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Tag Archive: sports injury

  1. What is causing pain at the front of my knee?

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    Many athletes and recreational sports people suffer from on-going knee pain and soreness. Today Physiotherapist Sarah Marshall looks in more detail at one aspect.

    One of the most common types is Anterior Knee Pain (AKP). It describes pain at the front of the knee and can affect up to 40% of the population. It is especially common amongst athletes, yet not disrupt their sporting function or ability.

    What are the causes of AKP?

    There are many causes of AKP and I have listed the most common below. Symptoms will often present without specific injury. Any persistent pain must be assessed by an appropriate medical professional in order to make an accurate diagnosis who will then advise on the correct treatment plan.

    Patello-Femoral Joint Pain (PFJP) is by far the most common cause of AKP. Athletes will describe pain in and around the patella. I would not expect to see any significant swelling around the knee joint.

    Symptoms are usually aggravated by stairs, kneeling, squatting, lunging and running. PFJP can also cause pain at rest, especially when sitting for long periods (movie goer’s knee).

    A Patella Tendonopathy, Fat Pad Irritation / Impingement, Bursitis and Patella Instability with also produce AKP.

    What causes PFJP

    There are many contributing factors to the development of PFJP

    •  Local muscle weakness (especially quadriceps)
    •  Poor neuromuscular control
    •  Muscle tightness (especially quadriceps and hamstrings)
    •  Poor hip / pelvic control / stability
    •  Poor foot posture / mechanics

    All of the above will increase the functional loading of the Patello-Femoral Joint which is likely to cause inflammation and pain with repeated use. PFJP is also a very common complaint following any knee joint surgery and must not be missed as referred pain from an old Posterior Cruciate Ligament injury.

    Management of PFJP

    knee pain

    Get your knee assessed by a Chartered Physiotherapist

    Always seek professional advice if you can before embarking on a rehabilitation programme. Initially, pain levels need to be managed and controlled before early rehabilitation can be progressed.

    Pain Management

    •  Activity modification i.e. avoid aggravating factors
    •  Taping techniques
    •  Acupuncture
    •  Soft tissue massage

    Rehabilitation

    •  Stretching programme (hamstrings, quadriceps, gastrocnemius, anterior hip structures)
    •  A graded strengthening programme with initial emphasis on quadriceps
    •  Hip and pelvis stability exercises ( transversus abdominus, gluteus medius)

    (Post rehab, there are 3 keys to maintaining Knee Health)

    There are limited surgical options for this problem with relatively poor outcomes.

    A biomechanical assessment of the foot can help determine whether shoes orthotics are indicated. Commitment to rehabilitation must be adhered to for many months in order to achieve individual goals.

    Unfortunately, without the appropriate management, PFJP often develops into a chronic problem.

    If you want an individual assessment on your knee pain, then please book in to see me.

     Sarah Marshall 

  2. 5 Tenets of Sports Injury Rehabilitation

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    Movement is the foundation of sports injury rehabilitation

    Dr Grace Golden gave an insightful presentation on returning to sporting activity at GAIN 2018. I liked her systematic approach which was well illustrated with video examples. She also had a large amount of creativity and fun involved in her rehabilitation sessions.

    Coaching the injured athlete

    sports injury rehabilitationGrace “coaches” the rehab sessions, which is different from the experiences of many athletes who are returning from injury. Grace understands the need for skill development and fun in the rehab process. She often works on the sidelines with teams and integrates the rehab with the sport training. This is very important for athlete morale (it also helps remind the coach that the athlete is still alive and kicking).

    Communicating between members of staff is also important. The rehabilitation world uses inconsistent language when working with injured athletes:

    • Return to activity.
    • Return to sport.
    • Return to play.
    • Return to competition.

    What are we trying to do? All of the above are different in intensity, but athletes are often told to “rest for 4 weeks” by a medical professional. There is a difference between graded exercise progressions and competing in a regional tournament.

