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Things are constantly evolving in the world of sports medicine. With a better understanding of how the human body works, comes an ever changing understanding of how best to treat it. One such notion which needs to be challenged is the age old acronym of R.I.C.E (Rest, Ice, Compress, Elevate) used for the management of acute injuries.

The “Rest” part of this strategy may in fact cause delayed healing and muscle atrophy. Several studies that have compared early PAIN-FREE movement to complete rest have shown decreased healing times and improved pain.

As I stated above, what is quite important is to start moving early on, but specifically without pain. Even some serious injuries/operations should allow for a degree of movement that is pain free.

Another area of uncertainty is the application of “ICE”. Whilst there is evidence that ice causes a numbing effect on tissue (by decreasing the speed and transmission of nerves), thereby reducing pain, the notion that icing decreases the inflammatory response and speeds up healing is being challenged.

Some studies are showing that the application of early ice (for 20 minutes in the acute stage of an injury) may in fact reduce the healing potential of tissue, and cause longer term negative effects on the healing collagen. So if your intention is to reduce pain, then ice may be appropriate, but if you think you are assisting the body healing process, think again…

What is now being suggested is a new acronym – M.E.A.T

MOVEMENT – as discussed earlier, must be pain-free

EXERCISE – the correct exercises done early on have been shown to reduce muscle wasting and improve outcomes

ANALGESICS – used to control acute pain, but be careful not to “mask” the pain so you can go back to activity too quickly. Again, avoid anti-inflammatories at first.

TREATMENT – from a Physiotherapist or other sports medicine practitioner. We can use other modalities to improve circulation and assist healing.

The Editor in Chief of The Physician and Sports Medicine Journal was quoted as saying,”Do you honestly believe that your body’s natural inflammatory response is a mistake?” I’ve said it in my article on anti-inflammatories, the first stage of healing is INFLAMMATION, but it seems we have all been hell-bent on trying to stop this.

It would appear that the more we learn about how to heal the human body, the more we realise it does a pretty good job, all on its own!

Ric@PhysioPRO

Shock wave therapy (also known as extracorporeal shock wave) is a cutting edge form of treatment in the world of sports medicine. Its a very similar technology to that used to “blast” kidney and gallstones, and does not involve electrical shocks (don’t panic, this isn’t the dark ages) but rather mechanical pulses, similar to sound waves.

Although the physiological mechanism of how exactly this mechanical pulse works is still not fully understood, the research shows us that the “waves” cause microtrauma and inflammation, stimulating the formation of new blood vessels and nerve cells, and speeding up healing of tissue. There is also a positive effect on reducing pain through a pain gate mechanism.

In other words, it improves blood supply and speeds up tissue regeneration!

So why is this so amazing you ask?

Well basically its taking something the body would normally do on its own, and speeds it up significantly, without the need for injections or surgery. Numerous medical research reports have shown that shockwave therapy can be 80-90% effective at completely and rapidly resolving injuries within 3-6 applications.

The most significant application in sports medicine is in the treatment of chronic tendon, muscle and joint conditions. So things like:

• Tennis elbow/ Golfers elbow
• Rotator cuff tendinopathy
• Frozen Shoulder
• Trochanteric Bursitis
• Hamstring tendinopathy
• Achilles tendinpathy
• Patella tendinopathy
• Plantar fasciitis
• Muscle knots and trigger points
• ITB friction syndrome
• Chronic ligament pain
• And even more conditions are healing in weeks instead of months…

It is particularly effective in breaking down the calcification of tendons, commonly seen in the shoulders, as can be seen in the x-rays below…

As technology and techniques improve, so will we find new uses for shock wave therapy. In fact, I chatted to a Doctor at one of the top SA rugby teams, who said they use shock wave to treat nearly all injuries on their players and are getting fantastic results.

Already studies show that in bone fractures that either wont heal quickly, or at all, the application of a single shock wave treatment was effective in causing fracture healing in 87% of patients.

It also has applications in the healing of diabetic foot ulcers, treating cardiac chest pain and erectile dysfunction…but don’t come to me for that!

