Search Results: stretch

Check Your Stretch

Ask anyone why they stretch and you will usually get a pretty consistent answer.  We want to “loosen up”, improve movement in some part of the body, recover faster/reduce pain, and avoid sore muscles.  However, you may find it surprising that your trusty stretching routine you’ve been doing for years could be limiting your progress in the gym, field, or court.  Should we be surprised that a generic list of stretches probably won’t do much for these specific goals?

It is often misunderstood in fitness and health that in stretching, one size does NOT fit all.  Just like those exercises your trainer gave you to improve your game, your stretching program should meet your needs to help you reach your goals.

So if you’re feeling stiff or sore and it’s not getting better, take a minute to identify your goals for stretching.  Here are some of the major reasons I see in the clinic and on the field, and a look at some of the strategies to make them work for you.

  1. Stretching for pain relief and recovery
  2. Stretching for increased flexibility and range of motion
  3. Stretching for injury prevention and performance

Stretching for pain relief and recovery:

People who are recovering from a muscle tear, have had surgery, or a chronic condition such as stroke or Parkinson’s are often prescribed stretching to improve mobility and aid in recovery.  They experience muscle tightness and pain that is caused by overactive nerves holding the muscles in a tightened, protected, state.  Since the muscles are constantly under tension, these people have a much higher risk of muscle injury and inflammation during activities and exercise.

The goal of stretching for pain relief and recovery is to get the muscles to quiet down.  This involves gentle stretches that are low effort and free of pain.  A study by Kubo et al. (2001) showed that consistent gentle stretching caused something called “stress relaxation” of the muscle. Stress relaxation occurs when sensory receptors in the muscle, called golgi tendon organs (GTOs), react to increases in muscle tension.  As a response to protect against potentially damaging stresses, they send a message to the brain to lower the activity of the muscle, causing a relaxation and decreasing muscle tension.  In other words, after stretching the muscle allowed the joint to move more freely through its full range.  The authors suggested that this may be a possible mechanism for a reduced risk of injury with stretching exercises.

Stretch techniques for pain relief and recovery

In order to maximize the results of stretches for pain and recovery, start conservatively but work up to performing your stretches multiple times, as long as you avoid pain.  Always remember that the first priority is to not cause any more pain and swelling (inflammation) in the tissues.  As a muscle lengthens from a stretch, its tension will rise.  The key to stretching for pain relief is to ease the nervous system before muscle tension rises high enough to cause any pain.  That’s why it is very important to slowly progress the number of times you stretch to make sure you don’t get a negative reaction.

You can put this into practice yourself by holding your stretch for 20 seconds so that it you feel a gentle pulling in the muscle, but that does not cause discomfort.  After 3 consecutive days of doing this, you should be confident you can do more without irritating the muscles.  At that time, you can try performing the stretch a second time with at least a minute between stretches for the same muscle.  Continue this strategy until you are able to perform the stretch three times pain free on a daily basis.

Stretching for flexibility and  improved range of motion:

Prolonged postures and repetitive movements can cause our muscles to adapt at the cost of our mobility.  In these cases, the muscles are still normal and healthy, and may not even be sore or painful.  Yet some will have shortened to accommodate the body’s “new normal”.  Improving range of motion is possible by using prolonged stretching that is just “before” the onset of pain, and held for a longer duration than for pain relief.

Laboratory studies on stretching have shown that stretching can promote changes at the microscopic level and make your muscles actually longer.  Sarcomeres are the muscle fibre’s building blocks that are lined up end-to-end to give it its length.  Sarcomeregenesis is a term used to describe an increase in the length of the muscle fibre (Martins et al., 2013).  When applied enough times for long-enough duration, a stretch actually stimulates the body to build more sarcomeres. The more sarcomeres, the longer the muscle fiber, the looser the muscle, and the more flexible you will be.

In order to successfully increase range of motion, the focus must move toward the muscle itself, meaning that tissues need to be able to handle more tension for a longer duration without becoming painful.  Still, the most important rule is to avoid painful stretching habits at all costs.

Stretching to the point of pain makes the muscle fight back against the stretch as it contracts to stop the excessive movement.  In turn, golgi tendon organs won’t help lower muscular tension, and sarcomeregenesis becomes physiologically impossible.  In fact, five of seven studies evaluated in a recent meta-analysis (Apostopoulos et al., 2011) showed that stretching to discomfort and pain produced no improvement in range of motion regardless of the population studied.

Stretch techniques for flexibility and improved range of motion

If you have a muscle that is limiting your mobility but otherwise normal and pain free, you can try the following approach.  Find a comfortable body position that does not involve supporting your bodyweight over the part you are stretching, so that you can relax and use a minimum of effort to hold the stretch position.  Perform your stretch and hold it for approximately 1 minute, repeating it 3 times with at least a minute rest between each repetition.

Stretching for injury prevention & performance:

Despite popular belief for some, stretching doesn’t show any overall effect to reduce overuse injuries.  However, there may be a benefit in reducing acute muscle injuries in running, sports that involve sprinting, or other repetitive dynamic muscle contractions.

Surprisingly, the current research indicates that stretching before exercise may help prevent muscle injuries in sports with a sprint running component but not in endurance-based running activities, where overuse injuries are more common.  They key is to incorporate at least a 10-minute warmup that includes movements in your sport, just at a lighter intensity.

Stretch techniques for injury prevention & performance

Active people who participate in sports and exercise regularly generally don’t have limited movement and do not experience muscle pain as described earlier.  They can stretch more intensely before experiencing pain, and hold a stretch for a longer-duration may have a greater potential to decrease injury risk.  A meta-analysis by Behm et al (2016) observed that several studies on this topic have indicated a 54% risk reduction in acute muscle injuries associated with pre-activity stretching followed by a specific warmup.

Setting Your Stretching Goals

So if the problem is that you stretch and stretch, but never get better, then something in your program is not supporting this long-term adaptation of your muscle fibers.  Start by checking your body position, the intensity you are using to stretch, and the both the frequency and duration of the stretches.  For athletic events, make sure you are fully warmed-up by doing dynamic movements that mimic the sport itself, but are at a controlled speed.

Other important factors that can contribute to tightness and pain include imbalances in your muscles.  Imbalances can get in the way of the normal physical response to appropriate stretching, and should be assessed by a trained musculoskeletal therapist.

If you would like more information or would like to find out how you can improve your range of motion, reduce muscular pain, or improve performance, please feel free to contact John Gray at, or call us at The Orthopaedic Therapy Clinic at 416-925-4687.


Stretching Myths and Facts


By: Svetlana Marianer, Reg. Physiotherapist, MSc. Pht

Most of us have been taught that stretching is an important part of our health and fitness program but do you know whether the following statements are true or false?

Stretching prevents injury?
Stretching enhances athletic performance?
Stretching is always good?
Stretching must be painful to be effective?

Whether to stretch or not is confusing particularly as the recommendations seem to change from year to year and from professional to professional. If we ask the average individual why and when to stretch, the typical answer would be: before and after exercise in order to protect muscles from getting injured. Seems reasonable, doesn’t it?

Unfortunately, the science behind stretching is not as simple as that. Although stretching has been strongly promoted as a way to decrease the risk of injury, prevent muscle soreness and improve performance, there is insufficient evidence to support these perspectives.

The Facts

Here’s a quick review of what current research shows:

1. The University of Sydney1 reviewed 10 studies on stretching before or after athletic activity and the conclusion was that stretching before exercise doesn’t prevent postexercise muscle soreness, and neither does it prevent overuse or acute sport injuries.

2. Additional research2 comparing runners who stretched prior to a race with those who didn’t showed surprising results. The group that didn’t stretch ran faster than those who did! The conclusion was that the ability to produce and power was decreased by stretching.

3. Furthermore, in 2012, researchers from the University of Zareg in Croatia reviewed 104 studies of people who only practiced static stretching as their warm-up and found that this practice reduced muscle strength by 5.5%.

1 Herbert & Noronha, 2012

2 Buresh & Trehearn, 2009


Lastly, an experimental trial conducted in 20133 found that it took almost 10 minutes to

      recover the strength lost by five minutes of static stretching. In other words, passive stretch prior to activity may actually be detrimental to sports performance.

When to stretch?

After reading this, you may be asking yourself why you were ever told to stretch, however the majority of this misinformation lies in a confusion of the understanding of the difference between stretching and warming up. Although these terms are used interchangeably they have very different meanings. Warming up is the act of raising the core or body temperature via external means or exercise. 4. In the context of exercise warming-up requires the performance of movement and the expenditure of energy to enhance the body’s readiness for exercise. This cannot be achieved with a passive act i.e. stretching. With a little more digging into the literature, a better clarification shows that warm up prior to exercise is what prevents injury, whereas stretching has very poor effect on it (Fradkin et al., 2006).[expand title=”Read more…”]

Nevertheless, let’s not forget about stretching completely. The latest studies show that the stretching is still important and is appropriate for different reasons. Stretching increases joint range of motion, improves joint function and increases performance of your daily activities and balance (Hong et al., 2012).

