4 part series on low back pain – Part 4B: What to watch out for when seeking treatment

Read below for some hot tips, so you get the most out of your treatment.

1. Be careful of radiation exposure with what investigations you are told to get. 

  • As mentioned in the previous post, CT scans should only be done if absolutely necessary. They are cheaper for you than an MRI. However, CT scans are very high dose radiation. Be careful! 
  • MRI is a popular investigation of choice for the lumbar spine. This is because it provides lots of information on both soft and hard tissue structures. The good news is that there is no radiation exposure with MRI. However, you are typically out of pocket by about $300.
  • Xrays are helpful to show us the boney alignment of the spine. If your pain is in the lower back, then you only need an Xray of your lower back. Getting an Xray for the entire spine is usually unnecessary.
  • Most commonly, your referring practitioner will be able to get the most valuable information from getting you to have both an MRI and Xray.  

Left: An MRI of the lower back, showing the integrity of the lumbar discs.

Right: AN Xray of the lumbar spine. 






2. Your pain should improve with treatment!

  • You should not get an increase in pain after a session with your physio, chiro, acupuncturist or massage therapist. If your pain does increase, make sure you let your practitioner know.
  • If your pain is not improving after a few sessions, change practitioners or see your doctor (or Sports Physician). Either they are doing the wrong treatment for you or have not diagnosed you properly. Don’t keep going back just because!
  • As your pain improves, treatment should reduce. Don’t let any practitioner tell you that you need 3-4 treatments per week for 12 months. That is costly and unnecessary! Instead, your treatments may start at once (max twice) per week and as your symptoms improve, treatments should gradually reduce to once per 2-3 weeks. 
  • The most shocking warning I need to tell you is this… don’t be conned into making an upfront payment for 12 months worth of treatment, involving 3-4 sessions per week. Read the above dot point again.. treatment needs to be reducing as your symptoms improve not staying the same.

3. Be careful of some ‘out there’ wording that some practitioners use. 

  • No your spine cannot ‘be out of alignment’ and no it can’t be ‘popped back in’. Don’t let these terms scare you. 
  • And nor can your spine change position on X-ray after a few treatments.
    • Don’t let a practitioner take an Xray of your spine, do some treatments and repeat the Xray claiming that they have ‘straightened’ your spine. We have normal curvatures of our spines that are there for a reason (see the picture below).
    • Research shows that the position of a joint (measured using an Xray) does not change before and after a joint manipulation (i.e. crack).  
    • Instead, to improve the posture of your spine, be sure to keep working on your strength, flexibility and posture. For more information on how to do this, get along to a Physiotonic class today. Visit www.physiotonic.com.au to register. 


Above: the normal curvatures of the spine. 


There is one final blog past on this 4 part series to low back pain. Keep reading for more information on the ultimate answer for managing low back pain. 

4 part series on low back pain – Part 4A: Typical treatment options

Now that you are reading the final part to this series, you are becoming an expert on low back pain! Keep reading to learn about how to treat and manage your back pain. Treatment posts include:

  • Part A: Typical treatments options and when to see a doctor
  • Part B: What to watch out for when seeking treatment
  • Part C: The ultimate answer for managing low back pain


PART 4A – What are the most typical treatment options you can pursue? What do you expect to get out of these treatments? 

  1. Physio
    • Your physiotherapist will assess your spine and identify the main issues contributing to your pain. They will work out where you are:
      • Tight. Your physio will then help improve your movement by various manual therapy techniques including massage, joint mobilisations, muscle energy techniques and potentially dry needling. You will be given stretches to work on between treatments to help maintain and improve your movement.
      • Weak. After having back pain, your physio will give you exercises to help you activate your deep core (see previous blog post titled ‘the core essence of running’ to learn more about the core) as well as strengthen other muscles such as your buttock muscles that may also be weak.
    • Your physio will also give you advice on:
      • what exercise you can do while you have back pain. Exercise like swimming is particularly good for you if you are suffering from low back pain. If you don’t want to do freestyle, try walking in the pool. You will feel surprisingly good afterwards!
      • When you can return to your normal exercise regime and if this should be modified. 
      • Posture, posture, posture. You really need to get cracking on improving how you sit, stand and move. Learn how to get those core muscles switching on in functional position
  2. Massage
    • Massage therapy can be helpful at easing tension and improving movement.
  3.  Acupuncture
    • Is a form of alternative medicine that you can certainly try. Some people really like it and find it helpful. Acupuncture is holistic and seeks to improve the flow of energy in your meridians. (NB Acupuncture is very different to what a physio offers with dry needling. Dry needling targets trigger points, not meridians).
  4. Chiropractic
    • Is a form of alternative medicine that emphasizes treatment of the musculoskeletal system under the belief that mechanical disorders affect general health via the nervous system. The main chiropractic treatment technique involves manual therapy, especially manipulation of the spine.