So if you, or anyone you know has one of the above conditions, give us a call to see if Shock Wave Therapy might be the treatment for you…

Ric@PhysioPRO

How to safely increase your running distance

With summer just around the corner, most people have started getting ready for their beach body. You may have taken up any number of sports to achieve this, but certainly, the most common “seasonal sport” is running. Running is a relatively cheap, easily accessible sport, but if you are not careful with how you increase your distance it could turn into a costly exercise…

Most runners have heard of the 10% rule. This states that you should never increase your distance by more than 10% from the previous week. This “rule” has not been validated by science and a recent article published in the Journal of Sports and Orthopaedic Physical Therapy, revealed some interesting findings.

The study followed 874 novice runners for 1 year and gave each runner a GPS watch to track their distance. Based on their weekly running increase, they were placed into one of three groups: less than 10%, 10%-30% and more than 30%. In total 202 participants sustained an injury over the course of 1 year and what will surprise most is that the total number of injuries per group were not much different.

Yes, there was an increase in the number of distance related injuries in the group that increased by more than 30% compared to the group that increased by less than 10%. So injuries like patellofemoral pain (runners knee), iliotibial band syndrome, medial tibial stress syndrome (shin splints), gluteus medius injury, greater trochanteric bursitis, injury to the tensor fascia latae, and patellar tendinopathy (jumpers knee) were more common in the group that increased training distance by more than 30%.

A possible explanation for this is that when you increase your distance, your running speed decreases (especially if you get fatigued). If your speed decreases, you have to take more steps to complete a given distance and the increased number of steps equates to increased “wear and tear”.

However, this was not true for all injuries. Injuries like plantar fasciitis, Achilles tendinopathy, calf injuries, hamstring injuries, tibial stress fractures, and hip flexor strains were just as common in all 3 groups. These injuries may be linked to running pace rather than distance, and its only through more research that these answers will be revealed.

So, all that science can presently advise is that you progress your weekly distances by less than 30% per week over a 2-week period.

Train smartly!

Ric@PhysioPRO

Article by Rasmus et al, titled “Excessive Progression in Weekly Running Distance and Risk of Running-Related Injuries: An Association Which Varies According to Type of Injury” J Orthop Sports Phys Ther 2014;44(10):739-747. Epub 25 August 2014. doi:10.2519/jospt.2014.5164

In May 2012 I wrote an article on “The risk factors in knee pain”. In this article I discussed a study which showed the relevant risk factors in developing ANTERIOR knee pain, or otherwise known as Patello-Femoral Pain Syndrome (PFPS). You can read the article by clicking HERE.

In this study, one of the five risk factors that were found to be associated with PFPS, was “STRENGTH”, specifically that of the Quadriceps muscles which straighten your knee. Some of the advice then given was to strengthen your quadricep muscle through exercises such as squats and resisted knee extension.

Now, in a more recent study which examined the amount of strain placed on the Patello-femoral joint (knee-cap) during different exercises (squats and knee extension), researchers were able to conclude that there are “safe” ranges of motion during these exercises as well as “unsafe” ranges, which would either place a little or a lot of strain on the Patello-femoral joint.

:

Results:

What the above image demonstrates is that during a squat movement, the “safe” range of motion is between 0 and 45 degrees of knee bending, and the “unsafe” zone from 45 to 90 degrees of bend. So when performing a squat to strengthen the quadricep muscle in PFPS, ONLY GO HALF WAY DOWN!

However, when performing a seated knee extension exercise, the “safe zone” is from 45 to 90 degrees, and the “unsafe zone”, 0 to 45 degrees of bend. So when performing a resisted leg extension exercise, ONLY GO HALF WAY UP!

By training in the “safe” zones for both of these types of exercises, you can strengthen your quadriceps muscles and at the same time, avoid feeling knee pain. If you are already experiencing pain under your knee cap, always consult your Physio prior to starting these exercises. Once you can do these exercises pain free, your Physio will progress them accordingly.