In summary, if injury prevention is the primary objective, the evidence suggests that stretching before exercise should be limited and the focus should be on warming-up. However if the goal is to maintain good range of motion and joint function then stretching should be done regularly after physical activity. This is why stretching is an integral part of most therapy programs.

Should stretching cause pain?

Although many people believe that to get the most from their stretching they need to feel pain this is one of the most common mistakes made with exercise. Feeling a low-level of discomfort or having a low-grade awareness of muscle activity for 20-30 minutes after exercise is acceptable however stretching is NOT meant to be painful. It should be pleasurable, relaxing and very beneficial. Stretching is only beneficial when you feel better during AND after the activity. If the pain increases or persists STOP the exercise and consult your physiotherapist for an evaluation to determine if stretching is the best approach for your goals and symptoms.

The Take-aways:

You can now answer the quiz knowing that research doesn’t support these myths and can quote the facts when the person next to you in the gym tells you that you are not doing the right exercise program.

3 Yishihisa et al., 2013

4 Oxford Dictionary of Sport Studies


1) Prevent injuries and improve range of motion and joint function, by warming up before an activity and stretching after.

2) Stretching should be pleasant, relaxing and pain free

3) If you feel pain either during or after a stretch, stop the activity and consult your physiotherapist.



Wrist Fractures: What to expect from therapy

Your hand and wrist are a critical part of your everyday function. Until we injure we take these functions for granted.  No one ever thinks it will happen to them but sustaining wrist fractures are an all too common type of injury.  Whether it is from icy, wintry conditions or a loose carpet causing you to slip this injury should be treated to ensure the best outcome possible.  Having assessed and treated so many patients with wrist fractures over the last 35 years I have seen the value of an individualized program of exercise and “hands-on” physiotherapy after wrist fractures. I have found that this approach gives you the best chance of getting your life back to normal as quickly as possible.

If you have recently broken your wrist here’s what you want to know about the injury and what to expect from your therapist during a rehab program. 

Why do we break our wrists?

Injuries to our wrists and arms occur when we fall as we instinctively reach our arms out for protection. Wrist fractures can easily be caused when you land hard on your hands. As you land on the palm of your hand the wrist is forced backwards adding a bending force to the bone in the forearm. The commonest fracture in the arm is the “Colles” fracture, a break of the radius bone (one of two forearm bones, the other is called the ulna).  In medical jargon we call this a “FOOSH” injury. A fall (F)  on (O)  the out-stretched (OS) hand (H)

The arrow/black shading shows the area of a Colles Fracture

Other causes of fractures

Fortunately, not every fall causes us to fracture. A broken bone is more expected when we fall from a height such as off a ladder or down stairs.   Conditions such as osteoporosis, make bones easier to break. While Osteoporosis is thought to only affect older people it can also be present in younger adults. If you fall from a standing height and break a bone your Family Physician should consider whether to order a Bone Density Test to check the quality of your bone structure and discuss treatment options.

Is it a fracture or just a sprain?

Right after the fall you may wonder if you have a broken bone or just a sprain.  Initially, if you have broken a bone, there is usually significant pain around the wrist, swelling and unwillingness to move the hand or wrist. If the bones are displaced, when you look at the forearm from the side, the alignment of the bones looks like a dinner fork.  The presence of a ” dinner fork deformity” is a tell-tale sign of a Colles fracture. If you experience the above an urgent medical assessment is necessary. If the bone is broken an X-Ray confirms the break.

Medical Treatment; What to expect

A physician or Orthopaedic Specialist in the Emergency Room at the hospital will examine your wrist and look at the X-Rays to decide the best course of action. Most breaks are treated with a rigid cast for six weeks. The cast holds the bone in the correct position while healing occurs. While you are in the cast you will usually be allowed to move your fingers, thumb, elbow and shoulder to reduce the risk of stiffness.

A follow up X-ray is typically scheduled to check that healing is progressing. Once healing is confirmed, a referral to Physiotherapy is highly recommended for assessment of your hand and wrist flexibility and strength. A specific treatment plan can then be made to help you regain function as soon as possible.

How long will it take to recover?

The question I am often asked is “How long will it be before I’m back to normal?” Everyone is different and during your first few treatment sessions progress is measured to see if you are “on track” and improving. My experience with these injuries is that most people are recovered by about six months.

I find the best recovery is when you individualize treatment to ensure we have the best plan for you to regain joint flexibility, strength and function as quickly and safely as possible.  In my next article I will outline what to expect from therapy.

Contact us

If you have injured your wrist you can book an appointment to see me while you are in the cast or right after the cast comes off.  Call us at 416-925-4687 to book an appointment or contact Gareth Sneath, Registered Physiotherapist, MScCH MCPA Grad Dip Man by email at

Five Ways to Get Rid of Neck Pain

Our lives are hectic.  This means we don’t always pay attention to where our bodies are in space or the subtle signals our body gives us indicating it is unhappy with the position we are in. Over time if we continue to ignore our body signals, we get pain that eventually does not go away. Fortunately there is something you can do to reverse this. Simple things can make a huge improvement in reducing muscle tightness, mobility and most importantly helping you to get rid of pain. Here are five ways that I find helps to get relief from neck pain.

The first way to get rid of neck pain is maintaining posture

Maintaining proper posture allows for a more efficient machine – our body. My colleague once said, “effortless posture first requires a proper base of support”. If we are slouching either at home, work, or during transportation, we are probably not on our base support and it becomes harder to sit upright.

Finding the bones in your bum will help you achieve this base support and foster good posture. First you need to find the bones located at the lower buttock area, these are referred to as the “sits bones”. If you reach with these bones as deeply as you can into the seat, it will help you have good sitting posture and off load the spine. At first it’s easiest to learn by sticking out your butt as your sit down, although after awhile you will be able to find this position without exaggerating the position.

Whether you are sitting in a chair, sleeping in bed, reading a book, or any activity, being mindful of where your body is in space will foster good postural habits. Try not to have your head forward with your chin protruding forward (jutting).

Did you know – your head in an upright position weighs about 12 lbs however, when your head is in a forward position it is equivalent to 60 lbs. That is a lot of added tension that can easily be avoided. A helpful trick to check your posture is to measure the distance from the tip of your nose to your chin.  For most people your best posture will show this is the same distance from your chin to your chest (sternal notch). This will help you stay connected with where your head is positioned in space.


The second way to get rid of neck pain is sleeping posture

It can be hard to keep good neck posture at night as many people toss and turn when they sleep. We may start on our side and end up on our back, or horror of all neck horrors – on our stomach, by morning. When lying on your side, try maintaining a good distance from your ear to the shoulder as shown in the picture below. This will reduce the strain on the neck. When you sleep on your back, make sure you are not using too much pillow as that will force the head forward.

left is incorrect posture – right is correct

It’s important to see where your head is in relation to your chest when you get in a comfortable position to sleep. Use the same tips as mentioned above. When you are sleeping, make sure you do not have a draft on your neck at night – either from a fan or an opened window. Our muscles can develop areas of irritability,  discomfort and reduced range of motion from the cold. Our tissue thrives on proper circulation and the cool air will cause your blood vessels to constrict, reducing blood flow to the tissue.

The third way to get rid of neck pain is proper ergonomics 

There´s a good chance that you are not experiencing neck pain from sleeping wrong but from sitting wrongMany people have occupations that require long periods of sitting throughout the day. Making sure that your workstations are ergonomically correct is very important. Long hours in front of an office computer with an uncomfortable chair and your work station not set up properly, can contribute to you developing neck pain. Changing your posture regularly and setting some time to take a break, stand and walk around. Don’t forget to take at least 5- to 10- minute breaks after every couple of hours.




The fourth way to get rid of neck pain is hydrotherapy 

Hydrotherapy is the application of water of varying temperatures for pain relief and maintaining tissue health. It is a great cost effective tool to use in any stage of healing. It is used widely for different purposes and even sports teams use it after workouts. Many of us use ice when we have just injured ourselves and is usually the only time cold feels good. While ice and heat are common forms of hydrotherapy, contrast is not as commonly used. Alternating from hot to cold is great for flushing out inflammation and improving circulation to the tissues. When we feel sore and achy, heat usually feels the best. The stiff parts of our bodies crave the circulation that heat offers the body.

The fifth way to get rid of neck pain is to exercise regularly

Find something, which is exciting to do – it doesn’t matter whether it’s swimming, climbing, cycling, etc, just make sure you enjoy it. Maintaining your physical activity is important for your health and maintaining healthy muscles. Try to keep core strengthening a priority as it helps to support the spine and takes undue pressure off surrounding tissue. Stretching the muscles and keeping all these tips in mind, will help you to prevent and get rid of neck pain.

These small tips can make a huge change in how you feel day to day thus improving your quality of life. For more information or if you have any questions, please contact me, Juliette Woodruff at or call The Orthopaedic Therapy Clinic located in Downtown Toronto to make an appointment. 416-925-4687

Chronic pain? Stress? Headaches? Craniosacral Therapy May Help!

