Case studies

Over the past 20 years as a physiotherapist, I've helped thousands of people recover from a wide variety of issues.

Some of my patients work – others don’t. Some are or have been professional sportspeople or in the military – others never exercise. Some have had major accidents – others have issues for no apparent reason. Some have had surgery, others are planning to have surgery, or are desperately avoiding it! However, what my successful patients do have in common is a strong desire to get better, a willingness to do the “homework” I give them – and they work with me, so that we can discuss what’s working, what isn’t working, and progress and refine their treatment programme accordingly. Read some of my favourite stories below.

Peter

Peter was only 22 years old when he travelled half way across the country to see me, complaining of pain in lots of different areas of his body: neck, shoulders, back, hips and knees! Unsurprisingly, he was really struggling to carry out his job as a farmer. He was quite depressed and at a loss to understand why he was in such pain, when he hadn’t experienced any severe injuries. He had seen lots of different therapists who had treated the painful joints, with varying degrees of success; and had also had blood tests, which had ruled out systemic issues such as rheumatoid arthritis.

When I looked at Peter’s body as a whole, it was immediately obvious that his feet (about the only parts of him that didn’t hurt!) were not working well. They were very stiff, and he stood on the outsides of his feet, with his big toes barely touching the ground! His posture was also generally poor, with multiple twists and restrictions.

However, when I repositioned Peter’s feet, he was amazed: almost all of his pain disappeared!

I therefore treated Peter, mobilising the joints of his feet and providing tailored insoles which effectively brought the ground up to meet his feet, allowing them to relax. Because he had travelled such a distance to see me, Peter wasn’t able to attend physiotherapy regularly, so I gave him some exercises to increase his foot flexibility and strength, and encouraging him to adopt a more functional foot posture. As I am writing this, it has been 8 months since I saw Peter, though we have stayed in touch; and he tells me he has been diligent with his foot exercises and that his whole body is feeling much better.

Bethany

Bethany was in her early 20s when she was diagnosed with psoriatic arthritis and fibromyalgia. She came to see me in her early 30s, having seen a host of other therapists, and really felt that nothing could be done for her. In fact, the only reason Bethany came to see me was the fact that I was already treating her sister, who was so sure that I would be able to help that she had forced Bethany to come along, and even paid for her assessment!

She was in a bad way: she couldn’t even smile, and told me that she hadn’t even been able to yawn without excruciating pain, for nine years. She was constantly fatigued, limped badly, and complained of “brain fog” – no wonder she was only able to work part time, even working with children in a job she loved!

As soon as I placed my hands on Bethany’s body, I could feel that her nervous system felt tight and “wired”. It felt as though her whole body needed to be calmed, nurtured and “listened to”.

The way into Bethany’s nervous system turned out to be through craniosacral techniques, where I place my hands lightly on different parts of her head and spine, and “listen” with my hands, following the involuntary movements of her body, and sometimes intervening, but always very lightly.

The effect on Bethany has been dramatic: after the first session she said she felt her “brain fog” receding. After four sessions she was able to smile, laugh, and yawn without pain. Her witty sense of humour has returned, and she says that her friends and family have all commented on how much better she is walking. I do not know when we will hit the limits of Bethany’s recovery; but I do know that her quality of life is far higher now than when we started, and that currently, she is continuing to improve.

Elsa

Elsa was involved in a severe accident as a 19-year-old physiotherapy student, in which she rolled her car into a lake. Subsequently she developed post-traumatic stress disorder in addition to severe depression, headaches and neck pain. She saw a physiotherapist and a psychologist for two years after the crash, but stopped seeing them when she realised that she had started to mentally associate the therapists with the trauma of the crash, rather than with recovery.

She did recover reasonable function and was able to return to full-time study and eventually work, but the regular, severe headaches and neck pain seemed to be ingrained.

I met Elsa when I redid Diane Lee’s 6-month course on the Integrated Systems Model in 2019. Diane regularly updates the course in line with new research, and I make a point of training with Diane whenever I can! A significant part of the course involves the participants assessing each other’s injuries, and Elsa was proving particularly complicated; but eventually, in the last week of the course, Elsa’s study partner worked out that there was a line of tension between the right side of her skull and the left side of her chest… where her seatbelt had prevented her from flying through the windscreen!

While this was a significant development, treating each other is not part of the course curriculum, and therefore on completion, Elsa came to see me to get her seatbelt injury treated.

