of stress in today’s society; actual poverty disrupts peoples’ ability to access specialized health practitioners, and purchase quality food, supplements, and natural medicines.

[3] Society has become more individualistic; people are addicted to mobile devices and social media at the cost of personal interactions with family and friends.

[4] Candida being the most common 


Preventing running injuries Part II

My previous article‘s main focus was about preventing running injuries and clarifying common myths and misinterpretations  that many of us make. The feedback was great and pushed me to write this follow-up article, focusing solely on the best running shoe that one should opt for when running; the minimalist shoe. The latter is not a specific type of shoe or brand, but rather a concept, which will be described in detail in this article. Prior to diving into this  innovative,  yet evidence-based subject, let’s review some of the key points made in my previous article.

Myth:  Shoe cushioning prevents injury 

  • Our feet are important. They inform us about the surface, absorb our body weight and adapt to the unevenness of the ground. Shoes provide essential protection from the cold and dangerous surfaces, but unfortunately they can also “over-protect” our feet, sending our brains the wrong message throughout much of our daily activities.
  • Through the increased rigidity of the shoe, the runner’s foot has become lazier and less efficient at processing the essential information that the ground provides. In others words, the brains receives a message telling it that the ground has no unevenness or risk and that the foot doesn’t need to work as hard to protect itself.  As a result, the foot slowly loses its ability to adapt and to quickly react to change, such as to different surfaces.  This failure to adapt quickly results in injuries as small forces add up or when a larger change is not felt quickly enough i.e. stepping off a curb.
  • In terms of performance, the elevation of the slope of the shoe causes us to change how we run.  This angle means that the first contact is with the heel.  This design converts the runner into a heel-striker, as opposed to the preferred running style of mid or forefoot striking. Because the contact is much greater in running as opposed to walking, we want to be able to absorb the ground reaction force through our muscles rather than our joints. This is why it is best to avoid the direct heel to ground contact when running.  
  • Coming back to the excess cushioning and “comfort” make the body feel protected. In turn, this reduces the need to protect us from painful stimuli, such as the contact of the heel with the ground. Therefore when we land on our heels and let our joints absorb the high impact forces of the ground we substantially increase the risk of injury.

How to find the “perfect” running shoe

Ideally, you want a shoe with the least amount of interference with the natural movement of the foot. This minimalism means that the more information the foot gets from the ground,  the more  accurate the signals from the brain will be to ensure protection of the foot. Whether  you are a beginner or simply looking to transition from your current footwear, think about purchasing a minimalist shoe. It is structured to be highly flexible, have a minimal heel to toe drop, a low weight and stack height and no motion control or stability devices. As part of a study led by researchers from the University of Laval, 42 experts from 11 countries defined the minimalist shoe and build what is called the Minimalist Index  (MI) which is composed of the five criteria.

Criteria Definition High MI
Flexibility The shoe is tested its flexibility and malleability The more flexible the shoe, the higher the MI score.
Weight Simply weigh the shoe on a scale The lighter the shoe, the higher the MI score. 
Stack height Measures the thickness of the sole The thinner the sole, the higher the MI score. 
Stability and motion control Accounts all technologies that promote rigitidy or arch support The less devices added in the shoe (to stabilize the foot or prevent flat feet), the higher the MI score. 
Heel to toe drop The drop is the difference between the shoe thickness under the heel and where the toes start. The flatter the drop, the higher the MI score. 
  • An example of a shoe with a minimalist Index of 100% is the Five Finger .  In contrast, the Hoka model  will be considered as an ultra- Maximalists shoe with an MI of near 0 %.  The running clinic developed a website in which you are able to  search for the minimalist index of your shoe by simply typing its name. A picture and detailed description of your shoe as well as its best use will appear.

Preventing running injuries- Careful when changing shoes;

It is important to recognize that if you are switching from one footwear to another, the transition should be gradual. In this case, most injuries are caused when the transition happens too quickly. The rule of thumb is that on average, runners should aim for a one month period for every 10% change in the Minimalist Index score. For example, one should plan for a 3 months transition time when switching from a shoe rated 50% to one that’s rated 80%. Staying conservative is key, otherwise more damage than good will be done to the body. Too quick of a transition towards a more minimalist shoe (higher score on the Minimalist Index) will typically result in symptoms to the foot, Achilles tendon or calf muscle. On the other hand, too quick of a transition towards a more maximalist shoe (lower score on the Minimalist Index) will generally cause symptoms to the knee, hip or lower back. In the end, everything is a matter of adaptation and you should listen to your body and make the transition between shoes progressively.