If you’re still in pain, and have tried all of the traditional approaches, maybe it’s time to try something different! Over the years I have been interested in the practice of craniosacral therapy but what prompted me to fully commit to bring this technique into my practice was my own experience with injury and recovery.  Up until recently I have been fortunate, despite a physical profession and competing in sports, most of my injuries did not last.  Having surgery and a car accident changed all of that.  It left me with pain that wouldn’t go away.  Traditional treatment helped, but like many of my clients I found that what I wanted was the quickest relief from pain and to return to a normal life.

The rehab process is a journey and sometimes a long one. I knew I was improving but the chronic discomfort was wearing me down.  I knew I needed to add something to the excellent care I had received by physiotherapist and chiropractor.  As I reflected on what I could do, I remembered a treatment that I had for a problem with my right hip a few years ago. It was unlike any therapy I had experienced, and the feeling of weightlessness was amazing especially since it felt like the therapist was doing nothing at the time. There was no massage, no stretching just this amazing sense of lightness and heat coming from the still hands of my therapist.

I decided to contact an experienced craniosacral therapist and book in.  Within a few treatments that nagging, unrelenting discomfort began to abate. I was hooked and began to explore it further to incorporate into treatments to enhance therapy results. I have been taking courses over the last couple of months with the Canadian guru of craniosacral therapy, Robert Harris, receiving a certificate in advanced craniosacral.  I am excited to have this technique to offer my clients and to further pursue knowledge in this area.

Craniosacral therapy and Echolocation

Craniosacral techniques are based on following the body’s signals as it tries to self-correct.  Using this approach, even hidden problems become accessible when you know how to follow the cues and let them show you where to work. In CST, the practitioner aligns themselves with the body’s attempt to heal itself naturally.

I have had many clients ask me how craniosacral treatment works and what I feel in the treatment. I have to say it’s an unusual feeling and it’s difficult to explain, however the closest I can come is to compare it to the sensitivity of BATS!

Bats have this amazing ability to navigate in the dark.  They use tiny vibrations (echolocation) to feel the world around them and to navigate through it.  They emit sounds at a specific frequency, amplitude, and intensity, which creates an echo allowing them to “see” the objects around them.

As a practitioner, I use the craniosacral rhythm as my own form of echolocation. My hands sense the craniosacral rhythm of your body, allowing me to feel changes in subtle, fine movements, letting me locate the restrictions.

Who Benefits from Craniosacral therapy?

Craniosacral therapy can be used for a variety of conditions to alleviate pain and discomfort and has a beneficial calming effect on the body. It is used to help change core patterns contributing to pain. CST can aid in relieving pain by calming the nervous system, restoring the body’s alignment and aiding in muscle function.

CST can provide relief for:

  • TMJ/tinnitus/vertigo
  • Headaches/migraines
  • Neck pain
  • Back pain
  • Shoulder Pain
  • Concussions/post-concussion
  • stress/anxiety
  • muscle and joint pain

What to Expect at a Craniosacral treatment

This therapy has very light and gentle touch that can be done through your clothing, and provides a calming effect on the nervous system inducing deep relaxation. Treatment sessions are one hour in length. The pressure used is about the weight of a nickel. For those of you who like the feeling that manual therapy provides this may not be your thing. This treatment is great for re-aligning, reducing stress, and offering pain relief.

The Theory of Craniosacral Therapy

Craniosacral therapy or CST as it is often called, is a gentle non-invasive alternative therapy. This form of treatment has evolved from the father of craniosacral therapy, John E Upledger. It is aimed at restoring your body’s mobility by utilizing subtle, small movements that occurs in all of us that we are not aware of. These movements are the result of the filling and emptying of the cerebrospinal fluid that baths your brain and spinal cord creating the craniosacral rhythm.

Craniosacral theory and practice is based on the understanding that there are continuous subtle movements of the cranial bones, which result in a rhythm of approximately six to twelve cycles per minute. This rhythm is understood as a response to cerebrospinal fluid (CSF) fluctuations within the spinal cord and brain environment. The increase or filling of fluid causes expansion and pushes the covering around your brain away from the brain, providing relief from pressure. When you breathe in, the fluid rises creating a physical movement of the expansion of the bones of the head and the rest of the body because of the pressure on the nervous system, and opposite for exhalation where the fluid decreases. As a practitioner I feel these changes with my hands, tracking the movement as it fills and the body turns out and then turns back in when the pressure drops. This filling and emptying phase of the cerebrospinal fluid crates a rhythm in your body.

How Many Sessions Do I Need?

I am often asked “how many sessions will it take before I am pain free?” To be physically healthy and pain free is a complex interaction.  Our body has many interconnections with a vast anatomical landscape of muscle, nerve, bone, lymphatics, and much more.

Everyone’s body is individual however I once read an article from another therapist describing the process of treatment as tuning a guitar. It’s impossible to tune a guitar perfectly the first time around. Instead you re-tune it until you achieve your perfectly tuned instrument. It’s a process of making minute changes until you reach your desired solution.

I thought that was a great way to describe it. How long it will take, depends on how out of tune you are.  Let’s say you come in with pain on the left side of your neck, I would not know whether the neck pain is a result of one, two restrictions or several years of accumulated tensions. As a therapist, I follow the tissue into the restriction and help it to release. For every release in the tissue, the whole body slightly adjust. With each change getting closer to a pain free neck until we reach the primary anchor- as the other therapist would say, “just like tuning a guitar”.

Contact me

For more information on craniosacral therapy or if you are interested in trying a different approach or know of anyone you think might benefit, please contact Juliette Woodruff at or 416-925-4687.


The Therapeutic Value of Listening



Stress is an Opportunity for Growth when Approached the Right Way

Stress is a fact of life. Sometimes it gets so bad we see ourselves as unfortunate, even as lost souls. But with the right understanding and resources, we can regain strength and actually grow from stressful situations. We can use stress to find our limits and boundaries—to challenge us and empower ourselves to heal.

Being stressed out is an opportunity for growth when you approach it the right way


Stress approached truthfully and intelligently can bring evolution on the highest level. I like to think of stress as an acronym, STRESS, which stands for:

  • Strain
  • Thoughts
  • Rest
  • Energy
  • Support
  • Strategy

It’s an easy way to remember the different elements that make up this force that has such great impact on our lives. A clear and strong understanding of how stress is seen intelligently can only bring an opportunity for greater confidence in healing with it.


The combination of physiological, emotional, and energetic dysfunction is the first “S” in STRESS.

  • Physiological: Chronic stress produces too much of the stress hormone, cortisol, which triggers a cascade of unhealthy changes in the body. Functional systems, such as digestion, hormone, immune, and cognition, are affected by chronically high cortisol levels and eventually become dysfunctional.
  • Emotional: When the physiological systems are not functioning well, negative emotions come up more frequently. Anxiety, depression, and nervousness are examples of chronic-stress related emotions. How we see life (with the glass half full or half empty) will affect our emotional reactions to stress, too.
  • Energetic: We exist on many different levels, energetically being one of them. (Read more about this in the Energy section further down.) When we’re healthy, our energy body is in synch with our physical body. When this dynamic is unbalanced we lose energy. A helpful analogy is to think of yourself as a computer with trillions of programs running, and how viruses in your system will slow it down or cause malfunctions.
  • Thoughts:  We are what we think about; high-vibration positive thoughts are healthier than low-vibration negative thoughts.Our thoughts affect our physical reality because we manifest what we think about, both consciously and unconsciously. From language to buildings to politics to technology to hamburgers—everything began as a thought.

We created words to articulate our thoughts and give form to our ideas. But often we don’t pay attention to the power of words. We use them indiscriminately, carelessly, angrily. Yet choosing our thoughts and words carefully, with wisdom, results in better outcomes. Positive words have a higher vibration than negative words—their energetic signature has better qualities. High vibrations are associated with positive feelings such as love, forgiveness, compassion and peace. In contrast, low vibrations are associated with harmful feelings such as hatred, fear, greed and depression.

In his book The Secret Life of Water, Masaru Emoto’s experiments with water molecules and crystallization patterns prove that the quality of thoughts and words (high vs. low vibration) influence the quality of water. In Breaking the Habit of Being Yourself, Dr. Joe Dispenza writes about the brain’s neuroplasticity and the power of words to create change—positive or negative.

  • High vibrational words: Love, Happiness, Compassion, Peace, Opportunities, Respect
  • Low vibrational words: Hate, Depression, Judgement, War, Problems, Dishonour


Strong sleep and restorative time outs are important for healing from stress. Our bodies have opportunity to heal when we sleep. This is when your functional systems and energetic systems regenerate and reboot.

Good sleep quality relies on a few factors:

  • intelligent duration ( 8-10 hours for most people )
  • a dark room to prevent disruption of your circadian biological clock
  • cool temperature
  • quiet setting
  • a comfortable, supportive bed.

Certain hormonal and physiological dysfunctions from chronic stress can disrupt sleeping patterns—seeking support from a qualified health practitioner may help. (For a well-researched, informative book on the importance of smart sleeping, pick up Lights Out by T.S Wiley with Bent Formby.)  Restorative time outs include going for walks in the park, sitting outside in the sun, deep breathing, and hugging. All these activities have been shown to reduce cortisol levels—read Cracking the Metabolic Code by Dr. James B. LaValle for more insight.