Ric@PhysioPRO

Article by Powers et al, titled “Patellofemoral Joint Stress During Weight-Bearing and Non–Weight-Bearing Quadriceps Exercises,” J Orthop Sports Phys Ther 2014;44(5):320-327. Epub 27 March 2014.doi:10.2519/jospt.2014.4936 

Back in 2011 I wrote an article called “How your BUM controls your BODY”.  In the article I explained why the gluteus muscles are such an important muscle to train because it directly affected your ankles, knees and hips. If you haven’t already read it, then I suggest you go read it by clicking here.

In about 90% of lower leg injuries, I find that these gluteus muscle needs strengthening, so its crucial if you have any of those conditions mentioned in the previous article. In the article I only showed one exercise to do that targeted that gluteus muscle. Today I want to give you some more so you can really work it.

Advanced Clam

The starting position for this exercise is much the same as for the original Clam shell exercise (lying on your side,knees bent and  heels touching). Place your forearm on the floor and then “push” your bottom knee into the floor, forcing your body to lift up off the floor-similar to a side plank.  Now move the top knee up and down, but keep the heels touching.

The difference here is that you are training BOTH bum muscles at the same time. The bottom leg’s bum muscle is having to hold you up whilst keeping static (isometric) whilst the top leg’s bum muscle is moving the top leg (concentric). Trust me, it’s a real killer and you should feel the burn in your bum, right behind your hip. Once you can do 3 sets of 15 reps, then try adding an elastic band around your knees. An added advantage of this exercise is that is also trains your core at the same time!

This one looks easy but don’t be fooled… Stand with one leg over the edge of a step. Now keeping both knees LOCKED OUT STRAIGHT, lower your one leg by dropping your pelvis down on that side (keep those knees straight!). Now lift that leg as high up as you can and repeat. You want to concentrate on slowly lowering the leg (eccentric movement), and you should feel a burn in the gluteus muscle of the leg that you are standing on. Again, do 3sets of 10-15, but the slower you go the better.

So there you have it, two more exercises to add to your prevention program! And to all my CrossFit Athletes, this WILL help with your squat form! Tight buns

Ric@PhysioPRO

Anterior knee pain is a common complaint among sportsmen. One of the main causes of anterior knee pain in younger athletes is a condition known as Osgood-Schlatter lesion.

This condition is extremely common in teenage boys with a high level of physical activity, generally occurring at the time of a growth spurt. Mainly associated with sports involving a lot of running and jumping e.g. basketball, soccer, gymnastics etc.

Examination reveals tenderness and pain over the tibial tuberosity (a small outgrowth on the shin bone where the patellar tendon attaches), with associated tightness of the quadriceps muscle. Excessive subtalar pronation (flat feet) may predispose the adolescent to the development of this condition.

The pain is mostly aggravated by exercise and thus the management of the condition requires the athlete to modify their activity levels i.e. the less activity they do, the less pain they will have. Osgood-Schlatter lesion is a self-limiting condition, which means with time it will resolve by itself but may take up to 2 years. This can be very frustrating for the athlete and parents especially if they do not understand the nature of the condition. In the long term the athlete may develop a thickening and prominence of the tibial tubercle which will present as a bump on their shin bone just below the knee.

When the athlete is suffering from pain the symptomatic management includes icing the region, electrotherapy, massaging and releasing the quadriceps muscle, stretching as well as correcting any subtalar pronation if present.

So if you are suffering from this condition head to your local physiotherapist for advise and treatment.

Andrew@PhysioPRO

I’m sure many of you out there have heard of the acronym “RICE”  which is used by athletes all over the world post acute injury. Where the R = Rest, I = Ice, C = Compression and the E = Elevation. One other very important letter can be added to this acronym which can have a huge impact on the athletes sporting career and well being…that letter is P…changing the acronym to “PRICE”  with the P representing Prevention.

If we can prevent or at least minimise an athlete’s potential for injury our work as sports physiotherapists is half done.