If you are curious to find out whether you are a heel or forefoot striker; whether you’ve got the right shoe; or would like an evaluation of your running pattern and mechanics, come see Svetlana Marianer Registered Physiotherapist, at the Orthopedic Therapy Clinic.  Svetlana has completed several courses related to the prevention of running injuries, and as a dedicated runner, she has firsthand experience with the field. She will be able to help you select an appropriate shoe, develop a customized running program and prescribe tailored exercises to help you achieve your running goals.

Disclaimer – 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.

References:   Esculier J-F., Dubois B.,Dionne C.E., Roy J-L and J-S. A consensus definition and rating scale for minimalist shoes. The Journal of Foot and Ankle Research; 2015.

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

Jaw Discomfort With TMJ (Temporo-mandibular joint dysfunction)

Jaw Discomfort With TMJ, by Juliette Woodruff R.M.T, Acupuncture Practitioner

Juliette Woodruff is a registered massage therapist practicing in downtown Toronto at The Orthopaedic Therapy Clinic. The temporomandibular joint (TMJ) is the most commonly used joint in the body.  It is estimated that most people open and close their mouth approximately 1,500 to 2,000 times a day for talking, chewing, swallowing, kissing, yawning, snoring, mouth breathing and facial expressions. It’s not surprising that this joint can get strained causing jaw discomfort.


Anatomy Of The Jaw Joint (TMJ)

 The jaw joint connects the lower jawbone called the mandible, to the bone on the side of the head called the temporal bone. These bones are where the joint gets its name – Temporomandibular or TMJ for short. When we open and close  our jaw the round part at the end of the lower jawbone (condyle) glides forward and back in the socket (fossa) located in the temporal bone.  For this gliding motion to be smooth it requires the soft disc that sits between the condyle and the temporal bone. This soft cushion-like structure separates the bones to allow the sliding effect (rotation) needed to be able to talk, chew, kiss, sing, and do a variety of other movements without pain. If you place your fingers just in front of your ears and open and close your jaw, you will feel the joint move. When there is a problem, you will feel the joint protrude out under your fingers or experience a click. TMJ – Temporomandibular joint dysfunction – YouTube

Symptoms Of Jaw Discomfort With TMJ

Jaw discomfort can cause a number of symptoms. When your jaw is a problem you may feel:

  • pain with opening and closing your mouth
  • pain when chewing gum or firm foods i.e. apples
  • clicking, popping sounds
  • limited opening of your mouth
  • locking of the jaw

Some symptoms may mimic other conditions.  TMJ issues can cause a pain in the ears similar to an earache. It can also cause a sensation of pressure, an annoying sensation of ringing in the ears (tinnitis), fuzzy sounds  and/or hearing loss. The TMJ issues can cause pain and tension around the head, neck, face, and shoulders. If muscles are involved, pain can be referred into the head causing headaches. The muscles involved in chewing (mastication) can refer pain in the forehead along eyebrows, the teeth (mimicking dental problems) and pain to the lower portion of the jaw. TMJ

Causes of Jaw Discomfort With TMJ

If the TMJ becomes damaged or misaligned, the soft disc may become compressed and torn from arthritis, trauma, or improper alignment of the jaw. Over time these bony structures, can deteriorate at an accelerating rate. The wear from the grinding on the joint, combined with the loss of the cushioning effect of the soft disc (articular), may cause difficulty in opening and closing of the mouth. The body may respond to this imbalance, by using the musculature of the face, neck, and jaw to try to realign the joint. As these muscles fatigue, additional muscles of the shoulder and back are progressively recruited into compensatory patterns.

Massage Therapy For Jaw Discomfort With TMJ

Many people clench their teeth at night without even realizing it. Once diagnosed, I wonder how many people never get a mouth guard? Perhaps you don’t want to be bothered with the annoyance of a plastic device sitting on your teeth at night and instead choose to avoid your dentist’s prescription. This avoidance may seem better at the time until your dentist finds hairline cracks in your teeth from clenching and grinding.  You may avoid it until you experience constant discomfort in the jaw, face, and other areas as the condition becomes more chronic. In addition to mouth guards, massage can be a useful therapy in the treatment of TMJ. Massage helps to lengthen the jaw muscles (treating trigger points), and reduces pain by treating the tension in the compensatory structures of the neck and shoulder region. Treatment is usually done while you are lying on your back so as to reduce pressure on the jaw area. It is often applied to the structures in and out of the mouth to achieve restorative normal motion of the jaw. The use of deep moist heat to increase blood supply to the fascia, muscles, shoulder and neck area can help loosen the tissue prior to treatment. Treatment may also involve the posture-related structures which influence the jaw position. Head forward posture or rounded shoulders create tension and excess muscle tension in the neck, and shoulders, altering the mechanics of the whole region.

