Injury recovery

LEA – Low Energy Availability

Written by: Caitlin Sargent

What is Low Energy Availability?

Research is coming to understand more and more about Low Energy Availability (LEA) and its wide-ranging implications on almost all systems of the body. Physiotherapists are well placed to help pick up on these signs to assist in early intervention. As with most conditions, prevention is better than a cure and the earlier treatment starts the better. So what is LEA?

Energy availability is very self-descriptive! It is measured using the equation below

Energy intake (ie food) – energy expenditure (exercise + energy needed for daily life) = energy availability

How can it present?

If there is inadequate energy intake for the activity being undertaken, then energy availability will be low which can have a number of consequences. These can include:

  • Poor immune function
  • Gastrointestinal dysfunction (including increased gut sensitivity)
  • Poor bone health/reduce bone mass
  • Endocrine/thyroid dysfunction
  • Menstrual dysfunction
  • Impacts on growth and development (in younger athletes)
  • Cardiovascular anomalies

As a physiotherapist, we may see:

  • Increased injury rate
  • Poor sleep and recovery, extreme fatigue
  • Decreased co-ordination
  • Irritability, depression or decreased concentration
  • Decreased muscle strength and endurance performance
  • Decreased training response

The science

While this is an evolving area of research, some recent studies suggest that up to 45% of recreational athletes and up to 80% or elite athletes either have or are at risk of LEA. In a sporting context, it is also referred to as relative energy deficiency in sport (RED-S).

It is relevant to note, that while disordered eating can play a role, many people are not purposely restricting their food intake. The combination of heavy training causing appetite suppression and underestimating the caloric demands of life + training is a factor in the high incidence of LEA.

Treatment for LEA/RED-S is usually led by a dietician (+/- psychologist if needed) and consists of fuelling strategies and modified activity until baseline health functions return. Physiotherapists can help play an important role in identifying LEA and managing graduated return to exercise/training.


The Thoracic Ring Approach as incorporated in the Barefoot Physiotherapy Plan

At Barefoot Physiotherapy we utilise techniques from multiple learnings all combined into our unique Barefoot Physiotherapy Plan. These techniques include; LJ Lee’s training in The Thoracic Ring Approach™all of our Bachelor/Masters degrees, Mulligan, Maitland and Ridgway Methods, Western Acupuncture, Dry Needling, and Pain Science/Graded Motor Imagery. We are continually learning and evolving our Framework and an essential part of it is the Thoracic Ring training we have had.

The Thoracic Ring Approach™ is an innovative assessment and treatment technique for the body (treating through the thorax – which is the middle of the back and ribs) based on a broader understanding of how these areas are designed to function optimally. It fits well within our framework of seeing the body as a whole and in the context of whole body movement and optimal health of the whole person.

What is a Thoracic Ring?

A Thoracic ring is the 2 vertebrae and the ribs attached. For example the T4-5 vertebral segment (including disc) and ribs 5 on left and right.




How do you know if the Thoracic Rings are ‘The Driver’?

With the assessment of multiple rings and treatment techniques for them we can facilitate optimal biomechanics and replicate ideal motor control for the Thorax while hands on. If this facilitation/correction improves movements/meaningful tasks we can know that this is a significant area of the body (and potentially a Driver further through the body). We combine this information with the rest of our Clinical Reasoning in our Barefoot Physiotherapy Plan to determine whether the Rings are a true underlying factor of the clients problem (ie the reason they are seeing a physio!). As the LJ Institute states: “The reason this is essential is that it is common for the thorax to be relatively pain-free but dysfunctional; the dysfunctional thorax creates adverse stresses, loads and forces that can cause pain in any other area of the body.”

Treatment of The Thoracic Rings

When we move well we feel good and we move more. But the catch 22 is that we need to have the body feel good enough to move. Our treatment framework is based on getting the body moving through hands on treatment initially and teaching people how to move well – whatever that is for them! This dynamic view of the body means that an essential component of treatment is training optimal muscle activation patterns and muscle balance around the thoracic rings if they are a Driver. Manual techniques, taping, needling and self-release techniques such as “self stack and breathe” are used to treat Thoracic Rings if we have found them to be Drivers or significant in the clients body. What this does is release non-optimal muscle patterns to create a window of opportunity to train new muscle patterns.




