Alex Nicholson

Sleep Habits

Physios are often asked about the best position to sleep in, and what is the best mattress or pillow to use. Unsurprisingly, there is no one answer. However, sleep is obviously a crucial time to allow the body and mind to recuperate. Here are a couple of tips that I often advise.

dog upside down

In patients with low back pain, especially if it is one sided and referring into the leg, I advise them to sleep with their sore side up and a pillow/s between the knee to unload the spine. This also works very well for hip pain, particularly bursitis, as it removes the tension of the leg from the hip.

Mattresses are often a great source of contention. The main advice that I give to patients is to make sure they feel comfortable and supported and check that they are not waking up in a valley in the morning! This would indicate that it may be time for a new mattress. This is where you need to have a trade-off between feeling comfortable but also supported. When patients are deliberating between a slightly softer or firmer mattress I generally recommend the firmer mattress as they tend to soften over time anyway.


When it comes to neck pain and pillows, I advise patients to select a pillow that maintains a neutral neck position. If you are unsure of what a neutral position is then you may want to consult your physio. The pillow chosen will vary depending on whether the person is a stomach/back/side sleeper, but it will also vary based on the person’s size and natural spinal curvature.

In general, side sleepers will probably need a high profile pillow, whereas back sleepers will likely only need a low profile pillow or sometimes no pillow at all (or a rolled up towel behind the neck).

When a patient is suffering from acute neck pain and finding it difficult to find a position of comfort, I generally recommend lying on your back with a McKenzie cervical roll under the neck. This usually keeps the neck in a minimally stressful position. If the patient also has associated arm pain, then I may advise them to have a pillow under their arm to support it and take the weight of the arm off the neck.

De Quervain’s and other Thumb Problems


De Quervain’s refers to a problem involving two of the thumb tendons. It is a common condition affecting new mothers and also office and manual workers (including physios!). In recent times, De Quervain’s has also become prevalent from excessive texting on mobile phones and is sometimes referred to as Blackberry Thumb, iPod Thumb,  or Texting Thumb. Pain normally presents around the base of the thumb and/or the wrist. It is caused by overuse of the thumb tendons from either repetitive or sustained wrist deviation. New mothers often suffer from it due to holding their wrist in awkward positions for long periods of time whilst nursing their baby.

De Quervain’s can often be avoided by correcting wrist position to a more neutral position and by breaking up sustained or repetitive movement patterns. For new mothers, rest or avoiding certain wrist positions may not be practical and in that case, a brace may help to spread the load and reduce the likelihood of developing a De Quervain’s injury

Diagnosis of De Quervain’s is based on the location of pain, provocative activities/tests, such as the Finkelstein Test, and possibly also an ultrasound (although this is often not necessary). The two tendons involved are the extensor pollicus brevis and abductor pollicus longs. They may become irritated, inflamed, thickened or swollen.

DQ injection

Treatment varies depending on the severity of the condition. Anti-inflammatories or a cortisone injection may be recommended early on to settle down the pain. Other treatments include ice, bracing, shockwave therapy, dry needling and massage. However, the most important component of treatment for a tendon injury is strengthening exercises.

Strengthening exercises are usually essential in restoring normal thumb and wrist function. Even if the pain settles with other therapies, if the tendons are still weak they are vulnerable to re-injury. These exercises need to be prescribed by a physiotherapist so that they are matched to the current status of your De Quervain’s injury.

DQ skier

Other common thumb injuries include Skier’s thumb and osteoarthritis of the base of the thumb. Skier’s thumb results from the thumb being pulled back too far, causing one or more the thumb ligaments to tear. This injury needs to be assessed and graded by a qualified physiotherapist. Usually bracing is necessary to ensure that the ligament heals to its correct length. Occasionally, surgical intervention is required if the injury is more severe, involving the volar plate. If it is not managed properly there may be an increased risk of developing thumb osteoarthritis.

For more information, contact your physiotherapist.

Shin Splints



What are shin splints?

Shin splints is a general term used to describe pain in the shin (usually the front or inside) and is a common problem in runners. Physiotherapists refer to shin splints as medial tibial stress syndrome (MTSS) as the pain most commonly occurs along the inside border of the shin bone (tibia) and is the result of overuse which causes inflammation of the bone and/or muscle in that region.

Diagnosis of shin splints

The severity of MTSS is quite variable. A low grade injury usually means that the main problem is muscle tightness or inflammation and this should settle relatively quickly with the appropriate treatment.