Self – Treatment Strategies For Jaw Discomfort With TMJ

  • Learn how to self-massage your jaw muscles
  • Eat softer foods
  • Avoid repetitive jaw movements such as gum chewing
  • Apply heat to help relax neck and jaw muscles, but use ice when the jaw is inflamed
  • Correct your posture throughout the day (re-position head posture/watch forward head shoulder position or slouching)
  • Release tight musculature by massaging a tennis ball in your shoulders and at the base of the neck
  • Lie on a foam roller to stretch chest muscles and mobilize your mid-back
  • Learn jaw exercises to release tension
  • Avoid sleeping on your stomach to reduce strain on the neck

Other causes of Jaw Discomfort – TMJ

It’s important to get a proper diagnosis.   if symptoms persists as there are other possible causes of jaw discomfort such as:

  • Autoimmune disease
  • Infection
  • Strain from dental procedures
  • Stress

If these self-help strategies don’t work, or if the pain and discomfort in the jaw increases, then you should discuss your symptoms with your dentist, physician, and/or physiotherapist. Disclaimer-This information is not meant to replace medical/health advice. Contact your health professional to ensure the diagnosis and treatment are appropriate for your condition.

  3.  Canadian Dental Association
  4. Physiotherapy management of Temporomandibular Joint (TMJ) pain

Thoracic Pain 101

Gareth Sneath, PT, MCPA, Grad Dip Man Ther, MScCH
July 2015

There are many reasons why patients experience pain symptoms. It is common in practice to see patients with pain in the upper back, or “thoracic” spine, that area around, between or below the shoulder blades. Whilst sometimes associated with a whiplash type injury there are also those patients who deny any traumatic cause for their symptoms. What are some causes of thoracic spine pain? Below is a brief explanation of three causes, one degenerative, one postural and one due to a condition called osteoporosis which can produce a fracture of the vertebrae.

1 Degenerative conditions (discs, facet joints) in the middle to lower part of the neck can refer pain into the thoracic area. There may not always be much in the way of neck pain per se however the cause of the thoracic symptoms is in the neck. Clinically we can determine if this is the case by carefully examining movements of the neck to see if they aggravate the thoracic pain. You can also do your own evaluation by asking yourself if the pain gets worse when moving your neck in certain directions or does it worsen when adopting certain neck postures.

2 If your thoracic pain is worse after adopting certain prolonged (usually stooped) positions the symptoms may be related to postural overloading of the neck or upper back tissues. Think how it feels at the end of a long day after sitting in front of your computer. If it is worse, then consider changing posture by sitting more upright to evaluate the effect. Look at your posture from the side in a mirror. Does it feel “normal” to sit in a slumped posture with your head poking forward? If so, it’s time for change. (This is how most of us tend to sit which can overload the thoracic curve causing postural pain over time) I tell patients to “go tall” in sitting or standing and to work on their ability to maintain a more upright position more consistently. This can take some time and effort to develop tissue tolerance and muscle endurance

3 In some older patients, particularly post menopausal females, osteoporosis (thinning of the bone) is a fairly common diagnosis (1 in 4 females will develop this condition) If you experience sudden onset of pain in the thoracic spine after lifting, bending, twisting or stooping this may indicate a fracture of the vertebral body. X-Ray evaluation confirms or rules out a fracture. Once the acute symptoms have settled down and sufficient healing has occurred an important part of treatment involves developing muscle strength and endurance particularly for the back muscles. These need to be diligently performed and supervised initially to ensure appropriate technique.

There are many potential causes of pain symptoms and the above information gives some brief insight into three of them. Evaluation by your health care professional can help to determine the cause of your symptom(s) before deciding on the appropriate treatment. This process begins with taking your history so giving some thought to when your symptoms started and why plus what makes them worse or better is very important. This information along with a physical examination and consideration of any other medical tests is very useful in determining the cause.

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.

Where does it hurt?