    Tenet 1 Start simply

    Practise and evaluate locomotor skills in isolation.  This means training in single planes and one direction of movement at the start. Work on the fundamentals before athlete specific and specialised movements.

    Criterion based rehab” may be a better method than “timeline” based rehab. Grace uses the single leg squat (SLS) as one criterion.  One target is to do 70 sls in a 2 minute span, ideally with a 90degree knee angle, but 70-90 degrees is acceptable. The athlete rests for 2 minutes then repeats, building up to 3 sets total.

    This prepares the athlete for 2 minutes of running or jogging better than “rest”. Having objective criteria improves understanding between athletes, medical staff and coaches.

    Can your athletes do 70 single leg squats in 2 minutes when healthy? Are they fit to play now?

    Tenet 2 Common agility tests should not serve as the primary training stimulus or pathway to progression

    Whilst agility tests like the Illinois agility test, the 3 cone test, or the T-test may have a place in training, they are very simplistic. This means they are quickly learned and the stimulus is redundant after a few attempts.

    Better to think of a variety of exercises using different stimuli. This includes decision making in a controlled fashion.

    Tenet 3 The order we combine locomotor skills influences acceleration or deceleration exposure

    sports injury inhabilitation

    Deceleration is loading

    The injured body part is loaded more in deceleration activities than acceleration, Grace trains acceleration early or first and then adds deceleration.

    (See Damaging nature of decelerations)

    Tenet 4 Add discrete skills in transitions for directional and plane changes

    (as long as they have been trained previously).

    Grace broke this into 4 different phases:

    1. Continuous direction and continuous speed.
    2. Continuous direction and multiple planes.
    3. Multiple directions and multiple planes.
    4. Multiple directions and continuous planes (cutting progressions).

    Tenet 5 Be mindful of how what you are doing today is preparing the athlete for what they need later

    Or, “start with the end in mind”. The goal of rehabilitating injured sports people is very different from rehabilitating the normal population. Jogging on a treadmill pain free could be a successful outcome for Joe Public.  That is nowhere near enough for a field/court team sport person, so the rehab process needs to be structured along different lines.

    Summary

    I have barely touched the surface of Grace’s presentation on sports injury rehabilitation. Her presentation was rich with detailed examples of the exercises she uses. Most important for me was how she integrates the work with the coaching staff. It is all too easy to rehabilitate in a clinic room that doubles as a bunker.

    Further reading:

     

  3. Reconditioning athletes: Bill Knowles seminar

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    “An exercise is something you do a movement is something you feel.”

    Bill Knowles reconditioning

    Bill Knowles

    Was the title of Bill Knowles’ seminar on rehabilitating (reconditioning in his terms) athletes from sports injuries.

    The question he asks himself is “what’s in the best interest of the athlete?” This often means pulling the athlete out of the injured body and getting them to recognise their athletic spirit again.  All too often in rehab settings, the focus of the treatment is on the injured part, rather than on the person (see previous seminar)

    Once you recognise that the entire body is supporting the injured knee then your perspective on getting the athlete back to competition changes.

    A few key considerations on rehabilitation

    Bill outlined some of his principles that underpin his approach to reconditioning.

    • Rate of force acceptance (deceleration) vs rate of force development (acceleration). The latter is much talked about and measured, the former is where injuries often occur.
    • Rehabilitation (medical model) vs reconditioning (performance model)

    We are looking to get back to performance so we need to think about this from the onset (I will use the term reconditioning from herein).

    • We have to stay professionally stimulated” as improving the journey helps athletes. (It’s hard to stay professionally stimulated if you are handing out photocopied sheets of paper with “3 sets of 10” for each exercise for every person who walks into your clinic).

    This then encourages us to think of more athletic ways to train. A good way to start improving the journey is through a movement that is familiar to the athlete. Bill showed a video clip of an athlete very soon post injury, who was walking in water with a knee brace and even did some low level bouncing).

