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What Was the Study About?

Tibial stress fractures (TSFs) are common overuse injuries in runners. They happen when repeated force on the shinbone causes tiny cracks that outpace the body’s ability to repair them. Many clinicians and coaches think that the way someone runs – their biomechanics – might influence who gets these injuries. This 2023 review study set out to find out whether runners with TSFs really move differently from runners without them.

How Did They Study It?

The authors searched major research databases for studies that compared running mechanics between injured runners and healthy controls. They found 359 possible papers, but only 14 met strict criteria for analysis. Most of these studies were retrospective (looking back at runners after injury) and had small sample sizes- so as always, more research that prospective and more controlled would be nice!

What Did They Find?

When all the data were combined:

  • There were no significant differences in ground reaction forces between runners with TSFs and uninjured runners. In other words, impact and braking forces were similar in both groups.

Some individual studies did find differences in variables like tibial stress, tibial acceleration, rearfoot motion, or hip movement, but these findings were not consistent across studies.

What Does This Mean?

Based on the best available evidence:

  • We can’t confidently say that runners with tibial stress fractures have a distinct running biomechanics profile.
  • Current studies are too small and too varied to draw strong conclusions.
  • Larger, better‑designed research is needed to clarify whether specific movement patterns truly increase the risk of TSFs.
  • In the meantime- stick with the things we KNOW related to printing stress fractures:
    • Adequate caloric intake
    • Vitamin D supplementation
    • Adequate calcium intake
    • Strength work
    • Being smart with your training load- building slowly, taking recovery days and weeks strategically

If you have any questions about pain you’ve been feeling- feel free to contact our Waterloo based chiropractors, physiotherapists or book online HERE.

By Dr. Sean Delanghe BSc (Hans), DC

Anybody who has had plantar fasciitis knows how annoying and painful it can be. A common treatment we see out there is the use of therapeutic ultrasound- but does it actually help? That’s what this 2025 meta analysis looked at.

Plantar fasciitis is a common cause of heel pain that is often associated with overuse, repetitive loading, and biomechanical factors. The attachment at the heal biomes irritated, and the pain can sometimes be debilitating – especially in the mornings!

The authors performed a meta-analysis of 13 clinical trials including 594 participants. The main outcomes of interest were pain intensity and foot function. Pain was measured using visual analog and numeric pain scales, while function was assessed using the Foot Function Index (FFI) and the American Orthopaedic Foot and Ankle Society (AOFAS) score.

Key Findings

Pain intensity

  • Ultrasound alone did not show a statistically significant improvement in pain compared with no treatment.
  • Adding ultrasound to conventional physical exercise programs did not provide additional pain relief compared with exercise alone.
  • When ultrasound plus exercise was compared with other interventions combined with exercise, some statistically significant differences were observed, but these generally favoured the other treatment groups.

In general, the authors concluded that ultrasound is not reliable as a primary modality for reducing plantar fasciitis pain.

Foot function

  • Ultrasound combined with exercise may provide small improvements in foot function when measured using the Foot Function Index.
  • Results were inconsistent across functional outcome measures.
  • There was no statistically significant difference in AOFAS scores between treatment groups in some analyses.

Mechanism of Action Discussion

The authors discussed potential biological effects of ultrasound therapy. Ultrasound may promote tissue healing through both thermal and non-thermal mechanisms. Thermal effects may improve local blood circulation, while non-thermal effects such as cavitation and micromassage may influence cellular activity and inflammation.

However, the heat generated by therapeutic ultrasound may not be sufficient to produce meaningful clinical effects in plantar fascia tissue over short treatment periods. Low-intensity pulsed ultrasound has been studied in other conditions and may have anti-inflammatory and tissue repair effects, but evidence in plantar fasciitis remains limited.

Plus- how much better is any of this than just applying a heating pad and loading the tissue with exercise?

Limitations

As with most research for muscle and joint pain, more research is always needed!

  • Only 13 studies were included, and high-quality randomized controlled trials were limited.
  • There was significant variation in ultrasound treatment parameters such as frequency, intensity, and treatment duration.
  • Many of the trials were many years (and decades) old!

Practical Applications

Therapeutic ultrasound, whether used alone or combined with conventional exercise programs, does not appear to provide meaningful pain reduction in plantar fasciitis. Ultrasound may have a small positive effect on foot function, but the clinical significance of this finding is uncertain. More high-quality randomized trials are needed…but if I had to bet, it’s likely just a waste of time trying it when strengthening and progressive loading is so much more effective and important!