If you are interested in seeing a Barefoot Physio trained in Thoracic Ring Approach please call 1300 842 850 or book online by Clicking Here


Physio protectometer

Neuroplasticity introduction

Written by Catherine Mullins

What is Neuroplasticity?

Neuroplasticity is the lifelong ability of the brain to undergo structural and functional changes in response to experiences. The medical world once thought that the brain stops developing in childhood but we now know that ongoing changes occur right up until death.

Information in the brain is transmitted from neuron to neuron via synapses (spaces). This is done through action potentials sending electrical signals along the neurons causing neurotransmitters (chemicals) to be released across synapses, attaching to the next neuron and continuing the process. Each synapse (space) can be linked to multiple neurons, therefore receiving information from a variety of sources. Neuroplasticity looks at the changes that can be made between neurons and synapses.

How does it change

Change can occur through the strengthening of existing connections, elimination of existing connections, or forming of completely new connections. Neuroplasticity is a huge component of rehabilitation following damage from strokes etc but it also very useful in recovering from acute injuries (eg changing balance and reaction times) or from chronic pain (changing movement strategies and functional capacity).

Not all neuroplastic changes are beneficial. Sensitisation of the nervous system can occur with strong or continuous stimulation, release of chemical mediators or by activation of the neuroimmune system.  This can negatively impact the firing of neurons by decreasing the amount of input needed to fire (reduced threshold) or increasing the reaction to a normal level of input (increased responsiveness). This means that things will start to cause a response at a much lower level of input, or with an exaggerated response.  I often use the analogy of a fire alarm.  We need a fire alarm to alert us when there is smoke and fire for our safety (i.e. a cut on the hand from a knife) but when the alarm goes off with burnt toast (i.e. a pen across the back of the hand) or even with steam from the kettle (a feather or clothing on the back of the hand), this is less useful and less accurate for us.

What causes changes

It’s not just physical input that can create change. Most people have heard of stress releasing cortisol into the body which is beneficial for the fight or flight responses but over time excess cortisol in the brain can prevent neuroplastic changes from occurring. Lifestyle factors such as poor sleep/nutrition or under or over exercising can lead to systemic inflammation in the body, increasing chemical mediators that further sensitise the nervous system.  

Deliberate engagement creates stronger connections. In the words of Donald Hebb, “neurons that fire together, wire together”.  The more that you follow a pathway, the stronger that pathway becomes. It’s all about deliberately choosing the pathway you want to follow!

Look out for Catherine’s next blog on Neuroplasticity in Chronic Pain

Physiotherapy Brisbane, Barefoot Physiotherapy

Neuroplasticity in chronic pain

Written by: Catherine Mullins

Chronic pain is defined as the presence of painful sensations that have lasted for more than 3 months and persist without the presence of physical tissue damage or pathology. Up to 20% of the population experience chronic pain at any one time.

What happens in the brain with chronic pain?

Part of the transition from acute to chronic pain involves neuroplastic changes in the central nervous system (brain and spinal cord) (see previous blog on Neuroplasticity for more info on sensitisation) and maladaptive (not useful) changes in body perception and awareness. This can physically result in a measurable change to the thickness of your brain’s grey matter (where majority of neural connections are found).

Two mechanisms that can occur in chronic pain involve the homunculus. The homunculus is the representative map of our bodies (both sensory and motor) within our brains. Each body part is given representation based on how many nerves are in the area and how much information is received/given. This representation map is (mostly) the same across all people.  In people with persistent pain (therefore persistent activation and input), the body area in question can become bigger in this body map, which means even more awareness of this area and an increased perception of pain. People with chronic pain tend to move less, move more slowly, and reduce the variety of movements.  This lack of input can lead to brain smudging in the homunculus and ultimately a reduced awareness around this body part.

Can we improve?

This can be changed again! Ultimately, we want to gradually introduce more variability to movement and postures, helping to remap the brain.  Sometimes we need to start with simply imagining ourselves performing an activity without pain (stimulating mirror neurons). Other times we can gradually return to activity, changing the load, duration and context to allow for pain free (or reduced) function.  We frequently utilise motor control exercises to help bring your awareness to an area and change patterning of muscle activation. Non-specific exercise of moderate intensity has been found to release BDNF (brain-derived neurotropic factor) and IGF (insulin-like growth factor), both of which help support neuroplastic growth.