     The restoration of athletic normal

    reconditioning athletes

    Interlinked

    We are looking to prepare the athlete for return to play whilst also addressing their injury.

    Physical literacy, athletic development and athletic normal are all linked and form part of a “training based prevention”.

    Compare that to a medical intervention led prevention strategy with exercises which mean they are “just doing stuff”.

    Training is through movement, not simplistic exercises.

    Our aim is “The ability to move efficiently in an athletic environment with precision style and grace.” We can “start encouraging biological healing through movement.”This exercise has the added benefit of encouraging sleeping which of course is a great healer.

    If you just look at things from as sports medicine perspective, you might be satisfied with an injury that is healed. However, “just because you are biologically healed, does not mean you are athletically prepared.”

    Bill then quoted Carol Welch: “movement is medicine for creating change in a person’s physical, emotional and mental states”.

    Followed by Plato: “Lack of activity destroys the good condition”.

    The athlete must not forget what is natural and simple (to them) so this must be incorporated into their reconditioning programme.

    A “protection mindset” contributes to complexity. This is unnatural and may add no enhanced healing quality if it compromises movement quality.

    Rebuilding the formula one car

    recondiitoning athletes

    Formula one ferrari

    Bill used a great analogy when looking at reconditioning. If your Ferrari formula one car is broken into pieces, you can attempt to rebuild it and end up with a red porsche. You have ended up with a fast red car, but it isn’t a formula one car.

    You have to know what the athlete looks like at the end. “I’m not interested in restoration of jogging, I’m interested in the restoration of acceleration, deceleration and change of direction.”

    injury rehabilitation devon

    Porsche

    Movement is so simple and yet so complex. Many clinicians prescribe exercises and restrict on other movements because they are uncomfortable with movement.

    (I know one physio whose end stage acl rehab was chatting to a footballer who was jogging on a treadmill! That was his “return to play” assessment).

    I have seen Bill present many times now since 2011 with several practical workshops too. He has given me the confidence to both discuss sports injury with clinicians and also work with athletes on reconditioning their serious injuries.

    (It helps that I can share ideas with my wife Sarah who is a Chartered Physiotherapist who has developed her knowledge of movement by becoming a level 1 strength and conditioning coach).

    acl rehab devon

    Bill, Vern and Nick Folker at breakfast

    Bill is a fine example of the GAIN faculty and attendees who learn from the different people and return to their settings to apply, innovate and develop their knowledge in order to help their athletes.

    I also spent an hour discussing ACL reconditioning and using the 4Dpro with athletes over dinner with Bill. This was very enlightening and will help the athletes I work with here in Devon: thanks Bill!

    Further Reading:

    Dr Mike Joyner on Sports Science: Servant or Master?

    Next up: Vern Gambetta the Talent Pathway.

  4. Let your child play sport rather than just compete

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    Children need to play more and compete less

    John Smoltz

    John Smoltz

    Children who get injured or burntout may be competing at sport too much and have too little opportunity to just play. These words on shoulder operations by Hall of Fame baseball player John Smoltz ring very true.

    I want to encourage the families and parents that are out there to understand that this is not normal to have a surgery at 14 and 15 years old. That you have time, that baseball is not a year-round sport. That you have an opportunity to be athletic and play other sports.

    Don’t let the institutions that are out there running before you guaranteeing scholarship dollars and signing bonuses that this is the way. We have such great, dynamic arms in our game that it’s a shame we’re having one and two and three Tommy John (shoulder operation) recipients.

    So I want to encourage you, if nothing else, know that your children’s passion and desire to play baseball is something that they can do without a competitive pitch. Every throw a kid makes today is a competitive pitch. They don’t go outside, they don’t have fun, they don’t throw enough – but they’re competing and maxing out too hard, too early, and that’s why we’re having these problems. So please, take care of those great future arms.”