If you have plantar fasciitis and have questions about how to fix it, feel free to contact one of our Waterloo-based physiotherapists or chiropractors HERE.


What is costochondritis?
Costochondritis is inflammation of the cartilage where the ribs attach to the sternum. It causes localized chest wall pain that can mimic heart-related pain but is not caused by cardiac disease. This summary takes an in-depth look at the most up to date research regarding this condition.

It is considered one of the more common musculoskeletal causes of chest pain and may account for up to about 30 percent of noncardiac chest pain cases seen in some clinical settings.

Clinical presentation
-Pain is usually localized and reproducible with palpation over the affected costosternal or costochondral joints.
-The pain may be sharp or aching.
– Symptoms often worsen with movement, deep breathing, or pressure on the chest wall.
– There is usually no visible swelling, redness, or systemic symptoms such as fever.

Diagnosis
– There is no specific laboratory test or imaging study that confirms costochondritis.
– Diagnosis is clinical and based primarily on history and physical examination.
– A key diagnostic feature is reproduction of pain with palpation of the anterior chest wall.
– Cardiac and other serious causes must first be excluded, especially in higher-risk patients.

Management
– Initial treatment is conservative and may include:
Analgesics such as acetaminophen and Nonsteroidal anti-inflammatory drugs (talk do your doctor!)
– Relative rest and activity modification is key. Complete rest isn’t good, but continuing with the activities that aggravate the condition do not allow for it heal!

Physiotherapy is also a crucial part of the management of this condition. Some examples include:

  • Stretching and mobility exercises
    These focus on improving chest wall and thoracic spine mobility.
    • Examples include:
      Pectoral stretching, such as doorway stretches
      Thoracic extension and mobility exercises
      Breathing-based mobility drills to reduce rib cage stiffness
  • Manual therapy
    • Performed by trained clinicians, this may include:
    • Soft tissue mobilization of the chest wall and surrounding musculature
    • Joint mobilization of the ribs and thoracic spine
    • Trigger point release and myofascial techniques
    • Rib mobilization techniques to normalize movement

Some small clinical studies and case series suggest that combining manual therapy with therapeutic exercise can reduce pain and improve function the most, but as always more research is needed!

Main takeaway
Costochondritis is an important and relatively common cause of noncardiac chest pain. It is diagnosed clinically after ruling out more serious co

nditions. Management is usually conservative and may include medication, rest, and targeted physical therapy interventions aimed at improving chest wall mobility, posture, and muscle function.

If you have questions about your pain, feel free to contact one of our Waterloo based chiropractors or physiotherapists, or book online HERE.

I’ve written about it before, but it’s time for another update! Sure, running can be linked to short and moderate term problems like tendonitis, but what about longterm wearing out of your joints even if you do everything right? That’s what THIS 2023 systematic review looked at.

The Study
This study is a systematic review, meaning the authors collected, analyzed and combined results from many of the previous highest quality studies looking at runners and non-runners to see whether running affects the development of knee osteoarthritis (OA). The review included 17 studies with over 14,000 participants. Knee health was assessed using imaging (such as X-rays or MRI) and patient-reported outcomes like pain and function.

Key results:
– Knee pain was reported more often in non-runners than in runners.
– Most studies found no meaningful differences in structural knee osteoarthritis (such as joint space narrowing or OA severity on imaging) between runners and non-runners.
– One study reported more bone spurs (osteophytes) in runners, but this finding was not consistent across other studies.
– Some evidence suggested that non-runners had a higher risk of needing knee replacement surgery than runners.

Practical Applications:

Our bodies are meant to move! This review shows that running does not appear to increase the risk of developing knee osteoarthritis. Running was not associated with worse imaging findings and may be linked to less overall knee pain compared to not running.

That doesn’t mean runners will not develop OA, but it does mean that odds are running is not to blame if it does. It also shows that there’s a chance that running helps to reduce general pain and reduce the odds of needing replacement down the road.

There are obviously many caveats to this- such as if you currently have severe OA it’s probably not a good time to start running. Talk to your health practitioner about of this research applies to you. However, what this review does tell us is the blanket statement of “running wears out knees” simply isn’t true!

If you have more questions, feel free to contact us HERE.

It can be a scary thing when you rupture your Achilles tendon! Yes recovery can be a long process, but virtually full recovery is possible in many case. The interesting thing that many don’t realize however is that OFTEN rehab is just as good as surgery– which is something this 2019 review study looked at.

Objective

The aim of this systematic review and meta-analysis was to compare operative and nonoperative treatments for acute Achilles tendon rupture. The authors focused on differences in tendon re-rupture rates, complication rates, return to work, and functional recovery between treatment approaches.