What’s up doc?

Knowing when to see a doctor over one of the practitioners listed above can be tricky. You definitely need to see your GP if your pain:

  • is severe
  • is worsening
  • is worse at night and stops you from sleeping
  • if you have any rapid weight loss or weight gain
  • is radiating down your leg and past your knee

Your GP can prescribe medications to help improve your pain. If you have a very acute bout of low back pain, the best thing you can do is get onto the right medication and rest in bed for a few days. Going for a massage or to physio when you are in debilitating and severe pain, wont help! The medication at this stage is the most important.

Be careful as to what investigations you are told to get. Typically, an Xray and MRI is ordered. Note that CT scans are very high dose radiation and should only be done if absolutely necessary.

If you need further medical attention, I couldn’t more highly recommend the use of specialist doctors such as Sports Physicians. These doctors are the most highly qualified to clarify the diagnosis, organize appropriate investigations and provide you with details on medical options for your pain, such as corticosteroid injections. 


Keep an eye out for our next post for this series, part 4B: what to watch out for with seeking treatment. 


4 part series on low back pain – part 3: What’s causing the back pain epidemic?

In part 1 of this blog series, we learnt the staggering statistics of how low back pain affects most of us. In the second part of this series we looked at where pain in the back actually comes from. Here we are taking a close look at the causes and symptoms of low back pain.

 What’s causing this significant back pain epidemic? 

Back pain simply comes down to the fact that we are too sedentary. Generally people are unfit, weak and don’t have much muscle tone.

Everything happens automatically at our finger tips. Take for example, bringing the groceries home. We drive our car into the driveway, press a button so the garage door lifts, drive in, load our shopping into the lift and the lift takes us up to the level of our apartment. Not much physical effort is required.


So why do fit people like runners get back pain?

There’s no doubt that running keeps us fit and strong. But the problem lies with what happens the rest of the time. People are sitting at a desk, in excess of 50 hours per week now. This is the time that we are getting deconditioned. This is the time our core muscles in particularly get weak.

Simply running for 30 mins here or there during the week, and doing some ab crunches isn’t going to fix the deep core deconditioning if the majority of the time we are stationary. 

What we need to do is adopt a lifestyle where we are continually thinking about and engaging our postural muscles to keep them activated. This means not slouching in your chair (how are you sitting right now?) and instead, moving, sitting and standing with your deep core muscles activated. By adopting good postures, this will ultimately take the load off the spine.

You need to concentrate every day on your sitting posture. Sitting in a slumped position, causes:

  • your hip flexor muscles to become tight and overactive
  • your buttock muscles to become weak
  • pressure on lumbar discs (see previous post for what the disc is), which will in turn cause wear and tear and eventually degeneration of your lumbar structures.

The wear and tear on your spine occurs on a daily basis from years of poor sitting. Microtrauma every day, every week, every month. Then, you go and do something fairly innocuous such as picking up your shoe from the floor, or bending down to make your bed or doing an unaccustomed activity like 1 hour of gardening… and then your back goes into ‘spasm’. This last list of activities is just simply the icing on the cake. The real cause has been all the deconditioning and bad sitting habits leading up to the event.

 Improve your core and postural awareness today. Visit http://www.physiotonic.com.au/benefits/office-workers/



Pain in the back can either be a deep ache or if your pain is acute, you may experience some sharp pains. The pain is usually made worse with sitting for long periods, bending, lifting and long runs can also stir up the back pain (particularly if you lack deep core endurance because your core muscles will fatigue, placing more stress on your spine).