If you’re experiencing chronic pain and want to know more – get in touch …. we love helping our community. You can book online here

Best physio brisbane

Breast and bottle feeding positions

At Barefoot Physiotherapy we have noticed a recent influx of pregnant ladies seeking us out for the aches and pains associated with pregnancy and for guidance remain as healthy and strong as possible throughout their pregnancy. One thing I often get asked is what positions are going to be best to feed their new baby in; whether that is breastfeeding or bottle feeding.

As a higher percentage of our pregnant mum’s develop discomfort and pain in the mid to lower back region it is important that you have a comfortable breast feeding position to alleviate any unnecessary discomfort and for your long term back health.

There is no one best ‘realistic’ position for bottle or breast feeding your baby. So below are some tips and strategies on how to minimise any upper or lower body aches in sitting or lying positions.

Womens Health Physio

General Tips:

  • Important to bring baby to breast rather than bring breast to baby.
  • Check body isn’t twisted and shoulders are relaxed.
  • Keep a glass of water nearby because once baby starts feeding you may be holding the position for a decent time.
  • Try and take quick position breaks when your baby takes a break to burp.

Breast Feeding/ Bottle Feeding Positions in Sitting:

  • Firm and supportive chair (be able to relax into chair to support lumbar curve).
  • Upper part of body resting against back of chair, one foot on footstool on side you are feeding from.
  • If you are feeding in a chair that reclines, limit the time spent in it or use pillows to support the lower back region.
  • Once baby has started feeding place a pillow underneath your baby for more cushioning and to take pressure off your upper body.

Breast Feeding/ Bottle Feeding Positions in Lying:

  • Try and lye on your side with a pillow under your head and between knees and baby lying next to you.
  • Try not to turn neck too far towards baby rather once baby has latched on keep your head and neck in a neutral position.

If you or anyone you know of is experiencing any pregnancy associated pains, muscle joint or possible nerve irritation please contact us. We can determine if it is a musculoskeletal issue before having to see a GP. We are open 5 days a week and a couple Saturdays a month. We have early and late appointments available. Please call us at 1300 842 850 or Click here to book an appointment.

Activity pacing

Activity pacing

Why is it important?

When getting back into an activity after injury or a flare up we want to go slow and steady! What we often see is a “boom-bust” cycle, where a person completes an activity at a higher level than what their body is currently capable of and then has an extended period of rest to recover.  This can be short term (i.e doing 15km run straight from 5km walks) or long term (e.g. starting gym classes 5 x week when previously only doing 1 x 30min walk a week).  Over time we can experience a gradual worsening of symptoms or decrease in function over time. This is because the bodies threshold continues to decrease as it hasn’t been appropriately challenged.

When starting to increase activity level you want to consider your current, symptom free, functional level.  You can consider this as a single activity as well as across a week. For example, two 5km walks a week on their own is achievable but if you add a gym session it becomes too much.  You can also use same approach for day-to-day activities like cooking and vacuuming.  The activities you choose depend entirely on you and your current capabilities. Pay attention to what you’re doing, how long you’re doing it for, and what it feels like. When you’ve worked out your current limit, reduce the average of the limit (across the week) by 10-20% and that’s your starting goal!

Ideas of Activity Pacing

Have a read of the below examples and see if you can think through one for yourself.

Example 1:

Goal:  Return to Park Run (5km – distance not time goal)
Current level: 3 runs a week; achilles pain begins at 3.2km, 2.7km and 2.5km.  80% of average is 2.25km.

Starting point: run 2.25km 3 x week and gradually build by 10% each week/fortnight.

Example 2:

Goal: Cook a daily meal

Current level: Cooking 3 nights a week, back pain starts after standing for 8 mins, 12 mins, 10 mins. 80% of average standing time is 8 mins.

Starting point: 8 mins of active cooking time then rest for 50% of active time before repeating active time.  Can increase by number of days, or amount of time standing by 10%.

For assistance in creating a specific pacing plan for your activity give us a call at 1300 842 850 or Click here to book an appointment.

Massage gun or ball for glute release

Should I get a massage gun?

With the increasing popularity and availability of the massage gun, one of the most common questions we get asked in the clinic is “Do those massage guns really work?”. So we thought we would break it down for you all.

