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Get the latest and most reliable information on pain relief & physiotherapy treatments at Macquarie Street Physiotherapy Clinic blog.

Do I need an MRI for my back?

Admini Si - Tuesday, December 04, 2018

As physiotherapists, we are often asked this question by clients who come to see us with back pain. 

There is a misconception among the public that MRI scans hold the key in finding out why they are experiencing back pain. 

A systematic literature review was undertaken in 2013, to review the imaging findings of individuals who did not report or experience any back pain. 

Interestingly, the review found that degeneration, disc bulges and protrusions were present in a high proportion of asymptomatic individuals and that these findings increased with age.

A summary of the results of the review are found on the table below:

Based on these results, it is worth taking into consideration that many imaging-based findings may be part of normal aging and not related to back pain.

MRI scans definitely have a place in confirming diagnoses but the imaging findings must correlate with symptoms and be interpreted in the context of the individual’s condition. 

If you wish to discuss your MRI scans or have any questions relating to your back pain feel free to contact Macquarie Street Physiotherapy to book an appointment.  

A full version of the systematic review is available via this link:

Posture Tips - Standing Desk

Admini Si - Wednesday, September 05, 2018

Standing Desks

You might think that a standing desk is the answer to all your back or neck issues at work.

However, did you realize it is possible to slouch at a standing desk?  And that your back or neck issues may continue as a result!

Standing slouching looks a little different to sitting slouching:

1)     Hanging on one hip
2)     Hips forward of the rib cage
3)     Pelvis tilted forward
4)     Leaning on the desk
5)     Craning to view the screen


Actually the last two points also can happen sitting, but it’s important to realize that standing helps only if you get it right!

Best standing posture:

-        Even weight on both legs (or have one foot on a small step)

-        Hips under rib cage, pelvis “neutral”

-        Chin tucked in

-        Stay on the move – you don’t have to stand stock still!

Remember, you can alternate between sitting and standing throughout the day.  At first it is recommended that you only stand for 30% of the day.

Understanding your experience of pain

Admini Si - Tuesday, August 28, 2018

Research into pain has increased significantly over the past decade.  We are gaining a greater understanding of, in particular, longstanding (chronic) pain and what might perpetuate it. 

We know that pain is about protecting us, but we are learning that it is not an accurate measure of tissue damage.  If our brain registers injury/threat, pain will result in a change in behaviour to protect our tissues (e.g., muscle, joint).   This is a very appropriate response when we have acute (immediate) pain, as it allows us to rest while tissues heal.  However, sometimes an adequate amount of time has elapsed for healing to take place, but the pain does not reduce. 

Why does the pain remain?

Pain scientists have identified a host of factors which might contribute to pain continuing long after the threat of tissue damage has ceased.  These include social life, family, stress, and a feeling of anxiety or depression relating to the injury.  Other contributors include poor sleep, prolonged opiate (pain killer) use and negative expectations.  Sometimes the language around pain promotes negative feelings about recovery; rather than talking about the body being strong and resilient, people may use ‘weak’, ‘broken’, etc.  Although pain can cause fear and anxiety, it is not helpful to use labels which suggest it will never pass. 

Being fearful can lead to protective strategies such as breath-holding and “gripping” muscles.  Rather than loading and strengthening tissues, avoidance can lead to weakness, disuse and further problems.  Sitting or standing “stock still” in order to avoid movement, is likely to increase stiffness and over-reliance on certain muscle groups.

What is the answer?

Time and again, the answer to chronic pain comes back to movement and exercise.  This, along with continuing to be occupied and maintain a positive outlook, have direct effect on our experience of pain. 

How do I exercise in the presence of pain?

1)     Exercise around the painful part:  The experience of grumbly knee pain is common to many – once we have knee pain, we often limp, avoid stairs, and accept a level of inactivity.  The knee joint, however loves to be strong and supported by surrounding muscles.  Here are a few examples of exercises which allow us to maintain good function around the knee and limb – calf raises, hamstring curls, core exercises, gluteal exercises such as donkey kicks all exercise nearby muscles.  Wall squats and straight leg raises exercise quadriceps (thigh) muscles without the repetitive movement which may aggravate a knee joint. 


2)     Isometric exercises: The last example of exercises are called isometric exercises – they involve muscle activation without joint movement.  These allow us to exercise the muscles around any joint in a (usually) painfree way.  The shoulder is another very good example of a joint which responds well to these exercises, where the muscles act against resistance without elevating the arm. Once there is better activation of muscles around a joint, exercises involving movement can be started.