    Baseball Hall of Fame induction speech, former Atlanta Brave pitcher John Smoltz

    If an adult is present, then the sport is organised. If the kids are left to their own devices they play more, compete with each other and on their own terms.

    Further reading :

  5. How can I stop my child getting injured?

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    “Injured young athletes are older, spend more time in organized sports, and specialize too early”

    injury prevention

    Could this be prevented?

    The evidence is quite stark if your child is spending too much time in organised activity rather than free play, if they have specialised in one sport and if they have gone through their growth spurt, then they are more likely to get injured (1).

    • 34% of middle school sports participants get injured each year with an estimated medical bill of $2billion (5).
    • Talented (or early developing) children get asked to play more sport and therefore have higher injury risk (2).
    • The cumulative workload increases injury risk e.g. Cricketers who do more than 75 throws a week (3).
    • Early specialisation in one sport leads to an increase in injury risk (4).
    • Young athletes participating in more sports hrs/wk than their age and participating in>2 times organized sports:free play are more likely to have a serious overuse injury (1).
    • Injury risk increases in teenage girls from 12-13 years old and teenage boys from 14-15 years old: at their growth spurts (6).

    Injury Prevention is always better than cure

    Why wait until your player is injured? I prefer to have healthy athletes available all year round.

    A 2 pronged approach is necessary to greatly reduce the risk of your child or player getting injured.

    1. Plan your schedule of training and competing. Include free play time.
    2. Implement a strength/ co-ordination exercise regime and stick to it.

    how to prevent injuryPlanning: The best place to start is to look at the next 4 weeks. Use this free 4 weekly planner to help. Put in all the school p.e., games and matches, then club training and matches, plus other activities.

    You will probably see a lot of competing and travel, with very few rest days, and little planned physical preparation: running, speed or strength work.

    How much free play does your child do? That is “jumpers for goal posts” mucking about with friends in the local park or school playground? None? Then they are at greater risk of injury!

    Decisions will have to be made about what is a priority, what is “need to do” rather than “nice to do”. If you are playing more than one age group of a sport, then you should consider dropping the lower one.

    Coaches should look at the overall workload that their best players are undergoing: it is unsustainable! Can you afford to lose your best player mid-season?

    how to stop getting injuredStrength/co-ordination training: It is the ability to control your own body throughout the match and the season that is the key to avoid getting injured. Your exercise programme has to be specific for young athletes: time spent on crosstrainers, exercise bikes and lying down on a bench is time wasted.

    They need to lunge, squat, brace, rotate, push and pull: in combination with braking, landing, jumping and moving from 2 legs to 1 leg, up, down and side to side.

    I get athletes to implement daily routines, at first only 5 minutes, then building up from there. This summer I have designed specific warm up routines for team sports players based on the recent research and my experience.

    Members of the Athletic Development Club have all been given my newly designed protocol cards to help them through the season.

    injury prevention

    Leg strengthening work

    The 11-12 minute warm ups contains all the movements necessary to help reduce the likelihood of injury, as well as improve their sporting performance. If done before every training session and match, the cumulative positive effect will be huge.

    Coaches and teachers need to take responsibility

    Quality does not just happen. People who believe so, are people who trust in miracles to make their way through life.  Quality excellence is an outcome of preparation and relentless practice. It is surely a given then, that there is time set aside routinely for this.” Frank Dick, Winning Matters.

    injury prevention

    Resisted running drills

    I often hear coaches and teachers bemoan the fact that they are struggling to field a team by December due to injuries.  Are they still practicing warm up routines that are ineffective and full of time fillers such as jogging, or encourage incorrect mechanics such as high knees and heel flicks?

    Do they have a strength programme that helps improve performance and prevent injury? Or do they just use generic exercises that require little co-ordination and involve a lot of sitting or lying down?

    A lot of coaches say they are doing the right thing, but how do they know?