What does a massage gun do

Massage guns aim to provide percussive or vibration therapy. The idea being that as the massage gun head oscillates in and out, small vibrations occur in the muscle, replicating the percussive techniques that massage therapists are trained in. If you’ve been to the clinic, you’ll know that this is not a technique that we commonly use. It is predominantly used for post-exercise recovery and occasionally in a pre-exercise/warm up capacity. In our experience, we don’t see it playing a significant role in injury recovery. This is also why, when we prescribe self-releases, we always encourage maintaining constant pressure on the tight spots for 60-90 seconds for most muscles, as this is what is usually required to make a noticeable change in the muscle tightness.

The evidence

There is some evidence that indicates percussive therapy administered by a massage therapist can help prevent delayed-onset muscle soreness (DOMS) and provide some relief for muscle tightness. As with most soft tissue treatment, the mechanism for this is largely neural – that is, the massage causes a response from the nervous system which responds, providing a short-term change in the tissue. This can be from increased blood flow or short-term inhibition of certain nerve endings which contribute to muscle tightness. Due to massage guns being relatively new on the market, there is minimal evidence at this stage investigating if they have a similar effect as percussive therapy performed by massage therapist.

How a massage gun works

Similar to rubbing your shin if you hit it on the coffee table, massage guns can also decrease pain in the short term by using the “pain-gating” theory. That is, if the brain is busy processing the input of touch (either your hand or a massage gun), it can’t produce pain too. This may actually be one of the bigger selling points of massage guns. Often the discomfort of doing self-releases is a preventative factor for people. So with therapy guns often being far more comfortable, this barrier can be removed. While the preference would be sustained pressure on a single spot for 60-90 seconds, if the realistic options are massage gun or no release… we would definitely choose massage gun! If you are looking at getting a massage gun or using one for the first time – think less is more. That is – pick the smaller vibrations and the flattest head (most come with a variety of attachments) and start with just 1-2 minutes per muscle group.

Physio in the water

Water running with Caitlin

As the weather warms up, many of us are looking for cooler exercise options. Water running is a great choice as it can be scaled up and down for fitness and experience level. With the added summer benefit of being in the water.

There are a few different ways you can engage in water running – each with varying technique, intensity and muscles used. Since water provides resistance to movement, all forms of water running will load the hip flexors more than normal walking and running. So this is worth keeping in mind if you have injuries or known strength issues in this area.

Shallow water running

The buoyancy of water means that running in the pool is a great low impact way to introduce the body to running. Running along the bottom of the pool means you can start to learn the mechanics of running without the same impact. Most public pools have either a shallow end or even a couple of shallow lanes that mean you can run along. Gently contacting the bottom of the pool while keeping your upper body out of the water. I would recommend this for people who are more hesitant in the water or are looking for a way to increase their tolerance to impact in preparation for return to running (eg following a stress fracture or pregnancy). Whilst you can scale the intensity of this up and down, generally this kind of water running won’t elevate your heart rate as much. So its a better choice for people with a lower level of cardiovascular fitness.

Deep water running

The other alternative is to run in the deeper water. Staying afloat will usually require a higher intensity and therefore result in a higher heart rate. This makes it a good option for people wanting to cross-train to maintain fitness during an injury. Given that these forms are higher intensity in nature, they are better suited to interval efforts. For example: 30 seconds work, 30 seconds rest x 20. Rather than a steady state effort for 20 minutes. There are two different technical approaches to deep water running outlined below. Both can be done with or without a floatation belt. Not using the belt is a way to increase the intensity/difficulty, as you have to generate all the energy to stay afloat.


Trying to mimic as close as possible to usual running technique. Getting knees up, toes up and cycling through along with arm swing. This form of water running in particular will load the hip flexors heavily so might need to be paired with hip flexor muscle releases

Arm focused run

Thinking of the leg action more as a freestyle kick/flutter (whilst still staying upright in a run position). Focusing more on a strong and fast arm drive. This comparatively is less load on the hip flexors, but more load on the abs and shoulder muscles.

If you’re looking for different forms of exercise to incorporate into your routine, have a chat with your physio about whether water running could be suitable for you. You can book with us online here.

Knee injuries

Let’s talk knee injuries.

The knee joint is relatively simple and moves as a hinge joint (i.e bending and straightening). The joint itself is an articulation between our femur (thigh bone) and our tibia (shin bone) for the hinge movement and patella (kneecap) sitting over the front to increase our quad strength. There are a series of ligaments, articular cartilage and muscles that are involved in this joint.