We are vibrational beings composed of many different energetic systems, including meridians, acupuncture points, chakras, and etheric fields. Vibrational Medicine by Dr. Gerber is one of the most respected and well-researched books on energy medicine. Unbalanced, stressed energy systems can affect physical biological systems (particularly the hormonal systems) and create disease.

One of the techniques I use in my practice is tapping.  It is a simple, effective way to reset and rebalance our energy systems. It’s part of a method called the Emotional Freedom Technique (EFT), which helps people deal with stress and unhealthy emotions. For more in-depth opportunities to experience energy medicine, seek out healing practitioners who use the tools I have found have found most helpful in my practice such as Reiki or Qigong. Acupuncture can also help to balance energy. These skills can introduce you to new and exciting healing methods to reduce stress.


We are all here to do two things in this world: learn and help each other out. I tell this to my patients all the time. I’m also fond of signing off my emails with “Unity and Healing”. Why? Because stress is humanity’s common denominator—we all experience it, no matter what our lives look like. With such a strong connection pulling us together, it’s natural to unite for support and healing. Friends, family, health practitioners, and support groups are all potentially blessed opportunities to heal and grow from stress.

Strategies for Stress:

We all need a well formulated and executed plan to evolve from stress. (We don’t just need it—we deserve it!) You are the only one who can control YOUR life and to be successful, strategy is pivotal.

Five Minute Living: An intelligent strategy includes having the right support (see the second-last “S” of STRESS, above), and the “Five Minute Living” concept: anyone can find five minutes a few times per day to regain a healthy state of being and happiness. Five minutes of deep breathing, stretches, tapping or other energetic practices, walking, positive affirmations, peaceful quiet sitting, hydration, supportive eating and supplements, and hugging a loved one is time well spent on powerful approaches to dealing with stress.

My patients who come to me for help managing stress may get a Reiki treatment or Qigong session. Or maybe they’ll get some bodywork to release tension. But they will also get coaching to help them adopt the practices I’ve mentioned here as part of STRESS—like exercise, better sleep habits, nutrition, positive affirmations—so they can find balance in their daily lives and learn to handle stress like a master.

If you are experiencing stress and would like to learn how to manage it or would like to learn whether Reiki, Qigong and energy balancing can help you, please contact Dr. Adonis Makris, DC at 416-925-4687 or email at

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


Hip bursitis treatment: steroid injection vs. Dry Needling & acupuncture

If you have been diagnosed with hip bursitis or tendinitis you may want to consider other options before committing to steroid injections. A new wave of research is suggesting that application of Dry Needling (DN) acupuncture, as an alternative to steroid injection for treatment of hip pain and functional limitations, is safe and just as effective1!

What is bursitis?

Bursitis refers to inflammation of the bursa. A bursa is a fluid filled sac that provides cushioning between tendons and/or bones around your joints2.

Although it is a common diagnosis, hip bursitis is an often-inaccurate term used in the medical field. The majority of cases described as hip bursitis actually have no inflammation in the bursa!  Muscle tears, tendon strains and trigger points can all cause pain in this area1.

The most common risk factor for pain in the outer hip area is overuse injuries (also referred to as repetitive stress injuries). Running and standing for long periods of time are common causes.

What are the symptoms of hip bursitis and tendonitis? 

This condition is characterized by tenderness to touch over the bony prominence on the outer aspect of the hip1. In more acute stages, pain is often described as localized and sharp. However, more chronic conditions can be felt as dull and achy.

You might also experience pain with certain movements or positions.  Your hips may hurt when you are standing and bearing weight. This pain can be more noticeable as you shift your weight to stand on the affected leg. This pain may occur when you are walking, climbing up/down the stairs, running, prolonged standing and cycling. You may also experience pain when there is simply too much pressure on your hips, like when are trying to sleep on the affected side.

How common is hip bursitis/tendinitis?

It is estimated that 10% to 25% of us will experience chronic hip pain within our lifetime1. You are more at risk for pain in this region if you have any of these issues:

  • low back pain
  • osteoarthritis
  • IT (iliotibial) band tenderness
  • excess body weight

What is Greater Trochanteric Pain Syndrome?

The term bursitis is often used as a catch-all term for pain felt in the outer aspect of the hip and thigh. We now know that pain in this body area can be caused by a number of issues. Bursitis, gluteal muscle tears, tendinopathy and trigger points in any of the muscles crossing the hip can all be a source of this discomfort1.

As we gain a deeper understanding of sensation and causes of pain, the complexity of understanding the source of the problem is leading us to prefer the term Greater Trochanteric Pain Syndrome (GTPS) over bursitis. This change reflects the fact that the bursa is not always the main source of the hip pain. It also helps us to consider more comprehensive solutions as it encompasses a wider variety of causes.

Is steroid injection beneficial?

YES! Therapeutic steroids – sometimes referred to as corticosteroids or cortisone – are helpful in treatment of a number of different conditions3 (such as hip bursitis). Therapeutic steroids are similar to the hormones your body releases to fight illnesses, injuries and help reduce inflammation in your body. Your physician or specialist will inject a small amount of steroid to control pain and inflammation in a bursa, joint, tendon or muscle. A local anesthetic is also commonly injected at the same time.

Are there any side effects to steroid injections?

Although rare, there are a number of adverse effects associated with steroid injections that should be considered. Side effects of steroid injections can include4:

  • mild allergic reactions
  • temporary increase in pain
  • swelling
  • blood sugar increase

More severe side effects may include weakening of tendons and ligaments with multiple injections in one area over a short period of time. Achieving  minimal relief after two injections is generally considered as a contraindication to having more injections4.

Are there any alternatives to steroid injection?  

Recognizing that hip bursitis is not the only cause of hip pain, other treatment options are being considered as alternatives to cortisone injections. Massage, stretching and appropriately selected exercises can all be helpful. A recent study1 shows that Dry Needling – also known as intramuscular stimulation (IMS) – is just as effective as steroid injection for treatment of GTPS (including bursitis and tendinitis)!

Dry Needling acupuncture can help!  

Dry needling (DN) is the Western approach to acupuncture. In this technique thin needles are used to stimulate local trigger points in muscles. DN treatment reduces muscular and myofascial pain, releases trigger points, and helps restore movement. (To learn more about Dry Needling technique and how it works, click here).

The key to an effective treatment is about appropriate diagnosis! By completing a detailed assessment, your physiotherapist will identify trigger points and muscles that carry excessive tone (i.e. are too tense). Once the right trigger points are identified, fine sterile needles are inserted through the skin to release these knot-like thickenings in the muscles and fascia. Muscles around the side and back of buttock region, muscles of your thighs and muscles of the lower back often respond well to dry needling for treatment of GTPS1.

When should you consider Dry Needling acupuncture for your hip pain?

Dry needling is a safe and effective alternative to corticosteroid injections for treatment of many types of hip pain.  It can be selected as an alternative when cortisone injections should not be used – such as drug allergies. Or if you prefer this type of approach, dry needling can be an appropriate substitute.

Dry Needling can benefit you if:

  • Hip pain is making your day-to-day function more difficult.
  • A steroid injection resulted in minimal or no relief.

Contact us if you are interested in learning more about alternative options to injections or would like to book a treatment for your hip pain.  Speak with Milad Bazaz-Jazayeri, Registered Physical Therapist – – to learn more about treatment options that fit your needs best.






  1. Kindyle , Brennan , Allen Bryce, and Munoz Maldonado Yolanda. “Dry Needling Versus Cortisone Injection in the Treatment of Greater Trochanteric Pain Syndrome: A Noninferiority Randomized Clinical Trial.” (journal of orthopaedic & sports physical therapy) 47 (April 2017): 232-239.
  2. American Academy of Orthopaedic Surgeons. Hip Bursitis. March 2014.
  3. Labrosse, Julie, et al. “Effectiveness of Ultrasound-Guided Corticosteroid Injection for the Treatment of Gluteus Medius Tendinopathy.” American Journal of Roentgenology 194, no. 1 (January 2010): 202-206.
  4. Cardone, Dennis, Alfred Tallia, and Robert Wood Johnson. “Joint and Soft Tissue Injection.” American Family Physician 66, no. 2 (July 2002): 283-289.



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.

Preventing running injuries Part II

fitness runner stretching legs before run

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.



hands with rsi syndrome over the keyboard of laptop

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

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

What causes RSI?

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

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

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

Tips to prevent injury

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

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

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

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

Here are 5 simple and effective ways to limit injury.

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

If you are injured these tips are also helpful in your recovery however it is also important to have your physiotherapist look for other issues.  Undetected weakness, poor coordination and compensatory movement patterns can all prolong your recovery from these debilitating and painful injuries.

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

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

Energy Work: A Holistic Approach to Rehabilitation

Joanna Miller Registered Physiotherapist, BA, MPT 

My journey with energy work started before I became a physiotherapist and is what led me to pursue this career. In my early 20s, I had chronic, severe hip pain and wasn’t getting relief from the various passive and active therapies I had tried. I was referred to a physiotherapist and was confused when she started using a very light hands-on technique on my lower abdominal and hip region. Before I had a chance to think of a good way to politely leave the session, because I knew this method wouldn’t work for me, I started to feel a sensation of something shooting down my leg. It was the first time I felt something finally getting into my hip pain. I was convinced this technique was magic and was surprised when I found out that anyone could learn how to do this. From there, I started the process of applying to school to become a physiotherapist, so I could share this work and help people.