    Badminton coach James Elkin, Volleyball coach Denise Austin and the Fencing coaches at the SWFencing Hub have shown a great Growth Mindset by looking at what we are doing with their athletes and then changing their practice.

    Summary

    injury prevention programme

    Technical drills

    Injuries are far from things “that just happen“. Chronic pain is abnormal in teenagers, it can be prevented.

    Parents, look at how much physical preparation and free play your child is involved in compared to organised camps, travel and competing.

    Coaches and teachers either come to one of our strength and conditioning coaching courses or I can run a workshop for your staff that will help all your players and teams.

    Let’s work together to help produce healthy, happy and thriving young sportspeople.

    This video discussion with Brian McCormick gives more of an overview and guide for parents.

    References

    1. Br J Sports Med 2014 48: 611
    2. Br J Sports Med 2014;48:1265–1267.
    3. Br J Sports Med 2011;45:805–8.
    4. Br J Sports Med 2013;47:503–7.
    5. The Physician and Sportsmedicine 42(2): p146-153 (2014).
    6. Acta Orthop. 80(5) p563–567 (2009).
  6. How to reduce the risk of ACL injury for females.

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    Why are Females at Higher Risk of ACL Injury?

    Female athletes have a 4-6 times higher incidence of ACL injury than do male athletes participating in the same landing and pivoting sports” (1)

    Hormonal changes: Hormonal changes during the menstrual cycle can have a direct effect on neuro-muscular performance.

    Anatomical differences: Females have a smaller intercondylar notch, therefore a smaller ACL.

    An Increased Q Angle will influence landing technique negatively.

    Slower reaction times: Females have slower and less efficient reaction times due to different neuro-physiology i.e.differences in spinal motor control.

    Poor landing mechanics: Reduced leg power will cause an increased reliance on the quadriceps and ligamentous structures at the knee and ankle .An increased Q angle in females has a direct impact on landing mechanics.

    Less power: Females have reduced power and muscle development.

    Implementation of practical neuro-muscular warm-up strategies can reduce lower extremity injury incidence in young, amateur female athletes.” (2) 

    Reducing the risk of ACL injury

    This diagram summarises the key factors found in recent research on preventing ACL injuries in female athletes.

     

    Screening: Musculo-skeletal screening can help identify specific problem areas for each individual athlete

    Footwear: Wear appropriate and good quality footwear to facilitate good foot/ankle mechanics and help control ground reaction forces.

    Conditioning: Functional conditioning work, related to individual screening outcomes and specific to sport requirements. To include stretching, strengthening, plyometrics, review of landing techniques, sports specific drills and balance exercises.

    Warm Up: Use practical neuro-muscular warm-up strategies (see conditioning work).

    Oral Contraceptives: Use of oral contraceptives pre-competition has been shown to have an effect. Reearch is hampered by ethical concerns.

    Further Reading: 

    References:

    1. Hewett et al American Journal of Sports medicine March 2006 34(3) 490-498
    2. Herman et al BMC Medicine July 2012 19 10(75)
    3.  Stojanovic et al Research in Sports Medicine July 2012 20(3-4) 223-238
    4.  Walden et al British medical Journal May 2012 344 e3042
    5.  Irmischer et al Journal of Strength and Conditioning Research November 2004  18(4) 703-707

     Sarah Marshall Chartered Physiotherapist

  7. Planned Performance Training: Bill Knowles

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    “Having nothing enhanced my career”

    bill knowlesBill Knowles doesn’t have any magic answers or quick fix exercises.  His approach to injury rehabilitation based on good coaching and insisting on excellence in every exercise means injured athletes getting back to competition readiness sooner.

    Knowles delivered a quite extensive review of his methods and some research on “Return to competition strategies for the load compromised athlete”. This included video clips of his athletes working and also his ideas on creating the right environment and team for athletes to excel within.

    He started out having to work with big groups of people and not much kit, so he had to innovate and adapt right from the beginning.