3)     Keep moving!: Being on the move if you have chronic pain is always preferable to prolonged static positioning.  Movement might include walking, cycling or swimming as alternatives to more demanding exercise, until you are ready to progress. 

Good Help and Support:

It is important that you feel you can trust your health care professionals to guide you regarding appropriate exercise and movement, and it also helps to have the support of family and friends.  It might be that some strategies can be taught with the help of a psychologist, as well as your GP/physician and physio.  If you attend a gym or play sport, having the coach/trainer on board is also worthwhile.  And for workers with chronic pain, it is helpful to have the support of your employer.  There are also pain management courses and specialists to assist which you could consider. 

Easter Calf Pain

Admini Si - Wednesday, March 28, 2018


Autumn is here, calf pain appears.  As the weather cools we will see the return of two of our favourite patient groups.  The first is the over 35 soccer player and the second the recreational fun runner gearing up for the season.  

The most common type of calf pain seen at this time of year is not an acute tear but more a chronic tight overloaded calf.  An acute tear is characterised by sudden stabbing pain in the calf when twisting or sprinting, usually pushing off with an extended knee.  Whereas an overloaded calf is felt as a progressive tightening of the calf, perhaps halfway through a run or in the second half of a soccer game.  Pain and tightness might build so that the activity needs to be stopped, or possibly continued but with ongoing pain. The calf may then be then sore for a couple of days, pain occurring with walking or on stairs.  After a few days, it has usually mostly resolved. However, the next time soccer or running is attempted the calf problem will reappear, possibly even earlier in the activity. This can become a vicious cycle.

This article deals with a chronic overload of the calf rather than acute tear, but the reason for the occurrence is often the same.  

Background to the overloaded calf:

Easter Calf Pain

Easter is a period where there is a rapid increase in activity in our over 35 soccer players, due to a sudden increase in training and games. This in combination with reduced rest periods between games and little preseason fitness training is the perfect storm for a calf overload. These calf issues are generally seen more at the start than at the end of the season as people are fitter to play later in the season.

The calf muscle is more likely to become overloaded due to three factors 1) weakness, 2) sub-optimal biomechanics or 3) rapid increases in training load with inadequate recovery.   Often it is a combination of all of these things.  

1. Weakness:

Sportspeople choose varied ways to increase their fitness.  They may add additional runs in the week, run further than previously, add speed work or hills.  They may get over-zealous at the gym. These rapid increases in loading can cause problems for the weak calf.
A basic assessment of calf capacity can involve a single leg calf raise to fatigue.  A basic rule you should be able to do 30 single leg calf raises at a slow pace (3 seconds up, 3 seconds down) before fatigue.  If you are unable to do this, calf strengthening should be part of your programme.

2. Biomechanics:

Physiotherapists are always looking for biomechanical reasons for calf overload. The list is extensive, and may relate to the feet, knees, hips, and back.  It is important to consider the whole kinetic chain when assessing running mechanics.  A common finding is reduced gluteal and quadriceps strength whereupon the calf is required to provide too much running propulsion.  Poor hip stability due to weak gluteals can also result in the calf working as a stabiliser and as well as propulsive muscle leading to fatigue and pain.  

Changes in running style can also overload the calf.  Progression to forefoot running increases calf loading by over 10%.  Transitioning to minimalist shoes with a zero drop also results in significant increases in calf load.  Altering running technique in this way is not necessarily good or bad, but sufficient time is needed to adapt.  Such changes should also not be made at a time of increased training load, e.g., in preparation for a race. 

Gait analysis and physical examination can highlight significant biomechanical issues, weakness
and tightness.  This can serve as the foundation for a strength programme to help you avoid injury.

3. Training load:

Suddenly realising it’s Easter, and time to get fit, as the first competition is only two weeks away is not the best approach to pre-season training!  Equally, swimming all summer may have helped maintain some cardiovascular fitness, but it won’t prepare you for leaping on to the sports field without some land-based preparation. Of course, maintaining fitness and strength is recommended throughout the year, but we would recommend sports-specific training for any competitive sportsperson at least six weeks prior to playing.  

4. Managing the overloaded calf:

Recent onset mild calf pain/tightness can sometimes be managed by simply reducing some load i.e., missing one or two games or cutting out the long run and the hills.  

Treatment of the fatigued calf can include stretching, massage or dry needling to remove knots in the muscle so it can function better. Strengthening exercises are also appropriate.  