If your symptoms have persisted, are worsening or you are getting pain running down your leg past your knee, make sure you see your doctor or physio. 


Keep reading our next post for more information on how to treat and overcome your back pain. 

4 Part series on Low Back Pain

Part 2 – Where does pain in the back come from?

part one of this series (see previous blog post) looked into the shocking statistics that demonstrate the significant problems back pain is causing to australians. it effects so many of us. in this blog post, we look more closely into where the pain actually comes from. 


Back pain can be acute or chronic, sharp or achey, radiate to your legs or hang in the lower back and buttock. But where does the pain actually come from?

Back pain is commonly due to general wear and tear of all the structures around your back. This can include the joints, the disc, and the muscles. Typically, not just one structure is involved, but a bunch of them.  

Most commonly, however, the disc is the main source of pain (does a ‘slipped disc’ sound familiar?). There are 5 lumbar vertebrae. In between the vertebrae there are discs, which act as cushions between the vertebrae. The discs have an:

  • inner part, called the nucleus pulposus which is like soft jelly
  • outer part, called the annulus fibrosis which is like a harder jelly


Left: Demonstrates your entire spine with your cervical (neck), thoracic (mid back) and lumbar (lower back) vertebrae.
Right: Shows how the disc and vertebrate are positioned. 

When the disc herniates, part of the nucleus leaks backwards. From more minor back injury to more severe this is what happens to the disc:

  • The nucleus can just touch the edge of the disc, causing pain (protrusion)
  • the nucleus touches the edge of the disc and if the wall weakens, this can irritate the nerve roots (herniation)
  • a portion of the disc leaks out through a tear in the disc’s outer wall (extrusion) and may separate from the disc itself (worst case scenario, sequestration). 

The picture below summarises this. 

Below is what a bulging disc typically looks like on MRI (side on view). 

The disc doesn’t necessarily have to herniate to cause pain. It can degenerate or thin. In a normal disc, its height is maintained by water and protein. As we age or as the disc degenerates, the water and protein content in the disc, decreases. See below. 




Sciatica describes the symptoms of leg pain and possibly tingling, numbness or weakness that originates in the lower back and travels through the buttock and down the large sciatic nerve in the back of the leg. Most commonly, sciatica is caused by a protruding disc, degenerated disc or a narrowing of the boney canal that the nerve passes through. 

The majority of us, however, do not have 1 particular structure that is the main source of our back pain. We typically have general wear and tear that affects many structures in our back. Therefore we present to a health professional with a grumbly back that never seems to get better. Keep reading the next 2 posts, where we will cover:

  • Part 3 – causes and symptoms
  • Part 4 – treatment 



4 Part series on low back pain

Part 1 – Society’s pain in the back



Back pain has become a real pain in the back to society. Up to eighty per cent of Australians will experience back pain at some point in their lives and 10% will experience significant disability as a result. Back pain disrupts individuals’ quality of life and accounts for an enormous cost to the community. It is costing Australia billions each year in health care and time taken from work due to back pain.

The National Health Priority Areas (NHPAs) are diseases and conditions that the Australian government have chosen for focused attention because they contribute significantly to the burden of illness and injury in the Australian community. The 9 NHPA’s are:

  • Cancer
  • Cardiovascular health
  • Injury prevention and control
  • Mental Health
  • Diabetes Mellitus
  • Asthma
  • Obesity
  • Dementia
  • Arthritis and musculoskeletal conditions.

Back pain is the most common condition in the bracket of “Arthritis and musculoskeletal conditions” as a NHPA. Interestingly, a staggering 14% of Australians (3.0 million) are affected by back problems, followed by 8% with osteoarthritis (1.8 million), 3% with osteoporosis (728,000) and 2% with rheumatoid arthritis (445,000) according to 2011-12 self-reported estimates. To read more visit http://www.aihw.gov.au/national-health-priority-areas/.

Back pain is a big issue and we need to do more about it.

Watch this space for the following blogs to this series:

  • Part 2 – where does the pain come from?
  • Part 3 – Causes and Symptoms
  • Part 4 – Treatment.

The core essence of running

There would be far less runners’ injuries if runners had a stronger core. Does this mean you need to jump on a Pilates Reformer, use the TRX or do 100 crunches per day? No!