Elsa’s nervous system had tightened up along the line of the seatbelt, and stretching her muscles did not work – in fact, it made her feel worse. I therefore used a combination of craniosacral and visceral techniques to gently “untwist” her nervous system and restore the neural flexibility between her cranium and her pericardial ligaments. Her body loved it, and she could feel her headache and neck pain receding.

I then had to think of some “homework” for Elsa, as neural tissue doesn’t usually magically retain its flexibility after one treatment session, and she does not live in the UK so wasn’t going to be able to come back for more.

The Chinese say that the heart is the organ of joy, but Elsa hadn’t been feeling much joy lately, and her pericardial ligaments (the ones that hold your heart in the right place in your chest!) were feeling tight. I wondered whether some visualisation might help, alongside the physical treatment.

I asked Elsa to lie with her head on a still point inducer, while thinking of a time when she had felt really joyful. As she did so, I “listened” to her pericardial ligaments, and felt her chest relax and soften! Apparently we were onto a winner, so I asked Elsa what she had been visualising. She told me that two days before our session, she had been to see the play Harry Potter: The Cursed Child, and that this was the most joyful experience she could imagine! I therefore prescribed her the homework of using a still point inducer each night for 10-15 minutes while listening to Stephen Fry reading Harry Potter audiobooks! Elsa says it’s the best “homework” a physiotherapist has ever given her, and that her headache still hasn’t returned.

Jill

Some years ago, while on holiday, I was lucky enough to meet a delightful lady called Jill. Jill had recently had some bad news – she’d been diagnosed with stage 1 breast cancer and was waiting for surgery. We got chatting, and eventually she asked if I might be able to help her with her post-operative physiotherapy. This is her story.

Meet Jill, a delightful 63 year old journalist, recreational tennis player and volunteer at Battersea Dogs’ Home who was diagnosed with stage 1 breast cancer in 2014.

By the start of 2015, she had had a lump removed from her breast, and 14 lymph nodes (the average human has around 20) removed from her armpit, plus a course of radiotherapy.

When Jill came to see me in early 2015, her biggest issues were tension in her neck, shoulders and ribcage (a combination of cancer- and work-related stress, posture, tennis technique and surgery), a stiff shoulder (common after breast and armpit surgery) and a seroma (a buildup of fluid around the operation site, also common with breast cancer surgery).

I was also concerned about the risk of developing painful scar tissue and cording around Jill’s breast and armpit, found in up to 72% of women after lymph node clearance. Avoiding scarring, cording and stiffness takes some luck and a lot of dedication; and Jill certainly had the dedication. She practised her shoulder flexibility exercises every day and kept up her routine of eating well and water walking… and after a lot of encouragement and teaching from me, gradually built up the nerve to touch, and gently massage her breast.

For my part, I was doing lymphatic drainage massage, and gently mobilising the scar over her ribcage and breast, to minimise the risk of stickiness between the layers of tissue. This tissue is largely made of fascia or connective tissue, which responds well to very gentle touch but flares up with heavy-handed treatment.

I also gave Jill a few sessions of craniosacral therapy, which is thought to help the nervous system calm down – invaluable for people whose minds are racing and nervous systems highly strung after the shock of a cancer diagnosis and then radical treatment.

Within just a couple of months, Jill’s breast tissue – which had felt quite rubbery to the touch after radiotherapy (after all, it had just been microwaved) started to feel much more mobile and vital. Her seroma gradually settled, and the flexibility returned to her shoulder.

When her surgeon reviewed her, he was amazed at her progress – not only do most women struggle to ever get normal flexibility back after cancer surgery, but he felt the lack of scarring and tethering in her breast and ribcage was extremely unusual.

Jill has continued to work hard on her posture, flexibility and strength; and while she still pops in for treatment every now and then, she’s back on the tennis court, working and living a full life. And she’s absolutely convinced that quality physiotherapy had a major role to play, both physically and in terms of her confidence.

John

As a 25-year-old construction worker in rural Australia, John agreed to help a friend work on the roof of his parents’ boathouse. However, as John was working, he slipped and fell off the roof. Very unluckily, his neck smashed into the keel of an upturned dinghy; and his friend looked down to see John on the ground, with his head facing up, and his body facing down. He had broken his neck and badly damaged his spinal cord.

Amazingly, John was still alive when he arrived at the local hospital. Miraculously, there was a young spinal surgeon visiting! John was his eighth patient, and the surgery took eight hours to complete. When John awoke, it was to the news that although they’d been able to save his life, he would be paraplegic, with no movement or feeling in any of his limbs.