Calf Pain Injury

For the more problematic calf overload, more serious strengthening needs to occur. To achieve true strength gains, muscle fatigue needs to be induced by exercises. It can take six weeks to realise those gains. Calf strengthening with weight or a calf raise machine allows traditional strength thresholds to be used. Such as 10 to 15 reps to fatigue 3 to 4 sets two to three times per week. Once the calf is stronger, it also needs to be incorporated into functional exercises, e.g., cutting and weaving for soccer players.

Preseason training should include strengthening key running muscles - calves, glutes, quads and core. Runners should increase using the 10% rule, and try not to have more than one hill or speed session per week.  Strength and speed gains come slowly, don’t force these changes.  

We hope you get to stay in the paddock this Easter and don’t end up on the couch with the eggs!!


How important is calf stretching for prevention of injury?

Admini Si - Thursday, August 03, 2017

calf muscle

Stretching will make tight muscles feel more comfortable and freer.  Flexibility in the calf is essential for all running sports.  It reduces the chance of straining/tearing the calf muscle during a match or whilst running.  Stretching the calf will also relieve the strain on other muscles which might be working harder to compensate.

What are calf muscles?

They are the muscles of the lower leg which are involved with propulsion, hopping, and jumping by their attachment at the heel.  Racquet and other ball sports, running and cycling recruit calf muscles.

There are two main muscles which make up the calf.  These are:

1)      Gastrocnemius – this starts above the knee and attaches at the back of the heel via the Achilles Tendon.  It helps with propulsion (heel raise) as well as knee bending.

2)      Soleus – this starts below the knee and attaches at the back of the heel via the Achilles Tendon shared with gastrocnemius.  This muscle is important for propulsion upwards and forwards, and balance.  It is the most commonly strained (as many as 95% of calf strains are soleus strains).  Running is the main cause of calf strain.

Why are my calf muscles tight?

Calf muscles can be tight for a number of reasons:  after exercise they could be tight just from normal use (particularly if you are new to the exercise), or from over-use (often accompanied by DOMS – delayed onset muscle soreness).  If you are weak in the gluteal muscles, or tight in the hip flexor muscles the calf will tend to work harder when you walk or run.  Also, a tendency to weight-bear in your forefoot or wearing high heels can result in tight calf muscles.  Sitting shortens the gastrocnemius muscle of the calf, and so can make this tight.

Does stretching reduce calf tightness?

Stretching any muscle, be it hamstring, quadriceps, adductors or calf is relevant if the muscle is tight.  Stretch exercises reduce calf tightness by lengthening the muscle fascicles.

How should I stretch?

The gastrocnemius is best stretched with a straight knee (PIC).

The soleus is best stretched with a bent knee (PIC).

The heel can be flat on the floor or dropped over a step. Dropping the heels over a step could aggravate the Achilles tendon, so watch out for any tendon pain with this (PIC).

When should I stretch?

Static stretching should be performed regularly and held for 60-90 seconds.  It should not be done much sooner than 2 hours before a sporting match. Current research suggests that pre-match warm-ups should be more dynamic such as lunges and leg swings, jumping, etc., rather than static stretching.

Static stretching should also be performed after playing or training.  It can be performed as part of a daily routine, or for relief at any time the calf feels tight.

Other ways to stretch the calf:

Calf stretching occurs with a number of yoga poses, including downward dog.  These incorporate other muscles, fascia (or connective tissue) and the “posterior sling” which includes the structures at the back of the leg and spine.  This is more of a “whole body” stretch incorporating sciatic nerve and hamstrings, gluteals and back muscles, which can add benefit to a calf stretching programme.

Eccentric strengthening exercises (muscles lengthening as they contract) have been found to increase fascicle length in the muscles, and so increase flexibility.  An example for the calf is returning down from a calf raise exercise.  Dead-lifts, although mostly eccentric strengthening for the hamstring may also incorporate the calf and help lengthen and strengthen it.

Dynamic stretching such as squats, lunges, leg swings, and calf raises on a step, can also help keep the calf flexible.

In Summary:

Keep the calf muscles flexible using static stretching – either isolated to the calf or involving other muscles.  Closer to a match or run, dynamic stretches are preferable.  Eccentric strengthening also improves calf muscle length.  To reduce over-reliance on, hence tightness in, the calf muscles, make sure other leg muscles are strong to assist in propulsion during sport.