Ligaments and Meniscus

Collateral Ligaments: attach between the femur and the tibia outside the joint capsule and control side to side movement. The medial collateral ligament (MCL) is on the inside of the knee and the lateral collateral ligament (LCL) is on the outside.

Cruciate Ligaments: inside the joint capsule making an ‘X’ attaching from the femur to the tibia and prevents movement forward and backward. The anterior cruciate ligament (ACL) attaches from the front of the joint surface on the tibia to the back of the joint surface on the femur and the posterior cruciate ligament (PCL) attaches from the back of the joint surface on the tibia to the front of the joint surface on the femur.

Patella Tendon and Ligament: attaching the patella to the quadriceps muscle and tibia respectively.
Articular Cartilage: a smooth and slippery covering at the ends of the bones to allow for smoother movement.

Meniscus: a ‘C’ shaped piece of fibrocartilage within the knee joint for shock absorption.

Common Injuries:

Because of the relatively simplistic nature of the knee joint it is often exposed to increased load if there is restriction in the hip or ankle (check out our blog on accumulative strain). In addition to this, it is often injured in a single traumatic event. And these injuries may include a ligament sprain, meniscal tear or even bone fracture.

The most common ligament sprains are the MCL (from a direct hit to the outside of the knee or an awkward change of direction) or the ACL (from a pivot on a planted foot and straight leg or from hyperextension with high load). The meniscus can also be damaged from awkward pivoting or repeated knee bending (eg squats).  These three injuries frequently present together – “the unhappy triad” due to their similar mechanisms of injury.   

So if you present to physio following a sudden injury we’ll ask what happened at the moment of injury (including any sounds); whether you are experiencing instability, catching, locking, giving way; if certain positions are more uncomfortable; the amount of bruising and swelling at the time of injury. And we’ll then use a variety of orthopaedic tests to assess the integrity of these structures.  Depending on the results of these tests we can decide if it’s necessary to scan the knee.  Most lower level injuries can be successfully managed with conservative treatment (i.e physio and exercise) and do not require surgical intervention.

Physiotherapy Brisbane, Barefoot Physiotherapy

Shoulder and the Rotator Cuff

Shoulder Joint Anatomy

The shoulder is known as a ball and socket joint and is made up of three bones: the humerus, scapular and clavicle. The humerus is stabilised in your shoulder socket through your rotator cuff. The rotator cuff is a group of four muscles that merge together as tendons to wrap around the head of the humerus . As the tendons assist in the rotation of your shoulder they are therefore named the rotator cuff.  The four muscles of the rotator cuff are supraspinatus, infraspinatus, teres minor and subscapularis.

What is the Bursa and Bursitis?

In the shoulder joint there is a sac called the bursa which is located between the rotator cuff muscles and the bony top of the shoulder (acromion). The anatomy of the bursa helps the rotator cuff tendons to move freely with shoulder movements with decreased friction.  In some instances when the rotator cuff tendons become irritated they can cause the bursa to become inflamed and painful. On imaging this irritation can present as bursitis of the shoulder joint.

What is a Rotator Cuff Tear?

Whilst the rotator cuff is a group of four strong muscles, they can be exposed to injury due to their constant use. A rotator cuff injury could be due to and external force (i.e. sporting injury) or the natural aging of the muscles.

It is important to note that as we age the risk of rotator cuff tears increase due to the constant repetitive strain that is placed on our shoulders. Research shows that 40% of the population over 60 years will have some form of rotator cuff tear but still be asymptomatic (pain free).

If you have pain

If however, you do develop symptoms from the tear which can include but isn’t limited to; loss of range of motion, loss of strength or pain, your physiotherapist can determine a suitable treatment plan to help you can regain your shoulder function .

To maintain the strength and range of motion in your shoulder it is important that tears be identified before they progress and cause more irritation. A physiotherapy treatment plan may include a combination of manual techniques, pain relief and exercises to strengthen the muscles.

If you or someone you know is experiencing any muscle joint or possible nerve irritation please contact us. We can determine if it is a musculoskeletal issue before having to see a GP. We are open 5 days a week and a couple Saturdays a month. We have early and late appointments available. Please call us at 1300 842 850 or Click here to book an appointment.