What is energy work?

Energy work is a branch of manual therapy that is part of a holistic approach to rehabilitation. There are many different types of energy work that can be used to treat acute and chronic pain and health conditions. At The Orthopaedic Therapy Clinic we use 3 types of energy work- Evolutionary Process, Reiki, and Craniosacral therapy. This article will focus on Evolutionary Process and will attempt to demystify this type of therapy.

What can I expect from an Evolutionary Process Treatment?

Your Evolutionary Process physiotherapy session will begin with a traditional physiotherapy biomechanical assessment. Once your condition has been determined and explained, you will lie down and begin the energy work session. This technique is provided over clothes and usually takes you into a state of deep relaxation. The initial appointment is 90 minutes, which includes assessment and treatment. Evolutionary Process is an indirect, hands on technique where varying degrees of pressure are used to match the body’s resistance. This means that sometimes the pressure is very light and sometimes moderate to deep pressure is used.

Two fulcrums on the body are selected that relate to lines of tension in the tissues and your physical restrictions. The fulcrums are guided and stretched allowing deep layers of tightness to elongate and release. As the tension in the body releases, habitual postures and patterns ease, which leads to decreased pain and improved mobility.

Who benefits from Energy work?

During my 10 years of practice, I have studied various energy medicine techniques, and am currently treating patients using a technique called Evolutionary Process and have found it very useful in the treatment of:

· rotator cuff tears

· frozen shoulder

· disc bulges 

· decreased mobility following total knee and hip replacements

· headaches

· chronic pain.

Joanna Miller is a registered physiotherapist practising in downtown Toronto at the Orthopaedic Therapy Clinic. She practices energy work, Yoga therapy and traditional physiotherapy. For more information on Evolutionary Process and her practice contact Joanna at; for information on Craniosacral therapy contact Juliette at, and for information on Reiki contact Dr. Adonis Makris at You can also contact us at 416-925-4687 to book an appointment.

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

Tips To Relieve Mid-Back Pain And Discomfort

Tips To Relieve Mid-Back Pain And Discomfort, Juliette Woodruff Registered Massage Therapist, Acupuncture Practitioner 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.

How to return to sport after injury, Part 1.

When are you ready to return to sport after injury?  Suffering an injury is not only painful, it can also be frustrating and time-consuming.  It can make you impatient and want to return to your favourite sport as soon as possible. Yet, the single biggest risk factor predicting a future injury is a having a history of the same injury.  In other words, once you have an injury – despite overcoming your symptoms and pain – and regaining your full strength and mobility – you are between two and four times more likely to have another injury in the future. Scientists in kinesiology and physical therapy continue to examine the reasons behind this statistic; however, from experience I’d like to share some important tips that will help you to return to sport after injury and lower your risk of injury in the future:

Tip #1:  Don’t rush it.

Many people see the end of therapy as if they were climbing out of a dark hole.  Seeing the proverbial light, they charge back to their sport workout schedule as if nothing ever happened, blind to the reality that the time spent recovering has also left them out of shape. Unless addressed this loss of conditioning leaves you prone to re-injury or to new injuries.

Unfortunately, the line between fitness and injury is not only invisible, but also moves depending on where you are in your recovery process.  Complete recovery follows a path that continues well after discharge from therapy to ensure you have restored all elements needed for your sport.  As you return to your normal fitness routine, remember to build off of the progress made in therapy.  That means slowly progressing as your abilities allow until you reach, and then exceed, your pre-injury fitness levels.

Tip #2:  Incorporate recovery time in your workouts

Most often, what goes unnoticed is that exercise actually makes you weaker (in the short term) and that your progress is highly determined by the amount and quality of rest you receive between training sessions. This means there is a window of time within which you will make the best gains.  Clients who are are highly motivated to get back onto the court or course are often delayed by their eagerness to speed their return to sport.   Cutting into rest time means incomplete recovery, and can lead to an injury when the tissues are no longer able to manage the relentless stresses. However, this is not a license to sit on the couch for two days with a bag of Doritos and wait for your next scheduled workout.  Recovery not only includes rest, but also changes in your routine.  For example, attending a stretch class, going for hike or bicycle ride, or swimming are all strategies that can boost your recovery and help you to return to sport quickly and safely.

Tip #3:  There are no magic exercises.

Many people who are serious about their performance think they must only do sport-specific exercises, otherwise their workouts are a waste time and effort.  This fitness myth can greatly increase your risk of suffering another, and potentially even more damaging, injury; or lead to early plateaus by leaving out important capacities in your fitness.

The term “sport-specific program” is a fairy tale that just does not fulfil the promise of performance.  Neither is there a list of exercises that can develop you into a champion.  Even elite athletes work on their general fitness capacities and vary them as needed.  Having worked with many elite athletes over the years, including Olympian Heather Bansley (who competed for Canada in Beach Volleyball at the 2016 Rio Olympics), sports specific exercises actually make up a smaller part of the total conditioning program than you would think.

A major problem with the “sport-specific program” approach is that it can cause the person to hit a plateau too soon.  The cause is known as “overspecialization”, which occurs when important elements of a conditioning program are left out.  Highly-specific exercises are focused on one, or only a few, attributes of a sports skill (such as speed and agility.)  Adding these exercises too soon is like throwing a grade-schooler into college.  Not only are general fitness qualities overlooked, but also the speeds and stresses when performing these exercises may easily become overwhelming and send your performance in the wrong direction fast.

Although out of pain, most people are not quite back to one-hundred percent at the end of therapy.  To make the most efficient gains onward, your conditioning program should always start out general in nature.  The first step is to address fundamental requirements such as mobility, general strength and muscular endurance.  Exercises that involve multiple joints at the same time will help improve the functional movements that are essential building blocks to performance. Before adding specialized exercises, it is important to build a strong fitness base that will lead to the best results in your sports conditioning program.  You need to find a balance without pushing too hard too fast.

If you would like to learn more about general and specific exercises, please read this article, in which Strength Coach Nick Tumminello references a research paper I helped conduct when at UW to outline the implications for choosing exercises for your conditioning program. Please stay tuned for part 2 of this article where I will discuss additional factors to improve your fitness, and return to your sport after injury in a safe and effective manner. This information is for educational purposes only and does not constitute medical advice for any condition.  Reasonable and appropriate care should always be performed by a qualified health professional after a comprehensive evaluation to identify treatment goals.

John Gray is a Registered Kinesiologist and Certified Strength and Conditioning Specialist practicing in downtown Toronto at the Orthopaedic Therapy Clinic and throughout Metro Toronto.  His clients include athletes ranging from recreational to Olympic calibre level.

Physiotherapy Assistant

Working with a Physiotherapy Assistant at The Orthopaedic Therapy Clinic
Your Physiotherapist has determined that you will benefit from working with our Physiotherapist Assistant (PTA).  Working with a PTA is recommended at the Orthopaedic Therapy Clinic when it is determined that you will benefit from more frequent treatment and/or more regular supervision.  This information is provided to help you to understand the parameters and scope of the treatment that can be provided by our assistant.

Who is the Physiotherapy Assistant?
At the Orthopaedic Therapy Clinic our assistants are part of our Therapeutic Fitness team.   He/she has been trained to understand the treatments provided by our Registered Physiotherapists.  He/she can help you with your exercises and treatment modalities i.e. ultrasound, taping, stretching etc. He/she is able to provide many of the aspects of the program prescribed by your physiotherapist .

How is my PTA visit billed?
Your appointments will be billed as physiotherapy.  This can be provided when there are defined therapeutic goals. Your program and progress must be overseen by your physiotherapist or another physiotherapist at the clinic.  Your bills will reflect both your physiotherapist and the PTA’s name.

Booking Appointments
At the OTC we require a physiotherapist to be onsite at the clinic during your appointment.  The reception staff will help ensure this requirement is met.  This allows for a physiotherapist to be consulted if some aspect of your condition or treatment requires immediate review.