The reason the core has become so weak is because our lives are very sedentary. Sitting for 60 hours per week at the desk and then trying to run for half an hour isn’t exactly going to balance things up.


Running with a weak core, exposes you to poor running postures and hence injuries. See the examples below:

320981_461218550600714_1728400353_n    Unknown

 Picture A                                         Picture B

The runner in Picture A has a poor running technique due to areas of weakness. As he is not strong in the right places, particularly the core, he drops his hip and pelvis out to the side, which makes his knee drop in towards the midline and he lands heavily on his foot. This will expose him to lower back, hip, knee or ankle injuries while running.

The runner in Picture B, the one and only Usain Bolt, has the most superior ability to activate his deep core while running which gives him the ultimate stability and alignment that makes him the world’s fastest runner. Check out the position of his spine in the picture above.


Common core exercises that won’t improve your running posture:

1. The Pilates reformer

During WW1, Joseph Pilates helped wounded soldiers lying in their hospital beds who were looking very weak. So, he rigged springs to hospital beds, so they could exercise against resistance to improve their strength. This was how the reformer was invented. It is fantastic for rehabilitation. However, it is not functional enough for runners. Instead, runners need to train their inner core in running based positions.

images Unknown-1

Above: Pictures of Joseph Pilates on the reformer. Notice the resemblance the reformer has to the hospital bed.


2. Crunches

How about crunches then? Being able to do 100 crunches doesn’t mean you have a strong core that will improve your running technique. It just means you have a six pack.


Where does that leave you then?

The layers of your trunk muscles are like an onion. There are deeper layers and there are outer layers. Each layer has a different function.

The outer layers:

  • Are what people commonly exercise when they do sit ups and weights at the gym.
  • Are fast twitch fibers which means they will switch on and off to give you power.

The inner layers:

  • Are what runners commonly don’t exercise
  • Are slow twitch fibers which means they should be switched on all day to hold you up.
  • Are the muscles that give you a strong inner framework. They are stability muscles that give you good alignment and posture.

images-1 images-2 Unknown-2 images-3

Picture far left: Your core muscles are like the layers of an onion, with outer layers and inner layers.

Picture second from left: Rectus Abdominis – the 6 pack muscle that sits in the outer core.

Picture second from right: Transverse Abdominis – the inner core muscle that gives you the stability and alignment you need to activate to improve your running.

Picture far right: A corset resembles where the inner core muscle runs. The inner core literally sucks your gut content in  and stabilises your spine, like a corset.


The benefits of having a strong inner core are that you will have a much more stable framework to move from. And this is how injuries will be prevented.

To activate the inner core, think of a low deep triangle that runs from hip to hip and down to your pubic bone. Try to shorten the triangle by 1cm. As you do, keep your outer core muscles relaxed. Get this checked with an expert Sports Physio!


 The big secret to improve your running posture

Once you know how to activate your inner core, maintaining its strength is best done in running based positions. If you want to learn a language it’s best to go to that country to immerse yourself in it. That’s functional. If you want to learn how to switch your deep core muscles on while you are running, then do so in running based positions. That is functional. That is the key.

Squats are one of the most functional exercises a runner needs to get right with the utmost control of the spine. You don’t even need to use much weight. If your spine is in good alignment then you are more than likely activating the deep core muscles that give you your stability. Keep your spine in neutral alignment as you squat, and make sure you don’t over extend or over flex the spine. (Best to get your technique checked with a Sports Physio).


The Core 101 wrap up

It’s not about doing loads of ab crunches or spending years on a reformer. To be a strong runner, strengthen up in running based positions! Get yourself to a Physiotonic class today to learn from the experts. 

Getting to the start line

Getting to the start line


The sea of runners starting off their race as all 100 000 of them charge down William Street, has become an iconic image. A race every Sydney sider wants to do at least once – the City2Surf.

The exuberant atmosphere makes the annual event addictive to participate in. From elite runners to weekend warriors competing for their personal best times, to families walking the arduous 14km, we all pass the dare devils doing the event in the guerilla outfit and the bands playing along the way. Who wouldn’t want to get involved? And boy, oh boy, is it frustrating when injuries hold you back from doing the race.