However, six weeks later, as he lay in his hospital bed, John felt a flicker in his thumb. The next day, he felt two flickers. His body was (very) gradually coming back to life!

It turned out that John had sustained a partial rupture of his spinal cord, and not a complete rupture. He recovered the use of some of his muscles, but by no means all. But John is an extremely resourceful and persistent chap, and over the next 10 years, he stubbornly taught himself to walk again, albeit with a very severe limp.

Fast-forward 25 years from the accident. John was now 50, living in London and working in the banking sector. He was still able to walk, but because of the severe limp and loss of muscle control, his body was starting to wear out. His right knee was excruciatingly painful, and his ligaments had stretched so far that at each step, his knee collapsed backwards by 40 degrees!

He went to see a knee surgeon, the very sensible Ian McDermott, who told him that although technically he could repair the overstretched ligaments, if John continued to walk as he was doing, then the surgery would be wasted as the repaired ligaments would simply stretch again, and a second repair might not be possible. Instead, Mr McDermott recommended that John come to see me to try to sort out his walking gait.

When I first saw John, he was wearing a knee brace, which was supposed to stop his knee from collapsing; and an ankle brace that was supposed to hold his foot steady. He was also using a walking stick. His quadriceps and glute muscles (front of thigh and buttocks) were wasted to almost nothing, and his foot was badly twisted.

I did not know how much I would be able to help John; but this was certainly a challenge, and I was up for it! I felt that the first thing was to get John’s foot planted better on the floor, and to start getting his glutes activating, so that his knee didn’t collapse inwards with every step.

John worked incredibly hard at his exercises, and over the next few months he continued to exceed my expectations. After a few sessions, we were able to remove first his knee brace and then his ankle support – I made him an insole instead. His knee control improved and his trust in it grew. His walking gait became more controlled, faster and less painful. Amazingly, his knee ligaments actually seemed to shorten, and after a few months, he was not even able to hyperextend his knee to 20 degrees, let alone 40!

John’s walking gait will never be normal – his spinal cord has been severely damaged, and he will never have normal muscle control. But through his own hard work, with a bit of direction and input from me, he has avoided the need for major knee surgery, is much less reliant on his stick, and is able to walk for 2-3 hours at a time, whereas previously he was in pain at every step – a fantastic result which has improved his quality of life significantly.

David

By the time he came to see me, 48-year-old former Army officer David had had problems with his neck for nearly 3 years. Visiting me for the first time, he explained that I was the latest in a long line of chiropractors, physios, osteopaths and surgeons to examine him. He’d received several injections of steroids into his discs and facet joints, and undergone lots of manipulation. His latest MRI scans showed inflammation around two discs, and five inflamed facet joints; and David was worried that he was facing surgery, which he desperately didn’t want.

David couldn’t look over his right shoulder, and when he tried to do so, everything went a bit haywire! His upper cervical vertebrae shifted one way, his lower vertebrae the other way, and his first rib was stuck in elevation. His upper trapezius muscles were overdeveloped, and lower trapezius underdeveloped.

I quickly realised that the biggest issues were at David’s C2 (the top of the neck, just under the skull) and his first rib (by the shoulder and collarbone). The rest of his neck was getting compressed and corkscrewed between these two bones which were moving poorly, due to an overactive anterior scalene muscle (which links your upper neck to your collarbone).

Over the course of a few treatment sessions, David progressed from his C2 in place with one hand while consciously relaxing his scalenes, to moving while mindfully “floating” his head over his shoulders. Gradually we retrained his lower trapezius muscles so that his shoulder movement improved and he became able to move his shoulder without moving his neck, and vice versa – and within three months, David was able to return to his usual training (but with the new “cues” of “float your head and activate your lower trapezius” before each set of exercises).

Philip

Philip was referred to me by one of my favourite shoulder surgeons. Eight weeks earlier, Philip had fallen over while playing football in the garden with his granddaughter, and had hurt his right shoulder. He had been referred to his surgeon, who had quickly diagnosed a torn rotator cuff and ruptured biceps, and had carried out an open repair. It was now my job to help Philip get back to full fitness!

When I first examined Philip, I noticed that his right shoulder was sitting too far forwards in its socket, that his pelvis was rotated to the right, and that his right foot was twisted. However, when I repositioned his right foot, his pelvis untwisted, and his shoulder relaxed back into a neutral position.

The first job therefore was to sort out Philip’s right foot. I mobilised his foot bones and gave him exercises to practice; but as a temporary solution, I also gave him insoles which supported his feet into a better position.