Although a physiotherapist is allowed to provide supervision by phone, this is not the preferred mode at The Orthopaedic Therapy Clinic.  On rare occasions your appointment may need to be rescheduled if a supervising physiotherapist is not available.  If you have a specific issue with rescheduling an appointment please inform our reception staff, as the need for and effectiveness of providing remote oversight can be reviewed by your supervising physiotherapist on an individual basis.
Responsibilities of your Physiotherapist
Your Physiotherapist remains the primary overseer for all physiotherapy sessions including those provided by the PTA.   The Physiotherapist’s responsibility is to:
• assess your injury/issue at your initial and subsequent physiotherapy visits
• create a treatment plan based on your particular needs and goals.
• communicate the treatment plan to the PTA (verbally or through the chart)
• ensure ongoing communication throughout your course of  treatment
• provide parameters on frequency and length of appointments
• determine when a review is necessary with your physiotherapist.   At the OTC we require a review with the physiotherapist at a minimum of 3 month intervals.
What to expect from your Physiotherapy Assistant
Under the supervision and direction of your Physiotherapist, the PTA will help you progress your treatment program within the parameters outlined by your therapists.  This may include:
• Applying electrical modalities
• Sports and injury taping
• Monitoring clarifying and/or progressing your exercises
• Applying stretching techniques
The PTA may make modifications and progressions to your program providing these changes fall within the parameters of the treatment plan.  Should you require care outside of your treatment plan, and/or if you or your PTA identify a separate need that extends beyond your treatment plan, you should book an appointment to see your Physiotherapist for an appropriate evaluation
Services outside of the scope of a Physiotherapy assistant:
  • Changing treatment beyond your physiotherapy treatment plan, including modalities & exercises
  • Assessing the cause of a changed symptom or new symptoms
  • Developing non-injury related fitness programs. This service does not qualify as physiotherapy; however, it can be provided by our Therapeutic Fitness team.
  • Joint mobilization techniques i.e. manipulation, mobilization
Who to see & when
Your initial visit with the PTA will be prescribed by your Physiotherapist.  When you are working with both health professionals, it is important to know who to see and when.  The following  is designed to help you to determine which professional to book with.
You should see your Registered Physiotherapist :
  • For the initial Assessment
  • If you are experiencing new symptoms or if your symptoms have worsened or changed substantially since your last visit
  • It has been more than 3 months since you have been evaluated by your Physiotherapist.
You may see your PTA:
  • For follow-up treatment, such as ultrasound or taping, or to review your exercises when recommended by your Physiotherapist.
  • For on-going treatment or progression of current treatment providing there is no change in symptoms and/or you are progressing as expected based on the physiotherapy assessment.
  • If it has been less than 3 months since your last appointment with your physiotherapist
When your physiotherapist recommends you work with the PTA your signature will be required on our PTA document to acknowledge that you have read and understood our policy. If you have any questions about working with a PTA, or other concerns please contact your physiotherapist or our clinic director Maureen Dwight at 416-925-4687, For further information see the College of Physiotherapist’s website for the standard on working with a PTA

Do athletes have low back pain?

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

34943050_sOne of the most commonly accepted factors predicting recurrent low back pain is a lack of strength.  Your practitioner tells you that the reason you keep injuring is your lack of fitness or insufficient “core”[1], however the problem with this perspective is that many people find when they get more active their low back pain gets worse.

If strength is so important you would expect to see a lower rate of back injuries in athletes, but research[2] tells us that this is not the case.  Despite all those beautiful 6-packs and even an occasional 8-pack, athletes have one of the highest rates of low back pain.

This lack of correlation has been suggested by several reviews which have concluded the incidence of low back pain is a U-shaped curve.  The highest occurrence is at both the low and the high end of the activity spectrum.  Both the couch-potato and the athlete are equally at risk.  It is the moderately active person who is in the best place to avoid low back pain.

Compensatory Muscle Patterns

What often makes athletes more prone to pain is their dedication to their sport.  Many continue to compete while injured. This makes healing more challenging, as damaged tissues initially require a reduction in strain to be able to heal.

When the athlete decides to over-ride their natural inclination to reduce activity, not only do they raise their risk for further injury, they often do not perform as well.  The problem with competing injured, or when we make a decision to try to get fit while we are injured, is that the body naturally protects the injury.  Whether we want to or not, we compensate for the injury by changing the way we move.  We recruit muscles to support the injury and this means we then need to engage other muscles to produce movement.

Compensatory muscle patterns are useful as they help us to keep moving while we are healing, but they are never as efficient as healthy, normal motions.  When the athlete tries to perform at the top of their game, the high-level of demand can exceed the power and coordination available by recruiting these alternative movement patterns.  For the non-athlete these changes can often be seen in our everyday activities.   We tire more easily and can no-longer “go the distance”.  We begin to injure other joints.  Going back to sport or activity too quickly after injury may be revered by the coach and the sports press but these decisions often result in re-injury and a risk for other injuries.

Learning to be injured

Although compensation is a useful and natural process, it is also important to stop compensating once the injury has healed.  One of my coaches summarized it succinctly as “if you play injured, you are learning how to play injured.’

The problem is that during an injury our brain and central nervous system are “learning” how to move injured.  The plasticity in our brain begins to over-ride the older, more efficient movement patterns with these newer, less effective movements.  The longer you compensate the more difficult it is to return to pre-injury movements as your brain interprets the repetition as your commitment to continuing these motor patterns.  The more often you are injured the more you reinforce compensatory patterns, until finally these compensations become your new normal.

Symptoms of compensatory muscle patterning

In my practice I find that these learned inefficiencies of movement are one of the most common causes of recurrent episodes of low back pain.  They are often the reason why so many people eventually experience a similar change in their low back pain episodes.  Whereas initially the intense low back pain is followed by periods where you are pain free, suddenly you are in pain all the time.  The pain is less intense but it never goes away.

Compensatory muscle patterns are also one of the primary causes of other injuries.  After hurting your back many of my clients find that they are suddenly prone to a whole raft of other injuries.  They injure their knees or strain their hips.  Even a recurrent tennis elbow can be a symptom of the unrecognized presence of inefficient compensatory movement patterns.

The most common symptoms that prompt me to look for compensatory muscle patterns include:

  • Taking longer than 3 months to recover from an injury.
  • Hurting your back too easily i.e. picking up the bar of soap in the shower.
  • Low-grade back pain that never goes away.
  • Every time you try to get fit your back pain gets worse.
  • A sudden increase in injuries to other areas. Hip flexor pain, bursitis, recurrent knee injuries are common symptoms of compensation.
  • Your muscles remain tight no matter how often you stretch.
  • You sense you are moving differently but can’t correct it.
  • People tell you that you limp or are moving oddly but you can’t feel it.

Learning how not to be injured

When the cause of your pain is related to changes in movement, the key to getting better and for preventing future episodes lies in retraining your brain’s plasticity.  You need to re-establish pre-injury movement patterns and unlearn the compensatory movements. Fortunately the old adage of “you never forget how to ride a bike” applies here.  The healthier patterns still exist in your nervous system, you just need to remind your brain to use them.

In therapy I find that the key to getting rid of compensation is to first determine what is causing it. Once an injury resolves the compensatory patterns should naturally go away, but when they don’t there are four common reasons to consider:

  • You are still injured
  • Muscles are weak
  • Compensatory muscles are tight
  • Habit
  1. You are still injured

Prior to correcting compensatory patterns it’s important to check to see if the original injury has healed or if you now have a new injury.  Only when your tissues are robust enough to begin producing normal motion will you be able to get rid of compensatory movement. Once your therapist has determined the injury has healed, a program of strength and flexibility will help to get you on track.

  1. Muscles are weak

Although it is important to restore strength, a failure to recognize the presence of compensation can inadvertently reinforce inefficient movement patterns.  Your therapist needs to look for the specific muscles that need to be targeted before you start a general fitness program.  Moving to a general fitness program too quickly often only makes the strong muscles stronger and keeps the weaker ones weak.

  1. Muscles are tight

One of the key signs of compensation is a tight muscle(s) that never gets better no matter how much you stretch.  In compensation the tight muscle works too hard to generate the same amount of power as the more efficient primary muscle(s).

Unless you recognize that these muscles are over-worked they will continue to shorten and tighten.  No matter how much time and money you spend on massage, ART or stretching, the results will only be temporary.  Unless you retrain the primary muscle to take on its function, the compensatory muscle will fatigue, tighten and/or injure.

  1. Habit

Once I have worked through the first 3 elements in this list, the most common cause of continued compensation is that you have learned to compensate.  Repeated practice of a movement pattern causes your nervous system to commit to these movements. As anyone who has tried to correct their golf swing knows, once established these patterns of movement are hard to correct.  Not only does compensation affect how you perform in your sport, it also raises your risk of injury. As the saying goes, practice makes permanent, not perfect.

If you are having ongoing pain that never gets better and/or symptoms of compensation, it’s time to consider seeing a registered physiotherapist or kinesiologist who understands the underlying causes and how to correct them.  Developing a program which includes the repeated practice of healthy movement patterns will help your nervous system re-commit to efficiency and allow you to return to your everyday activities.  As an added bonus it also often improves sports performance as I find that the inability to correct a golf or tennis swing in adults is often a result of underlying compensatory patterns.

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.

Next topic:  How your brain prevents your low back from getting better.





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

When Hamstrings Attack

John Gray is a Registered Kinesiologist in downtown Toronto at at the Orthopaedic Therapy Clinic and throughout Metro Toronto.

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

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

Getting to the source of the problem

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

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

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

How to get better

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

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

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

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

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


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


Causes of Low Back Pain


Causes of low back pain and prevention

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

No one wants an injury.  First and foremost it hurts! 

Injuries stop you from participating in the things you enjoy, limit your involvement with family and just plain get in the way of life. When we first realize that we are in pain most of us hope that it’s just one of those uncomfortable muscle strains, like the ones we suffered when we were younger.  No matter our current age most of us remember our early injuries, the ones that recovered by walking it off or by taking a few days of rest and combining it with ice and stretching.