Runners are exposed to overuse injuries due to the repetition of the sport. Overuse injuries occur when the load placed on the body far exceeds what the body can handle. Imagine you have a pencil in your hands that you are trying to bend. As you apply a little bit of force, the pencil bends. But if you keep trying to bend it, eventually it will snap as the force through the pencil exceeds what the pencil can withstand. The same goes for your body. Your body can only reach a certain point before you get an overuse injury.

ImageCommon overuse injuries to runners can include stress fractures to the bone, shin splints, the dreaded ITB friction syndrome (see previous blog), wear and tear on the joints and cartilage (see previous blog) and knee cap tracking issues just to name a few.

The most common reason runners are exposed to overuse injuries is that runners just keep running, running, running, just keep running. What do sports like AFL, rugby union and netball have in common that running doesn’t?
These team sports have seasons. The players build up their fitness leading up to the season, play hard for the 14 week duration of the season, they then have at least 6 weeks completely off this sport. Sports exist in seasons to allow the body to rest and recover at the seasons’ end. This is the very reason why people participating in team sports are less likely to get overuse injuries.

Runners, on the otherhand, just keep running throughout the entire year.

It is not uncommon for us runners to get in the mindset of ‘I’ll just run a marathon every 2 months to keep up my marathon fitness’. We don’t factor in the idea of having running seasons. And this must be changed to prevent the notorious overuse injuries that runners so commonly experience.

Runners for your 3 hottest tips for preventing overuse injuries, here is what you need to do:

1. Plan your ‘macro’ cycle

This is your overall plan for the entire year. Develop running ‘seasons’ for yourself so you have periods in the year where you are doing other exercise. For example run through Winter to get yourself ready for the City2Surf or the Sydney Running Festival and train for some ocean swims in the Summer. This will allow you to load different parts of your body at varying times of the year, so no one structure or body part gets overloaded and therefore injured.


2. Plan you ‘micro’ cycle

This is your week to week plan. The average office worker should run no more than 3 times in the week, with each run being spread throughout the week and not on consecutive days. These 3 sessions should be varied within the week, with:
-one run being a shorter, faster run. This is where you can add in your sprints and hill sessions.
-another run at a medium length and moderate intensity
-and the third run should be a longer, slower paced run (how long will depend on what you are training for).


3. Stick to the 10% rule

Look at your training progressions and be disciplined with the 10% rule. You should only increase your training by a maximum of 10% each week. When you are just getting back into running, it can be tempting to start running everyday. Resist that temptation! Instead start with 2 shorter running sessions per week and slowly build up.


Adapt these hot tips to your running training schedule today to get yourself to the start of the race. Then immerse yourself in the electric vibe of the running festival.. just watch out for the guerilla outfit along the way!

Every runners nightmare – the dreaded ITB friction syndrome



With the major Sydney running festivals fast approaching, a very common overuse injury to try and avoid is the dreaded ITB friction syndrome. It’s like having the annoying feeling of trying to pay your credit card off – it takes a long time and it just keeps nagging at you.


What actually happens when this dreaded syndrome strikes?

The ITB is a long, thick tendon that runs along the outside of the thigh and knee. Its purpose is to give support to the knee. With repeated bending and straightening of the knee, the ITB and bursa rubs against the thigh bone (femur) on the side of the knee. This creates friction and irritation of the tendon and bursa. It’s just like having a blister, but under the skin.


Common causes

ITB friction syndrome is caused by a history of overuse and repeated mico-trauma. It can be a sign of fundamental training errors including:

  • A rapid increase in training
  • Excessive downhill running and running down stairs
  • Running on uneven surfaces

It is essential you look back through you training program with a fine tooth comb to assess changes to your training. You will then find that there is no coincidence that your training changes will have occurred at the same time your pain started. Therefore learn from your mistakes! And next time you want to increase your training, make the progressions smaller.


What do you feel if you have got it?

  • An ‘ache’ over the outside of the knee during and after runs
  • The pain may worsen to the point that you have to stop exercising and may limp after runs.
  • The side of your knee is particularly sore with walking/running downhill or going downstairs.