Study Design

The authors searched several medical databases to identify randomized controlled trials comparing surgical and nonoperative management of acute Achilles tendon rupture.

  • Fourteen randomized controlled trials were included, representing a total of 1,628 patients.
  • The average follow-up period across studies ranged from 6 months to over 2 years.
  • Outcomes analyzed included re-rupture rates, overall complication rates, Achilles Tendon Total Rupture Score (ATRS), ankle range of motion, and time to return to work.

This was a well designed study!

Results


• The overall re-rupture rate was significantly lower in the open surgical group compared to the nonoperative group, with re-rupture occurring in approximately 1 to 3 percent of surgically treated patients versus about 6 to 12 percent of nonoperatively treated patients.
• Minimally invasive surgical repair also showed a lower re-rupture rate than nonoperative treatment, with re-rupture rates closer to those seen with open surgery.
• Open surgical repair was associated with a higher rate of complications, with overall complication rates reported between 10 and 20 percent, including wound infection, delayed healing, and nerve injury.
• Nonoperative treatment showed lower rates of these surgical complications, generally below 5 percent.
• Minimally invasive surgery demonstrated complication rates similar to nonoperative treatment and lower than open surgery.
• Functional outcomes, including ATRS scores, showed no statistically significant difference between operative and nonoperative groups at final follow-up, with most studies reporting ATRS scores in the range of 80 to 90 points for both groups.
• Measures of ankle range of motion and calf strength were also similar between groups.
• Patients treated with minimally invasive surgery returned to work earlier, on average 1 to 3 weeks sooner, compared to those treated nonoperatively.

How does this apply to you?

This review found that surgical treatment of acute Achilles tendon rupture reduces the risk of tendon re-rupture compared with nonoperative management but increases the risk of complications, particularly with open surgery. Minimally invasive surgical techniques appear to balance lower re-rupture rates with fewer complications and may allow an earlier return to work.

That being said, long-term functional outcomes were similar between surgical and nonoperative treatments, suggesting that both approaches can lead to comparable recovery when appropriate rehabilitation is provided.

So this isn’t a one-option fits all treatment. Do you have a daily life that puts you at risk for re-rupture? Do you have a less active/ risky lifestyle with a high need to get back to work ASAP? These are the types of questions you want to ask yourself when making the choice that’s right for you.

If you have more questions or you want to book with one of our physiotherapists based in Waterloo, you can do so HERE.

This article examined whether dry needling (DN) is effective for treating plantar fasciitis (PF), a common cause of heel pain. Dry needling involves inserting thin needles into muscle trigger points wth a goal reduce pain and improve movement.

This is not meant to replace more important strategies like load management, strengthening/ rehab etc. But is it actually a useful adjunct to these better supported potions?

Methods

The authors conducted a systematic review and meta-analysis of previously published research.

Major research databases were searched (PubMed, Embase, Web of Science, etc.), and only randomized controlled trials (RCTs) were included.

Study sample

  • 12 RCTs
  • 781 total participants
  • Comparisons included:
    • Dry needling plus routine care (stretching, massage, exercise)
    • Dry needling alone
    • Other conservative treatments without dry needling

Key Findings

Pain Reduction

Dry needling combined with routine treatment resulted in significantly lower heel pain compared to routine treatment alone. Pain was measured using standard tools such as the Visual Analog Scale (VAS) and Numeric Pain Rating Scale (NPRS).

Mean pain score reduction ranged from −1.76 to −2.12 points, which represents a moderate to large clinically meaningful improvement.

Dry needling alone was not consistently superior to other conservative treatments for pain relief- so you still have to do the other stuff!

Functional Improvement

Dry needling combined with routine care led to significant improvements in foot function (measured with the Foot Function Index), and dry needling alone also showed better functional outcomes than other conservative treatments. This suggests dry needling may improve a patient’s ability to walk, stand, and perform daily activities, even when pain reduction is limited.

Timing of Benefits

Improvements were more consistent after one month. Short-term results (less than one month) were mixed, suggesting dry needling is more effective as a medium-term intervention rather than an immediate solution.

Safety and Side Effects

About 50% of the included studies reported minor side effects, most commonly temporary soreness, mild bruising, or minor bleeding at the needle site. No serious adverse events were reported.

Overall Conclusion

Dry needling appears to be a safe and effective treatment option for plantar fasciitis, particularly when combined with routine conservative care, used for at least one month, and aimed at improving both pain and foot function. However, the authors note that study quality varied, sample sizes were relatively small, and more high-quality randomized controlled trials are needed before strong clinical recommendations can be made.