These strains usually come from exercising too hard, but as we get older minor irritations become less the norm and instead, overdoing means we can damage tissues. Whether we tear a ligament, herniate a disc or sprain a joint, these tissues need more time to recover and that time can seem astonishingly long when you are in pain.  I find most people are caught off-guard when I tell them that their recovery will take a minimum of 6 to 12 weeks. What is even worse is that these tissues are also less likely to heal as completely as a muscle strain, so what is even better is to not get injured in the first place.

  • Injuries cause pain, damage tissues and take 6-12 weeks to recover

What causes low back pain?

Fortunately we are now at point where we are beginning to understand why we injure and research is providing guidance on the cause and prevention of injuries.  In this time of financial constraints this change in direction is particularly important as the long term effect and the cost of injuries to the health system is quite compelling. 

For example we now know that up to 50% of knee injuries will go on to arthritis within 15 years[1]. This disturbing statistic tells us that not only is an injury limiting at the time of the damage it can also be considered to be one of the most expensive conditions in health care and the work place.  From a cost perspective it ranks second only to the common cold.

  • There is over a 75% chance of having repeated episodes of low back pain

Up until a few years ago the cause of low back pain was largely unknown.  Unless you had a car accident or lifted an excessive weight most back pain is insidious.  This means that most people cannot identify the incident causing the injury even though it can be profound enough to change the course of their life.

  • Most people cannot identify what caused their low back pain

In the past the only predictor of low back pain was a previous history of low back pain.  Needless to say when it comes to prevention, this predictor is too little too late however there are now several strong studies that are beginning to show predictors for a first episode of low back pain. In my review I have come across four factors that can be identified as playing a role in increasing the likelihood of injury and although the research is not there yet, I have also found that many of these factors continue to play a role in repeat episodes of low back pain.  These factors are:

4 Factors Causing Low Back Pain

  1. Sleep deprivationcauses of low back pain
  2. Abdominal muscle’s reaction
  3. Weight
  4. Poor balance strategies

Over the next 4 e-blasts and monthly posts on our website I will be exploring each one of these causes of low back pain.  If you haven’t had back pain and want to limit the likelihood of it or if you want to lower the risk for future episodes then you may find that this advice is of benefit to you.  Remember that we are still in the early stages of understanding the causes of low back pain and that there are likely several other factors that we have yet to discover influencing this condition, however in the interim there is enough evidence in place to suggest that these physical causes are a good place to start.

Sleep Deprivation causes Low Back Pain

Getting a consistent, good night’s sleep is one of the simplest strategies to prevent back pain.  Not only does it help to prevent back pain, there are a whole host of conditions where it is clear that many of our body’s functions benefit from just getting a better night’s rest[2].  Many studies indicate we are a sleep deprived society and it is becoming more and more apparent that this is not a healthy state for our brain, body or our back. Despite the obvious importance on a general health level I find that most people ignore or dismiss this strategy’s effect on causing back pain until they understand the science behind the changes. 

When it comes to the spine, the effect of sleep deprivation is attributed to an alteration in our cellular chemistry.  Sleep deprivation prompts an increase in the production of substances called inflammatory cytokines[3].  An increase in these chemicals is thought to be the factor causing back pain. Even prior to understanding this relationship more completely I found that if you are not sleeping properly it took longer to heal.  A review of sleep patterns and habits is often one of the first strategies I review with my clients.  This often leads to a discussion on the barriers to good sleep as the problems interfering with sleep are as varied as the people.   Some just need to go to bed earlier whereas others need a full sleep study and benefit from more intensive treatment of underlying conditions such as sleep apnea. If you are not getting enough sleep or waking up not feeling rested it is important to determine what is getting in the way of your sleep.

Here are a couple of links with simple strategies to get a better night’s sleep:

Depending on the level of involvement you may need to see a professional to help you get to the underlying factors.  If you are having trouble with sleep try not to wait for symptoms before addressing what many of us already know is a problem as I can almost guarantee that the time taken to recover from an injury will exceed the time you spend in preventing an issue in the first place. Next time:  How important is core strength as a cause of 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.




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

Svetlana Marianer, R.P.T.

Svetlana Marianer is a registered physiotherapist practicing in downtown Toronto at The Orthopaedic Therapy Clinic.

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

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

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

Shoulder Anatomy

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

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

1. Why does my shoulder hurt when I swim?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

4. Is swimming safe for my shoulders?

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

Svetlana’s background

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

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

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

Reference :

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

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

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

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

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

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

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

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

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


A Simple Way to Prevent Whiplash Neck Injuries

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

 “Whiplash” (N) a rapid, uncontrolled movement of the neck backwards and forwards when hit from behind in a rear end car collision.

 As a physiotherapist I assess and treat many people who have sustained a whiplash type of injury. The consequences of this common injury can be painful, debilitating and require time and effort to recover from something that can often be prevented or minimized. While most patients recover there is a small percentage who go on to develop persistent pain and limitations which impact function and enjoyment of everyday life.

 Fortunately there is a simple and effective way to prevent this injury from happening and/or to reduce the damage to the tissues caused by a rear end car collision. Taking a moment to properly position your head restraint can pay off by avoiding the months of physiotherapy needed to help you recover.


 The answer to limiting and/or preventing “Whiplash” is to stop the neck from going too far into extension (backwards). This is the primary purpose of your head-rest however many people don’t have these safety structures properly set-up. Follow these simple tips to help to limit the likelihood of sustaining a whiplash.

  1. Ensure that the head rest is correctly positioned behind your head, no more than 2-3 inches away from the back of the skull. This may involve pulling the head rest forward or sitting up a bit straighter.
  2. The top of the restraint should be at least at the level of your ears and preferably at the top of your head. This position blocks the head and restricts the backward movement of the head to limit extreme, uncontrolled extension.
  3. Remember to consider passengers in the rear seats. If head restraints are available make sure these are properly adjusted.


Why does the neck injure more often when we are hit from behind?

 Even a relatively low speed collision can cause neck pain when you are in a car that is hit from behind. The problem is that in a rear end collision both you and the car accelerate forward quickly. Your heavy head “lags” behind your body and this rapidly forces the neck into extension (extension is the movement when you look up to the ceiling).

In everyday life extension normally does not injure our neck as we do it slowly and in a controlled manner. When the movement is too quick, the joints and soft tissues are forced into an extreme, compressed or stretched position. Your muscles, particularly those at the front of your neck, don’t have time to react to protect and limit this extreme movement. This strains the tissues causing pain and spasm.


In the event of an injury causing symptoms you may need medical advice and treatment from a health care professional. The first step is to exclude more serious injuries. Applying the cervical spine rules assists your health professional in determining if you need imaging such as an XRay.

If the diagnosis is a soft tissue strain the application of ice and rest is often the first course of therapy. Persistent  severe symptoms lasting longer than a week that cause reduced function should be evaluated by your physician or physiotherapist.

 Treatment is determined by your pain and by determining the structures that have been injured and how this impacts function. Initially therapy will focus on helping you to control the pain while you heal. As you improve the focus will shift to restoring strength, regaining flexibility and returning you to your full roster of daily activities.

 Funding for your treatment

 After an accident you should contact your insurer. In Ontario, once your claim is established your insurer will send you a series of forms that need to be completed to help you to have your therapy treatments funded. For more information on this process go to our website at

The Financial Services Commission of Ontario (FSCO) website also has helpful information on this process at

Gareth Sneath, PT, MCPA, MScCH, Grad. Dip Man. Ther., is a Toronto based licensed physiotherapist working at the Orthopaedic Therapy Clinic in downtown Toronto. He has over 30 years of providing treatment for clients with muscle and joint injuries in teaching hospitals and in private practice.

The recommendations and opinions expressed above are a guide and are not meant to substitute advice or treatment from your health care professional. A properly positioned head restraint will only reduce head and neck movement going backwards and will not prevent movements caused by forces from other directions.


New Services at the Orthopaedic Therapy Clinic

1. Individualized Yoga Therapy
2. Home physiotherapy treatments
3. Hospital physiotherapy treatments

Customized yoga therapy is a new form of exercise rehabilitation being offered at The Orthopaedic Therapy Clinic. Yoga therapy and physiotherapy are combined to meet your treatment goals and allow you to be independent with a progressive exercise routine. This program is designed for patients who are recovering from an injury by actively addressing mobility issues and weakness. Biomechanical imbalances will be addressed to prevent recurrence of your injury as well as prevent the occurrence of injuries in the future.
When should I use Yoga Therapy?
Yoga Therapy at our clinic is ideally suited for people currently undergoing treatment with one of our physiotherapists and for people who are looking to address pain and dysfunction with exercise. This program involves regular independent practice, making it ideal for people who are motivated to be active participants in their recovery. It is suitable for individuals with no yoga experience and for those who have practised yoga before and are looking to deepen their practice.
Who will I see?
At The Orthopaedic Therapy Clinic our Yoga Therapy program is provided only by a Registered Physiotherapist who is also a yoga instructor. Teaching is based on an understanding of your diagnosis and physical limitations; combining yoga poses into a sequence that will target your treatment goals. Proper alignment is emphasized by educating you about which muscles are being stretched and strengthened, and gentle adjustments increase body awareness and improve technique.
What can I expect?
At your initial session, your Registered Physiotherapist/yoga instructor will review your health history to determine if there are any restrictions or concerns for your participation. A yoga mat will be provided by the clinic. Please wear clothing suitable for exercise, and bring long sleeves for warming up and cooling down. Sessions are one hour, consisting of yoga poses and breathing exercises. Your therapist will collaborate with your health team to ensure you meet your treatment goals.
Yoga Therapy is provided by Joanna Miller R.P.T.