This done, I was able to focus on the tension and range of movement around Philip’s shoulder, which was unsurprisingly quite weak and stiff after six weeks in a sling! This meant getting his ribcage, shoulderblade, collarbone, neck and shoulder working normally, as they’d all stiffened up; and restoring muscle balance. However, Philip worked hard at his exercises, and I was able to discharge him less than six months later, with only a slight loss of internal rotation, meaning he couldn’t reach his right hand up his back quite as far as his left one – a pretty good outcome for someone who’d undergone such major surgery!

Diana

I met 32-year-old lawyer Diana when her aunt (one of my patients) called me in a panic. Two days earlier, Diana had sneezed while doing her weekly grocery shopping, and her back had gone into spasm. She’d had to leave all her shopping and be helped to a chair, and then call her flatmate to drive her to hospital. An X-ray had shown that she didn’t have any broken bones so she’d been sent home, and she’d barely been able to get out of her bed since.

When I examined her, it was clear that Diana had a case of what Sarah Key calls the “acute locked back”. This is when your multifidus muscles momentarily fail to support your lower back, allowing the capsule of your facet joint to get caught in the joint as you move your spine from flexion into extension, and causing instant excruciating pain and massive muscle spasm.

The first job was to get Diana out of acute pain; and I did this by gently working her joints and muscles until they relaxed, and then giving her gentle and specific exercises to practice. I encouraged her to see her GP; and my exercises, in conjunction with muscle relaxant and pain relieving medication, helped her to navigate to the initial stage.

The next stage was to work out why this had happened; and this is where I started to look further afield. It became clear that Diana’s habitual posture was quite twisted, and we traced this back to a fall on ice when she had hurt her ribs, after which she had always wanted to sit with her torso and hips pointing in opposite directions. Her hips were both tight, and so were the muscles between hips and ribs; and her pelvic floor muscles had become inhibited by pain.

Diana attended regular physiotherapy for around 3 months, and was then able to reduce the frequency of her treatment sessions, as her stabiliser muscles improved and started to support her more effectively. She has now taken up Pilates and dancing, to maintain her flexibility and muscular support system in a way that works for her, for the long term.

Emma

45-year-old nurse Emma had undergone surgery for torn cartilage in both hips, and her post-operative physiotherapy wasn’t going well despite the fact that she had been seeing her physio every week for months, and was working hard at her hip exercises in between sessions. She was taking strong painkillers – amitriptyline and gabapentin – but was still really struggling, and was unable to work. Emma was losing faith in her therapist, so her surgeon suggested that I might see if I could help her any further.

When I assessed Emma, the first things I noticed were that she had a twist between her ribcage and her pelvis, that the left side of her pelvis was very tight, and that she complained of pain in her left hip when she leant to the right. However, when I untwisted her ribcage and got her pelvis moving better, her pain and movement patterns improved immediately. It felt as though the ribcage and pelvis issues were overloading her hips. This was a moderately complex issue and I predicted that Emma would need a course of 12 sessions of treatment.

We based our initial treatment sessions around improving the flexibility and control of Emma’s thorax and pelvis, incorporating some visceral manipulation techniques as Emma’s descending colon (on the left side of her abdomen) felt restricted, as though it was gluing the ribcage and pelvis together.

After six sessions, we started to liaise with Emma’s GP about gradually reducing her painkillers and she was able to wean off the amitriptyline, though the gabapentin took longer. She was improving her thoracic control and practising hard, and although her hip control still wasn’t perfect, it was getting better. She was able to return to work for 3h at a stretch.

Emma had a big setback after 10 sessions, after she caught a nasty stomach infection and ended up in hospital for a week on a drip. This inevitably caused her to lose some of the muscle and control she’d worked so hard to regain; but within a couple more sessions she had got back on track, and after a total of 14 sessions, she was able to progress from physio to working with a rehabilitation specialist to strengthen her muscles and movement patterns.

Because of the damage to her hips, Emma knows that she will always need to maintain her strength and control; but she now has the tools to do this and is no longer in constant pain.

Sonal

Sonal, a 48-year-old lawyer, came to me on the advice of her knee surgeon. He had operated on her right knee 18 months earlier – a routine procedure to tidy up some torn cartilage – but she was getting worse despite having weekly physiotherapy. She was in despair, walking as little as possible (using two crutches to get about) and even worse, her left knee was starting to become painful, and she was terrified at the prospect of more surgery.