    Planned Performance Reconditioning (PPR) not injury rehabilitation

    Knowles started with talking about why he doesn’t use terms like “prehab” or “rehab”. These imply start and end points and a medical based model. The athlete would then walk back on to the pitch, start competition and get reinjured.

    Instead, the PPR should be an opportunity to get the athlete better and to ensure that they are stretched, challenged and engaged throughout the process. “Ultimately injury is an opportunity to become a better soccer playing athlete and potentially a better soccer player”.

    In high performance sports you should STRIVE for a better soccer player.

    In order to evaluate and plan what you are doing you need to combine Evidence Based Medicine (Science) with Experience Based Evidence (Art).

    The coaching of the rehab process was emphasised time and again, the athlete and the exercise must be coached well. “Exercise is something you do, movement is something you feel” get the athlete out of the injury and remember who they are”.

     A Joint Compromised Athlete is a Load Compromised Athlete

    JCA  injury rehabilitation  LCA

    The joint is not to be trained in isolation, it is part of the whole body and the loading has been compromised too.

    Once you are a LCA you are always an LCA. That is why you need an “Athlete Sustainability Programme”. This is something that is included throughout the year to prevent lapses.

    This is a Performance based model, compared to a Physio or Medical based model: they are not experts in planning performance training.

    This was a theme that came up several times over the conference (And Rob Newton mentioned this at the RFU conference too about Australian sport) where teams are now letting physios lead training sessions with “Pilates” or “core” and wondering why they are not performing on the pitch!

     “It’s a brain injury dude”

    Knowles explained something called “Arthrogenic Muscle Inhibition” (AMI) which is the change of the sensory receptors due to injury. This results in an inability to completely contract a muscle.

    This is a bilateral situation: Quadricep activation deficits of 7-26% in the unaffected limb have been measured. After an ACL injury the athlete is more likely to tear the opposite knee, and more likely to get reinjured than the non injured athlete.

    The AMI is severe in the short term, plateaus at about 6 months, and slowly declines over the next 18-33 months! So, training the rest of the body is important to prevent that getting weaker too. This must be continued for nearly 3 years!

    The brain has to be worked and rehabbed too: so lots of new challenges, games and activities must be included to ensure the athlete is ready to play and compete.

    The knee bone is connected to the head bone”.

    The Central Nervous System has been affected, so this must be trained too: “It is not a race to get them back, it is a process to get them better” Gambetta.

    Envelope of healing

    The upper limit of the envelope is for the elite athlete, but too much work leads to inflammation. Too little work is safer, but it is not causing enough adaptability.

    There are no time frames for the rehab procedures, instead criteria based progressions are needed. Function leads to the next stage. For example, biologically running might be right after 8 weeks, but mechanically the loading ability isn’t ready.

    The LTAD process gets interrupted by an injury, so other areas need to be worked on during the recovery. Contact sports players need to be “toughened up” to prepare for training, others can develop volume, load or skill ability. It can be a time to “increase the player’s bandwidth” of exercise competency.

    There are so many things that can be done to “stop the bleeding of skills and mindset” when injured.  Knowles gave great examples of working with golfers and soccer players on using limited skills, or slower actions with severely injured players very early on in the rehab process.

    Summary

    It was great to see how a World Class expert in rehab works, and how he is passionate about coaching athletes. The videos we watched and practical demonstrations we saw and did later really opened my eyes. (Physiotherapist Sarah and I discussed this when doing the rebounder exercises).

    The “Progression, Variety and Precision” that Ed Thomas talked about were very apparent in Knowles’s work.

    One of the good things about GAIN is the interaction between different professions. Everyone was learning from each other and recognising the transfer across areas.

    Come to our clinic

    If you want your sports injury rehabilitated, then you can come to our physiotherapy clinic based in Willand, Devon. Physiotherapist Sarah Marshall and myself have helped many athletes return to competition from injury.