The Brain that Changes Itself Altering Pathways to Reduce Pain

Admini Si - Monday, August 08, 2016

Blog by Dione Barrett, Physiotherapist at Macquarie Street Physiotherapy Centre:

My physiotherapy colleague, Lisa Smith, and I recently had the privilege of attending a two-day conference conducted by Norman Doidge. He is a Canadian-born psychiatrist and author of the popular books "The Brain That Changes Itself" and “The Brain's Way of Healing."


Norman Doidge along with other researchers and clinicians are leading the field in new ways to attack old problems by understanding neuroplasticity. Neuroplasticity, also called brain plasticity, is the process in which the brain's neural synapses (connections) and pathways are altered as an effect of environmental, behavioural, and neural changes.

Practice makes Perfect

Norman Doidge talks about “purposeful practice” in order to effect a change in neural pathways. Matthew Sayed also addresses this changeability in his book “10 000 hours”. Sayed points out the key elements to becoming successful in your field of expertise. One of the crucial components is purposeful practice over an extended timeframe. Doidge supports the effect this phenomenon has on success due to the effect on the brain.

When the Brain registers Pain.

Acute pain often starts in a familiar way - the body is exposed to painful stimulus – and the message travels from the tissues (for example, a disc injury in the lower back) to the brain. The brain registers the stimulus as pain. With ongoing, chronic pain, something has gone amiss, and the brain maintains the perception of threat or injury out at the periphery. Despite the threat no longer existing (long after the tissues of the back have healed) the brain still perceives that pain exists in the body. Chronic pain has been studied extensively. It costs millions of dollars a year as a society and costs many people their quality of life. We are only just beginning to understand what happens to drive chronic pain, and this is helped by new technology.


Today we have technology which allows us to see what is happening in the working brain through the use of Functional Magnetic Resonance Imaging (FMRI). A brain that is registering pain looks very different on FMRI to a brain that is not registering pain. Norman Doidge describes the brain of patients with intractable pain as if a brush fire had gone through it.

Case 1:

Doidge describes the case of a man with intractable pain who was educated about the difference between pictures of brains experiencing no pain and those with pain. The man took the image of a brain that was pain-free, and every time pain was experienced he actively and vigilantly imagined the picture of the brain without pain. Initially, there was no apparent change, but the man persevered. Using this imagery in his meditation over a two-year period, he was able to eventually resolve the pain. Amazingly, his FMRI pictures changed to that comparable with a pain-free brain. The rewiring of neural circuits allowed a normal function to return. He had actually changed the workings of his brain.

Such imagery has been used effectively with elite athletes to visualize positive outcomes from the performance. We now understand better why this works, and visualizing the pain-free brain is not dissimilar.

Case 2

A similar process was described with a Parkinson patient called John Pepper. One of the traits of Parkinson’s disease is a poor initiation of movement. This makes walking very difficult and often their gait is shuffling in appearance. John Pepper worked out that if he cognitively analyzed walking and thought about every movement as he walked he could use a part of the brain unaffected by Parkinson’s and override the shuffling gate. Again this required vigilance, persistence and an extended period of practice to overcome the rigidity of his movement.

These are two examples where using cognitive methods to retrain automated systems within the brain have been effective in overcoming a deficit in the brain.

Why is this relevant to what we do as physiotherapists?

The main reason people come to see a physiotherapist is pain.

Daily we see people who are in pain. As a result, they may have altered the normal movement of their body. In the early stages, this is a protective mechanism to avoid aggravating pain. But over time, altered use of muscles and joints may lead to muscle weakness or tightness in the affected area. Joints may become stiff if not regularly used and in good alignment. Long after the injury has healed, the resultant altered movement patterns may of themselves cause pain. From the above research, we now know there may be altered brain pathways as well, which keep registering pain.

I have taken these modern theories and used Norman Doidge and Matthew Sayed’s theories to get patients to actively focus on using the muscles that should be used, introducing a strong cognitive element to exercise. In addition, patients can use imagery to picture activating the correct muscle, once they have been educated about the anatomy. Encouragement is given for the patient to purposefully practice using the muscle in daily activities to restore normal body and brain function.

Physiotherapists can be mentors in showing patients how to move properly and educating them regarding their body. It is also our job to educate our patients about the science behind a purposeful practice, so they can be engaged and motivated with the exercise and advice we give. We welcome people experiencing chronic pain to attend Macquarie Street Physiotherapy for expert advice.

Macquarie Street Physio