Sonal told me that her physio had been focusing on making her train her leg muscles – her quadriceps, hamstrings and gluteals.

However, when I looked at her whole body, it was clear that both of her knees were collapsing inwards, and that this was actually happening because of her feet. Her foot muscles had become too weak to support her; and over time, her feet had stiffened into a collapsed position, and her control was even worse when she was standing on one foot than when she was on both, putting a terrific strain on her knees when she walked. As a result, at the point I met Sonal, even if she’d had the world’s strongest thighs and glutes (which she didn’t!), she wouldn’t have been able to support her knees properly.

Amazingly however, as soon as I got my hands onto her feet, got her foot joints a bit more mobile and then supported her arches, her knee pain decreased immediately. The change was so dramatic that when we walked back out from the treatment room into reception, for the first time in two years, Sonal wasn’t using her crutches! What seemed like her entire family were waiting for her; and when they saw her walking without support, albeit slowly and carefully, the whole room burst into tears.

I worked with Sonal for 12 sessions over the course of 9 months, and the improvement was significant. She worked hard on her foot mobility and muscle activation, and I prescribed temporary insoles to give her support. Within two months she was using an exercise bike, and her new glute exercises were starting to take effect. Two months after that, she went dancing in high heels at a friend’s wedding! And by the time I discharged her, she was regularly enjoying going to the gym and swimming, and a year later, she hasn’t needed any further treatment.

Dr Jones

Dr Jones is a consultant radiologist who specialises in imaging musculoskeletal issues. She’s outstanding in her field, and if you have an inflamed patellar tendon or tennis elbow then you might well end up seeing her as she analyses it with her ultrasound machine.

So when she came to see me with a painful left ankle, I knew she would have investigated it herself first, and sure enough, she had self-diagnosed a badly-inflamed peroneal tendon, and had been to see another physio, whose ankle strengthening exercises had not helped. By this point, standing on her left foot was excruciating.

A quick bit of anatomy: the peroneal tendon runs down the outside of the ankle, attaching the outer part of the shin to the outer part of the foot. We usually think of it as a muscle which everts the foot, effectively pulling the little toe up and out.

When I assessed Dr Jones, I found several small issues. She had a small twist at the top of her neck, with her C2 bone slightly translated to the right. Her shoulder girdle was rotated to the left, as was her pelvis, and the arch of her left foot was slightly collapsed. All of these minor issues worsened when I made her stand on her left foot.

I tried correcting Dr Jones’ foot position, and then her pelvis, but it wasn’t until I corrected her neck position that her body suddenly relaxed and realigned itself, and she suddenly stood on her left foot with confidence, without pain and without holding her breath.

She stared at me. “Wow!” she said. “What did you just do?”

Now, there are many possible explanations as to how an upper neck problem could affect your ankle; but the most plausible for me was that Dr Jones’ C2 was sliding to the right, and taking her head with it. Heads are heavy (most weighing around 5kg) and so this would pull her off balance.

In a non-weightbearing position, as I explained above, the peroneal tendon is an everter of the foot, pulling it up and out, as the insertion in the outside of the foot moves towards the origin in the outer shin. However, in a weightbearing position, the foot cannot move up and out as it is attached to the floor, so when the peroneal tendon is activated, it pulls the outer shin towards the outer foot.

Over time, Dr Jones’ left peroneal tendon had become the way she compensated, as her body fell to the right, following her head. She was effectively using her peroneals as a crutch. The peroneal muscles can cope with doing this once in a while, but they’re not designed to do this all the time, so my hypothesis was that, over time, her peroneal tendon had become overloaded, fatigued, inflamed and eventually painful.

Surprisingly, after treating her neck for just 10 minutes, I was able to touch and wiggle Dr Jones’ left ankle, and to work around her peroneal tendon in a way nobody had been able to do for the previous few months (it was important to do this, partly because it reinforced her belief in the treatment on her neck; but also because I wanted to reassure her nervous system that moving her ankle was a safe and normal thing to do, to give her confidence in her ankle; and to remind her peroneal tendon how to glide and move normally, and to reduce any inflammation and adhesions.)

Dr Jones quickly decided that she had to “leave her doctor’s hat at the door” when she came to see me. Intellectually, it didn’t make total sense to her that her neck would cause her ankle pain; but her body told her otherwise. So she worked hard at her neck posture, and in fact within 4 sessions I was able to discharge her from physio to rehab, so that she could go and work with a rehab team to strengthen her peroneals while (crucially) maintaining good neck posture.

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