If you have more questions about this therapy, or would like to try it, please contact us or book online HERE!

Today we’re looking at a systematic review that looked at strength training and its impact on adolescent idiopathic scoliosis- you can check out the full text HERE.

AIS is the form of scoliosis that develops in otherwise healthy teenagers for no obvious reason and is thought to have a genetic component, although no single genetic cause has been identified. It differs from scoliosis caused by congenital spine malformations, neuromuscular disorders, or age-related degeneration (we re not talking about these with this study). Scoliosis is defined as a lateral spinal curvature of 10° or more on Cobb angle measurement with vertebral rotation- and the vast majority of cases are AIS (80%)!

Sudy:
The authors analyzed data from 10 randomized controlled trials involving 449 adolescents (average age ~13.3 years, average baseline Cobb angle ~22.9°). Interventions ranged from 8 weeks to 6 months and compared strength training programs to no training or other exercise regimens.

Results
Compared with no intervention, strength training produced:

  • A mean reduction in Cobb angle of about 4.37° and improvements in trunk rotation (–1.07°) and vertebral rotation (–0.44°).
  • In quality of life as measured by the SRS‑22 questionnaire, mean scores improved by about 0.22 points.

When compared against exercise programs specifically designed for scoliosis correction, such as three-dimensional and Schroth-type exercises, strength training was less effective: the scoliosis-specific programs produced greater improvements in Cobb angle by about 3.95°, trunk rotation by about 1.69°, and aesthetic scores by about 0.89.

These findings indicate that while strength training has measurable benefits beyond inactivity, more targeted scoliosis-specific programs may achieve larger changes.

Practical applications
If you have AIS, do strength work! The data suggest strength training can moderately reduce curvature and improve patient-reported outcomes compared to no intervention, but it may not be as effective as specialized corrective exercise programs.

Surgery and risk of progression

I always get asked about surgery, when and if it is needed. Surgical intervention for AIS is generally considered when curves exceed approximately 45°–50° Cobb angle, especially if progression is likely or rapid while the patient is still growing. If you’re not close to this angle, you should be actively monitored as you grow, but you are not at risk for needing the surgery!

After skeletal maturity, when growth plates close and height velocity ceases, the risk of curve progression decreases substantially. Sometimes larger curves (>30°–40°) may still progress slowly into adulthood, but the main group we are concerned with are those who are still growing! If you have a relatively small angle and you are full grown, your risk of progression is extremely low (but you should still do strength work)!

Conclusion
Strength training can be beneficial for adolescents with mild to moderate AIS in reducing curve magnitude and improving quality of life compared to inactivity- you can’t go wrong with strengthening your spine!

If you have questions, feel free to contact with us to book online HERE.

IT band syndrome is a common condition that causes pain on the outside of the knee. This 2024 review article updates the current understanding of iliotibial band syndrome (ITBS).

Diagnosis
ITBS usually appears during repetitive activities and tends to worsen the longer someone runs or cycles. Clinical tests exist but have limited reliability.

Some key features:
• Pain develops on the outer knee after a period of running or cycling.
• Often described as sharp, burning, or increasing over time.
• Tests such as the Noble and Ober tests are inconsistent (orthopaedic physical exam tests).
• MRI is typically unnecessary; diagnosis relies mainly on symptoms and history.

Risk Factors
ITBS develops through a combination of anatomical structure, muscle function, and training habits.

• Older theory suggested the IT band rubbed over the thigh bone.
• Newer evidence shows the IT band does not slide very much.
• Pain is likely due to compression of fat and nerve-rich tissue beneath the band at about 30 degrees of knee bend.

Things we can’t change:
• Anatomical features such as leg alignment or prominent bone structure. This includes natural variations like being slightly knock-kneed or bow-legged, having a more pronounced lateral femoral epicondyle (the outer knee bone), or having tighter fascia around the thigh.

Things we can change:
• Weak hip muscles, especially hip abductors and gluteal muscles, which can allow the knee to drift inward during running.
• Training errors such as sudden increases in mileage or frequency.
• A large trial showed similar ITBS rates whether runners increased volume or intensity, suggesting rapid changes are the main issue.