Home Physiotherapy Treatments
The Orthopaedic Therapy Clinic recognizes that not everyone can make it into the clinic. Injuries, age and/or surgery sometimes makes it difficult to travel. Although we encourage our clients to attend the clinic, as there are more options for treatment, when this is difficult we can come to you. If you need this service check with our reception staff to see if we have a therapist in your area who can come to your home.
Hospital Physiotherapy Treatments
Sometimes patients need more treatment than is available in the hospital. Many hospitals now allow outside therapists to augment treatments. If you feel this service would be helpful you can get the process started by contacting the physiotherapist who is working with you at the hospital and ask them the procedure for bringing in an outside therapist. Once you have the therapists contact information check with our reception staff to see if we have a therapist in your area who can come to you.

Massage therapy for prevention and treatment for swimmers shoulder

Juliette Woodruff R.M.T, Acupuncture Practitioner
Juliette Woodruff is a registered massage therapist practicing in downtown Toronto at
The Orthopaedic Therapy Clinic.

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
joint. 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
athletes. 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, bursitis, and dysfunction with the acromioclavicular
joint. The symptoms and presentation may differ depending on the dysfunction.
(1) Circular motion

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

All You Need To Know About Ankle Pain!

By: Svetlana Marianer, Reg. Physiotherapist, MSc. Pht

Even though ankle sprains are common, they are not always minor injuries. Repeated or severe sprains can lead to further problems such as long-term joint pain, weakness and ultimately even arthritis. The healing time depends on the degree of damage to the ligament as well as your age and past history of injury.

Immediate Treatment

During the first 3 to 5 days following an ankle injury the appropriate treatment protocol can be summarized with the acronym POLICE:

P: Protection, immobilize the affected joint

OL: Optimal Load ie. weight bearing as tolerated with crutches or cane

I: Ice the affected area; 10 to 15 minutes every two hours (use a damp cloth between the ice and the skin to avoid burning)

C: Compression; apply pressure on the swollen area.  Ie. wrap an elastic bandage up to 10 cm above the affected area.

E: Elevation; raise the affected area above the level of the heart for as long as possible.

The ankle joint is composed of three bones; the tibia and fibula, making up the lower leg, and the talus, base of foot. The three come together and are joined by ligaments.  These strong elastic bands function to stabilize the ankle and keep the bones in place while allowing normal ankle motion. Lastly, tendons are cord-like bands that attach the muscle to the bone. These bands move the ankle and foot.


Ankle injuries

These injuries are defined by the kind of tissue, bones, ligaments or tendons you have damaged.


1. Ankle sprain:

Sprains are the most common ankle injury.  They are typically caused by a rapid shifting movement with the foot planted in the ground (such as in soccer) or a “wrong movement”/twist of the foot (such as missing a step). The foot rolls one way and the ankle turns the opposite way, causing the ligaments to either stretch or tear.

Depending on the severity of the injury and on how much damage the ligament suffered, an ankle sprain can range from mild to severe. The most commonly used classification is as follows:

v      Grade I: ligament stretch but no rupture; usually presents with tenderness upon touch, swelling, and stiffness but feels stable. Little pain with walking.

v       Grade II: Partial ligament rupture; commonly presents with redness, warmth, swelling and significant pain with walking. May or may not bruise.

v       Grade III: complete ligament rupture; may hear a crack or “pop” of the ligament, ankle feels unstable or “wobbly”, walking is difficult and painful. Usually bruising and severe swelling occurs almost immediately.

Healing and Prevention

Treatment by a physical therapist can help to speed the healing process and prevent complications and ongoing ankle problems.

2. Ankle tendonitis/ Tendon rupture

Tendonitis refers to the inflammation of a tendon.  These injuries are usually the result of gradual wear and tear from overuse or aging. In other words, tendons are commonly injured when we repeatedly make the same motion; either at work, during sports or throughout our daily activity. The inflammation is caused little by little and is a slow process

However, tendon injuries can also occur rapidly and suddenly, usually following a direct blow or trauma. If the trauma is either severe or the tendon is very weak, the tendon can rupture.  This injury is similar to ligaments and can either be partial or complete (depending on how many fibers have been torn).

Symptoms of tendonitis are:

  • Pain during activity
  • Stiffness of the ankle
  • Loss of strength
  • Tenderness to touch
  • Redness, warmth and swelling.

Symptoms of an ankle tendon rupture are:

  • Pain at rest
  • Swelling
  • Discoloration of the ankle region
  • An audible pop at the time of injury
  • Pain and difficulty with walking
  • Ankle stiffness as well as the feeling of instability of “giving out” of the foot.

Healing and Prevention

The key to a successful outcome for a rupture of any of the ankle tendons is early diagnosis and proper treatment. In the case where the diagnosis or the treatment is delayed, the integrity of the healing tissue may be compromised as a result of scarring and decreased blood flow. These complications prolong the recovery time and increase the risk of complications.


For a complete tendon tear the treatment of choice may be surgical repair followed by structured and aggressive physical therapy.  For partial tears a conservative physical therapy treatment without surgery is often the best option.

3. Fractures

An ankle fracture can consist of a break in one or more of the three bones (tibia, fibula or talus). This type of injury typically results from a fall, an automobile accident or some other traumatic event.

Often with fractures other tissues can be injured.  Ligaments may be severely sprained and can mask the symptoms of a broken ankle. An examination by a physiotherapist and/or your physician can help to determine if you need more investigation.

Symptoms of a broken ankle include:

  • Immediate and severe pain
  • Swelling
  • Bruising
  • Tenderness when touched
  • Inability to put any weight on the injured foot
  • Deformity, particularly if there is a dislocation as well as a      fracture



Greenberg,     G et al. (1994). Implementations of the Ottawa Ankle Rules.


ACL Injuries

Olympic Gold Medalist Overcomes Multiple ACL Injuries

Olympic snowboarding gold medalist Maelle Ricker has travelled a long road from 8 knee operations, including multiple ACL ruptures, becoming an Olympic Champion. She is one example of an alarming statistic showing that young female athletes are 4-6 times more likely to sustain a sports related ACL injury of the knee as compared to males in similar sports. This heightened risk for females has led the International Olympic Committee to release a position statement on the current causes and treatment and future areas for research related to ACL injuries in young females. An ACL injury is a devastating injury requiring up to a year of rehabilitation, before a return to normal physical activity. There is also a very high risk of developing knee osteoarthritis 10-15 years following this type of injury. The good news is there is scientific proof that a specifically designed exercise program and preseason assessment by a physiotherapist can help reduce the risk of an ACL injury and its life changing consequences. As in Maelle Ricker’s case with the proper rehab you may be even able to continue to compete at a high level of physical activity.

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What is the ACL?

The ACL is a ligament in the knee which runs from the shin bone (tibia) to the thigh bone (femur). Its job is to help stabilize the knee and to prevent excessive forward movement of the shin bone away from the thigh bone. Injuries range from minor overstretching to tearing or a complete rupture of the ligament. These injuries should be evaluated by a physiotherapist or an orthopaedic specialist to determine the severity and appropriate treatment. Depending on the severity, the knee can be more unstable and prone to repetitive trauma after these injuries.

Why are females more at risk than males for an ACL injury?

At this time the reasons why females are more at risk for theses injuries are not fully understood and are likely quite complex. However, factors such as bone size, bone shape and hormone differences have all been proposed to add to this risk. Research has also shown that females use different muscles and body positions when jumping and moving and these altered movement patterns may be what increases the risk of an ACL injury.

How can ACL injuries be reduced?

Risk factors such as bone size and hormone levels cannot be changed but how someone jumps and moves can be corrected and improved by a knowledgeable physiotherapist. Prevention is best achieved through learning how to land a jump properly and how to move quickly in ways which reduce the stress on the ACL. Incorporating exercises that focus on strengthening of the trunk and legs, balance training and agility drills are also beneficial. These programs can easily be incorporated into practices, training sessions or warm ups.

Who should participate in a prevention program?

The risk of ACL injury is particularly high for adolescent females, ages of 14-19 who are involved in sports with quick stopping and cutting movements such as soccer, basketball, downhill skiing, and snowboarding. These are the young female athletes who should be targeted to participate in an appropriately designed prevention program. It is also recommended that a physiotherapist performs a preseason screening examination to help identify risk factors such as poor muscle strength and flexibility which also can lead to injury. The bottom line is that with the proper evaluation and instruction young girls can reduce their risk of an ACL injury in sports and the devastating long term effects on their physical health.

For further information about ACL injuries, injury prevention programs or preseason screening evaluation please contact physiotherapist Mark Duggan, who has over nine years experience in orthopaedic and sports injury rehabilitation.