  1. Key signs and symptoms of a low grade injury are:
  • A history of impact loading (e.g. running) and usually a rapid increase
  • Tenderness along a large portion the shin bone or muscle
  • Pain improves after warming up (e.g. a few minutes into a run)
  • Pain generally does not return after cooling down
  1. A high grade injury refers to the presence of a stress fracture (a small crack or severe bruising in the bone) and in this case, rest from high impact exercise is essential (usually for several months). Whilst uncommon, if MTSS continues to be abused, it is possible for the stress fracture to turn into a complete fracture! It is therefore crucial to consult a qualified physiotherapist early to get an accurate diagnosis as this will dictate what the appropriate treatment is and stop your injury from progressing to a stress fracture.
  1. Key signs and symptoms of a higher grade injury are:
  • Tenderness over smaller, specific point/s of the shin and possibly a lump
  • Night pain e.g. throbbing or aching of the shin when in bed
  • Pain at rest or with simple weight bearing and poor tolerance to light impact activity


The cause of MTSS can be many things, but the most common factor is overload of the muscles/shin through training errors. For example, training for a marathon and increasing running distance and frequency too quickly which does not allow enough time for recovery and adaptation of the bone and muscle to the training stimulus. Training speed, frequency, duration, surface (e.g. grass vs concrete), and footwear, all contribute to the amount of load experienced by the bone and muscles around your shin. It’s a sensible idea to talk to an experienced physiotherapist or running coach about how to plan out and manage your training loads so as to avoid overloading your legs, particularly if you are new to running. Another good idea is to have your running screened. This involves a series of tests of your strength, endurance, balance and flexibility, as well as filming your running technique. Based on the findings of the screening, corrective exercises can be prescribed to minimise the risk of you developing problems from running.

Are radiological investigations necessary?

Patients often ask about whether an X-ray or scan is appropriate to investigate the severity of their MTSS. I generally do not recommend getting scans in the early stage as it normally settles with appropriate physiotherapy management and the results of scans do not change the treatment approach if you have been assessed by an experienced physiotherapist. The best way to manage MTSS is based on signs and symptoms anyway. However, in cases where the diagnosis is unclear or in patients who are very anxious or time constrained (e.g. building up to a Marathon), I often recommend an MRI as this does not expose the patient to any radiation and is quite sensitive for picking up the problem.

I think I have MTSS, what should I do!?

Treatment of MTSS depends on the underlying causes identified by your physiotherapist. For example, it may be determined that muscles around the hip are weak and causing the calf to overload. Therefore, strengthening and stability exercises would be the most important rehabilitation strategy. Another person may have excessive calf muscle tightness (from increasing their running distance too quickly) and this is causing compression and inflammation of the bone and tendons in the shin. In this case, loosening the muscles around the calf will relieve the tension and therefore the patient’s pain. This could be achieved through massage but I find dry needling to be far more effective.



So in summary, MTSS refers to pain in the front or inside of the shin and is the result of overloading of the bone or muscles in that region. Catching it early is important to prevent it progressing to a more serious grading of injury which requires complete rest from high impact activity such as running. A graduated running program and screening for biomechanical deficiencies (e.g. weakness, joint or muscle tightness) are good ways to reduce the risk of developing this common problem.

However, if you do suffer from MTSS, there are treatment options available to settle your condition and keep or return you back to running as soon as possible. For more advice or information, contact an experienced physiotherapist.

Headaches – understanding cause, triggers and treatment

Many people think that if they don’t have any pain in their neck then their headache is coming from elsewhere. However, the reality is that most headaches arise as a result of stiffness in the joints in the upper neck. When these joints get excessively stiff, they can refer pain into different parts of the head. Still sceptical?

If your headache is coming from your neck then skilled palpation (touching) of the neck joints and the overlying muscles by your physiotherapist will reveal whether your neck is the culprit by reproducing your headache.

For some people this is a little unnerving at first. However, it is a good thing if your headache symptoms are reproduced, as this then becomes the method for relieving your symptoms and confirms your neck as being the root of the problem.

Sustained pressure on the tight joints/muscles should cause a reduction in intensity of your headache as the tissue starts to release. Dry needling is another technique useful for settling down tightness. Once the joints responsible for the headache have been loosened you’re on your way to recovery.

Patients commonly report alcohol, hormonal changes, tiredness and stress as triggers preceding a headache. In terms of understanding the interaction between these triggers and the onset of a headache you need to understand that stimuli in the neck and the brain combine together to set your total level of sensitisation.

Think about it like a glass of water. If that glass is empty or minimally filled then you do not experience a headache. If the glass overflows with water then that level of sensitisation causes a headache. So the key therefore is how to stop the glass from overflowing. Stress, tiredness and hormonal changes are largely out of our control. But what if we consider neck stiffness as a trigger (even though you may not feel stiff in your neck)?

We can control our neck stiffness to a large extent through treatment, posture and exercise. So, if we keep the neck loose and empty the glass of water as much as possible then we can avoid teetering on the verge of overflowing the glass and causing a headache. If the glass is near or close to empty then it will take a big stimulus to tip it into overflow.

If headaches are impacting on your life, talk to your Physio about how to manage them or contact the team at Sydney Physiotherapy Solutions at either our Sydney CBD physio clinics or our new Chatswood Physiotherapy clinic.