What you need to do about it

  • Rest: without appropriate rest the ITB will continue to be inflamed.
  • Training loads: need to be reduced. Reflect on your training program with your physio. Assess WHY this overuse injury started. Learn from your training errors, so in the future you make more informed progressions to training loads to ensure the ITB can adapt to the demands placed on it.
  • Reduce Inflammation: regular application of ice (20 minutes on, 1.5 hours off), will provide pain relief. Anti-inflammatories prescribed from your doctor may also assist.
  • Correct strength imbalances:
    • Get your quadriceps muscles stronger
    • Most importantly, improve the strength of your pelvic muscle stabilisers i.e. your buttock muscles, to reduce the load through the ITB. This is to help your knee track straight ahead when you run and not rotate in. This rotating in of the knee excessively loads up the ITB. See the pictures below – A is the correct alignment and B is the incorrect alignment. This can be improved – you just need to know the right exercises. That is what Physiotonic can help you with! Go to  http://www.physiotonic.com.au/what-we-work-on/gluteal-strengthening/ for more info.


  • Massage and stretching:

o   Stretching – you should be doing this regularly anyway, but if not.. get cracking! Stretch out your major muscle groups in the legs – gluts, calves, quads, hip flexors, hammies.

o   Massage and/or release trigger points down the affected leg. Get rolling on a foam roller daily.

  • Wear appropriate shoes for your foot type. Get advice from a sports podiatrist.
  • Other medical interventions:

 o   Injections: See your Sports Doctor for advice on a corticosteroid injection if the problem persists.

o   Surgery: to release the ITB may be necessary in the occasional case that fails to respond to the above measures. Further advice should be sought from an Orthopaedic surgeon who specializes in knee surgery. Physiotherapy rehabilitation is recommended post-surgery.


To help correct your muscle imbalances and prevent the dreaded ITB friction syndrome, enroll in a Physiotonic exercise class today. Visit www.physiotonic.com.au to get in touch with us. 


The worn and torn knee. And a blurb on osteoarthritis.

Unknown   Have you tried increasing your running lately, only to be frustrated by the fact that you have vague knee pain and that your knees keep swelling up? It’s most likely signs of general wear and tear through the joint. We have 2 types of cartilage in the knee;

  • Articular cartilage, which lines the end of bones in a joint.
  • Meniscus – which is unique to the knee joint and is designed to help absorb shock as we move about and run.

We are born with cartilage that looks like a brand new dance floor: clean, smooth and shiny. As you get degenerative changes, the surface starts to look like a cobble stone road: messy, rough and tarnished.


Over time, your cartilage cops wear and tear, particularly if you have loved high impact sports and lots of running in your life. Osteoarthritis is simply these degenerative changes. Like you can’t make an old T-shirt look new, these changes in the knee cannot be reversed. And, much to your surprise, even though osteoarthritis is riddled in our population… we…. don’t…. yet… have…a…cure. There is so much in medicine we just don’t know, and this one on osteoarthritis is one of the biggest enigma’s in medicine that is still remaining.

Currently the only curative treatment is a total knee replacement, of which the lifespan is about 20 years in Australia. Whilst you can achieve relatively normal function, you can’t place them under large stresses such as running because the replacement will fail.

There are a number of non-surgical options that are currently being trialled (steroid injections, hyaluronic acid injections, stem cell therapy, etc). Unfortunately all have failed to show any benefit over placebo.

The current best advice for anyone in the early stages of osteoarthritis is to lose weight and restore good muscle strength to prevent the worsening of the disease.

You will be pleased to know that there have been some recent, large clinical trials looking at the effects of running with osteoarthritis. Running isn’t a complete no, no. In fact doing some running, in moderation, keeps your bones really healthy and strong!

Physiotonic joins the blogging world

Physiotonic are expert Sports Physios who run group exercise classes to help improve your buttock muscle strength, deep core stability and flexibility. By doing our exercises we will help you improve your posture. We specifically focus on helping runners to achieve their goals – and with our exercises, our runners will get a stronger, more stable running body to help you run faster! Visit http://www.physiotonic.com.au for more information. 


Our blog will focus on running tips, information on injuries and injury prevention, and a myriad of health and fitness tips to help get you on your way. Sit back, relax and enjoy!