  8. PRICE Guidelines for injury treatment

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    Current recommendations on treating injuries

    After witnessing the aftermath of the parents’ races at my daughters’ school sports day last week, I decided to review  the current Executive Summary of the Management of Acute Soft Tissue Protection, Rest, Ice, Compression and Elevation (PRICE) by the Association of Chartered Physiotherapists in Sports and Exercise medicine (ACPSM).

    PRICE guidelinesThe previous recommendations by the ACPSM were made based on evidence published up to 1996. These current clinical guidelines, which I have summarised below, were produced by a team of volunteers using evidence up to 2010. Each PRICE intervention has been graded as STRONG, WEAK or UNCERTAIN.

    PROTECTION AND REST (STRONG)

    Definitely unload soft tissue in acute phases after injury”. WHY?

    • Minimise internal bleeding
    • Prevent excessive swelling
    • Prevent re –injury

    The type and duration of the protection /resting phase is not clear and will depend on the specific injury and its severity.

    Progressive and mechanical loading plays a vital role in tissue healing. The transition from this protective stage needs to be supervised by a Physiotherapist.

    ICE (STRONG)

    Definitely apply ice after an acute soft tissue injury.” WHY?

    Cooling the tissues…..

    • Can limit the extent of the soft tissue injury
    • Provides pain relief
    • Can facilitate rehabilitation

    The guidelines suggest that crushed ice in a bag which is wrapped with a ‘damp barrier’ i.e. damp cloth or tea towel is applied to the area for 5 – 15 minutes every 2 hours.

    During sporting events, application of ice for > 10 minutes can have an adverse effect on athletic performance and increase injury risk.

    COMPRESSION AND ELEVATION (WEAK)

    sports injury treatmentProbably use compression/elevation after an acute soft tissue injury. WHY?

    • to limit tissue swelling
    • can reduce pain due to increased tissue pressures

    Evidence is poor to support the use of elevation and most of the research is conflicting regarding the use of compression.

    The guidelines conclude, “Probably don’t use high levels of compression with simultaneous elevation.”

    If compression bandages or external supports are used they must fit well. They can offer some support and give confidence to the injured when returning to normal function.

    Always consult with a Physiotherapist or an appropriate medical professional after a significant soft tissue injury.

    Sarah Marshall 

     

  9. Shoulder pain- how to get it better

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    In response to Tommy’s question about persistent shoulder pain.
    If you have shoulder pain, then there are a few things you need to do:

    Diagnosis- what is actually wrong with it? Going to the GP and being told to rest and given some anti inflammatories may work in the immediate future, but not necessarily in the long term.

    Similarly if you have a serious tear or rupture, then doing any exercise will make it worse- so you need to understand how severe it is first. Book in for a Physiotherapy (based in Willand, Cullompton) appointment to get the correct diagnosis.

    Do not participate in sport until you are pain free.

    The Rehabilitation process

    shoulder injuryStart to work on low level movement and control exercises. This includes extended press ups either against the wall or on the floor, shoulder rolls, shrugs, and protraction exercises.

    Isometric contractions are also useful in strengthening a specific weak point under control. So for a thrower/ striker/ racquet sport player, that might mean getting into your sport stance close to a wall and then pushing against that wall for 3-5 seconds quite hard. Rest for 10 seconds, then repeat 3-5 times. See how that react the next day and then you can increase that.

    If you have chronic shoulder pain, then it may mean you have to do these exercises on a daily basis as a preventative tool. (The same applies to chronic low back pain). Five minutes a day, every day will help stabilise that joint.
    From there you can start to add in multi joint exercises that use the shoulder in more functional ways- dips, press ups (lots of variety here), pull ups, dumbbell presses, and throwing lighter implements for short distances.

    Remember: Diagnose, move, stabilise, strengthen, function and consistency.

    However, this does not apply to healthy athletes- if it ain’t broke- don’t fix it.

    Instead try this series of healthy shoulder exercises to keep things working.