Treatment
Treatment centers on reducing irritation, improving strength, and retraining movement patterns. Functional rehab generally works the best!
• Temporarily reduce or modify painful activities in the short term.
• Strengthen hip abductors, gluteus maximus, and stabilizing muscles- has been proven to be one of the best approaches!
• Include balance, single-leg control, and running-specific movement retraining + slowly easing back into the sport that generated the pain.
• Shockwave therapy may help when exercise alone is not enough- something worth considering if you have a stubborn case.
• Steroid injections and surgery have weaker evidence and are used rarely

Research Gaps
While the understanding of ITBS has improved, more consistent and higher-quality research is needed to determine the best treatment strategies.

Some flaws:
• Research methods vary widely between studies- it’s hard to compare them because of how differently they were conducted.
• Limited high-quality trials on specific rehab programs- which exercises are best? We don’t really know.
• More comparison studies are needed for conservative and non-conservative treatments.

Take-Home Message:
• ITBS is mainly driven by compression, not friction
• Outer-knee pain increases with repetitive activity
• Hip weakness and rapid training increases are major contributors
• Best treatment involves structured rehab focusing on strength and movement control
• Shockwave therapy can help in tougher cases
• More research is needed to refine and compare treatment approaches

If you have IT band syndrome and have more questions, for out chiropractors or physiotherapists, feel free to contact us or book online HERE.

Does spinal manipulation actually help with acute neck pain? A recent systematic review and meta-analysis took a look HERE.

Acute neck pain , meaning neck pain that lasts less than three months, is very common and can lead to disability or persistent problems. The authors wanted to investigate how effective and safe SMT is specifically for acute neck pain, since previous reviews often mixed acute, sub-acute, and chronic cases, which makes interpretation difficult.

Methods
The researchers searched several major databases (PubMed, Embase, Web of Science, PEDro, Cochrane) up to March 20, 2023, for randomized controlled trials (RCTs) involving SMT versus control in adults with acute neck pain lasting less than 3 months. Outcomes of interest were pain intensity, cervical range of motion, and disability. They included 8 RCTs, with a total of 965 patients.

Key Findings

  • Pain: SMT significantly reduced pain compared to controls (mean difference 1.53 points lower on the pain scale, 95% CI 0.83 to 2.22)
  • Cervical range of motion: SMT improved neck movement in all directions (flexion, extension, rotation, lateral flexion). Flexion improved by a mean of 11 degrees (95% CI 9.10 to 12.93)
  • Disability: Patients receiving SMT had lower disability scores than controls (mean difference 6.20, 95% CI 2.59 to 9.81)
  • Safety: No serious adverse events were reported. One patient had a mild, transient arm sensation episode after SMT

Clinical Implications
Despite limitations (small sample sizes in some cases, dose/response not established), the review suggests SMT can be an effective and safe option for acute neck pain: it reduces pain, improves neck movement, and lowers disability in the short term. SMT is best considered alongside other treatments, such as exercise and education.

This study is a good start, but more research is required to determine which patients benefit most, how much and how often it should be performed, and which SMT techniques work best.

If you suffer from neck pain, or have more questions about this study, feel free to contact us HERE.

What the study is about

A January 2025 article published in the Journal of Clinical Medicine examined lateral elbow tendinopathy, also known as tennis elbow, which causes pain on the outside of the elbow and often affects adults between ages 35 and 50. When rest and physiotherapy don’t help, doctors sometimes use injections. The researchers compared four options: Platelet-Rich Plasma (PRP), corticosteroids, hyaluronic acid (HA), and saline to see which reduced pain and improved function the most over one year.

How the study was done

The study included 60 adults who had tennis elbow for at least three months without improvement. They were randomly placed into one of the four injection groups and each received a single injection. All patients followed the same stretching and strengthening program afterward. They were tested before treatment and again at 1, 4, 12, 24, and 52 weeks, measuring pain, arm function, and muscle strength. The researchers originally planned for 120 patients but were only able to enroll 60.

What the study found

  • All four groups improved over time in pain, strength, and function.
  • After one year, results were very similar across all injection types.
  • Corticosteroids reduced pain faster in the first few weeks.
  • PRP, HA, corticosteroids, and saline showed no major long-term differences.
  • Some patients in the PRP and saline groups had short-term pain increases.
  • No serious side effects were reported.

What this means

The results suggest that while these injections can help tennis elbow, none clearly outperformed the others in the long run. Corticosteroids worked faster early on, but one-year outcomes were similar to the other treatments, including saline. Since PRP and HA are more expensive, the findings raise questions about whether they are worth the cost. And in general, since non out-preformed saline, your best bet is likely to avoid injection all together and continue with rehab exercises and being patient- these things take time!

If you have more questions, feel free to book online or contact us HERE.

By: Dr. Sean Delanghe BSc (Hons) DC

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