  10. How to manage “Growing pains”

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    A guide to common growing pains in athletes

    Osgood-SchlattersChildren and adolescents endure many of the same injuries and mechanical dysfunctions as adults. However, in the maturing skeleton there are some specific conditions that are only seen in the young.

    Here is an overview of the common conditions, their causes and how to manage them.

    Osgood -Schlatters, Sinding-Larsen-Johansson and Severs lesions

    These are non-articular types of osteochondrosis or ‘traction apophysitis’. These specific conditions affect the growth plates, where muscle tendons attach to bone.

    They are normally seen in the more active and sporty adolescents during or after a growth spurt. Either one or both limbs can be affected. All three of these conditions are self- limiting and in some cases the symptoms can continue for years.

    Recovery rates will vary between each child. Investigations such as x-ray and diagnostic ultrasound are not normally indicated to make a diagnosis.

    • Osgood-Schlatters

    A common cause of anterior knee pain in the young athlete. Pain, swelling and local tenderness will be present at the tibial tuberosity, where the patella tendon attaches below the knee joint. In some cases a boney lump can be seen. Affects boys more than girls.

    • Sinding-Larson-JohanssonSinding-Larsen-Johansson

    A less common cause of anterior knee pain in the young athlete. Pain, swelling and local tenderness will be present at the inferior pole of the patella, at the superior end of the patella tendon (at the bottom of the knee cap).

    • Severs

    A common cause of heel pain in young athletes. Pain, swelling and local tenderness will be present where the Achilles tendon attaches onto the heel.

    What are the causes of Growing Pains?

    • Growth spurt (during this period bone will lengthen before muscle. This will put increased pressure on tendon attachment during exercise)   Increased intensity of training
    • Adaptation to a new sport, especially those which involve running and jumping.
    • Reduced muscle length, especially during or after a growth spurt.
    • Reduced muscle strength.
    • Poor control / stability at the spine and pelvis.
    • Poor foot mechanics.

    How to manage the condition

    • growing painsMonitor and keep a record of the child’s growth. This can help to adapt training needs specifically .e.g. during a growth spurt an increased emphasis on stretching is required and maybe some reduced activity.
    • Reassurance to the child that his/her condition is relatively short term and that by continuing with their sport is not doing any harm.
    • Activity modification (this should be guided by pain levels. There is no evidence to suggest that prolonged and complete rest is beneficial)
    • Regular stretching of the surrounding muscle groups
    • Strengthening of the surrounding muscle groups. This should be focused on during periods of reduced symptoms and limited growth.
    • Spinal and pelvic stability / control work.
    • Assessment of foot mechanics Maybe a need to change footwear or use of orthotics. Small heel raises or gel cushions can be useful to control the symptoms of severs.
    • Use of ice locally
    • Use of massage to surrounding muscles
    • Seek medical advice regarding use of analgesics and anti-inflammatories.

    Summary

    Growing Pains could be considered a normal part of growing up. A sound training plan and recognition of sudden changes in growth can help guide the young athlete through the problem.

    Any young athlete who is complaining of pain needs to be assessed by a medical professional.  You can book in at my Physiotherapy clinic in Willand, Cullompton, Devon.

    References

    1. ‘A heel cup improves the function of the heel pad in Severs injury : effects on heel pad thickness, peak pressure and pain.’ Perhamre et al. Scandinavian Journal of Medicine and Science. August 2012.vol 22.4.p516.
    2.  ‘Childhood lower-limb apophyseal  syndromes : “what is the egg on my leg?.”’ Stickland. SportEX Medicine. Jan 2011.47.p22.
    3. ‘Adolescent anterior knee pain’ Gerbino et al.Operative techniques in Sports Medicine. July 2006.vol 14.3.p203.
    4. Clinical Sports Medicine. Bruckner et Al. Third edition 2006.Mcgraw-Hill Australia Pty Ltd.

    Sarah Marshall Chartered Physiotherapist.