The International Federation of Associated Football (FIFA) recognized this and developed an injury prevention warm up program known as “FIFA 11+” mainly to prevent ACL (Anterior Cruciate Ligament) tears. The program is divided into 3 Sections:

• Part 1: focusing on slow speed running exercises with active stretching and player contact.
• Part 2: Six sets of exercises each with 3 levels of difficulty focusing on core and leg strength, balance and plyometrics.
• Part 3: Moderate to high speed running exercises combined with planting/cutting movements.

To download the full program please visit the FIFA 11+ site http://f-marc.com/11plus/home/

Things to remember: you need to be 14 yrs and older to start using the FIFA 11+ program and always use proper technique during all of the exercises, focusing on your form and posture.

For a prevention program to be beneficial it needs to be done at least twice a week and the exercises should be sport specific focusing on plyometrics, balance and strengthening.

So till next time remember…Prevention is better than Cure!

Andrew@PhysioPRO

Lateral knee pain (pain felt on the outside of the knee) is a common problem especially among long distance runners and cyclists.

The most common cause of lateral knee pain is probably iliotibial band friction syndrome (ITBFS). Other causes include lateral meniscus abnormalities, patellofemoral syndrome, biceps femoris tendinopathy (one of the hamstring muscles) and superior tibiofibular sprain. In some cases the pain could even be referring from the lumbar spine.

With so many possible causes of lateral knee pain, it is vital to make the correct diagnosis by

a)     looking at the mechanism of injury – in other words how you hurt yourself

b)    looking at the activity that brings on the pain

c)     having specific tests done by your physiotherapist

Your Iliotibial band (ITB) is a lateral thickening of the fascia surrounding your thigh. Proximally at the hip the tensor fascia lata muscle inserts into the ITB, as does a portion of the gluteus maximus muscle. Distally the ITB inserts onto the patella and tibia. Thus you can see by its attachments that it plays a role in lateral stability both at the knee and the hip joints.

The ITB has many functions

• Stabilising the pelvis in stance
• Flexion (bending), abducting (moving to the side away from the body) and medial rotation (turning inwards) of the hip
• Stabilising the knee in extension (when its straight)
• Lateral rotation (turning outwards) of the tibia on the femur

Iliotibial band friction syndrome (ITBFS) is an overuse injury presenting as lateral knee pain that is exacerbated by sporting activity.  Tenderness is elicited over the lateral femoral epicondyle which is 2-3 cm above the lateral joint line of the knee. The pain often develops at the same time or distance during the aggravating activity. A change in training methods or shoes, longer training and downhill running are often aggravating factors.

Obers test (which would be done by your physiotherapist) would reveal ITB tightness and quite possibly the patient would have tightness and shortening of the tensor fascia lata and gluteus maximus musles, which as discussed earlier, are attached to the ITB.

Treatment with ice and electrotherapy or corticosteroid injection should not only be focused locally on the lateral knee but foot and hip biomechanics should be looked at for more favourable long term results. It has been shown that runners with ITBFS can have significantly weak hip abductors in the affected limb, so focusing on correcting the underlying weakness and fatigability in these muscles is quite important. Myofascial release of the ITB, tensor fascia lata and gluteal muscles as well stretching these muscles is very beneficial. Dry needling and use of a foam roller may also be recommended.

The last resort – if all conservative management fails – is surgery. But before you decided to go under the knife visit your physiotherapist and see if they can’t provide a solution that works for you.

Andrew@PhysioPRO

This unfortunate injury is associated with sports that involve repetitive running, jumping, or kicking such as soccer and rugby.

The patella (kneecap) is a loose bone that sits in your quadriceps and patella tendons. It glides up and down a groove (the trochlea groove of the femoral condyle) as you bend and straighten your knee.

Patellar dislocation occurs when the patella is displaced from this groove, most commonly laterally (towards the outside of the knee). This may either be caused by something traumatic especially where there is a history of a traumatic force to the kneecap or it can occur in the absence of trauma as is the case in young girls with associated ligamentous laxity

The stabiliser in your kneecap that protects against displacement is the medial patellofemoral ligament. Anatomically it acts as a passive check to prevent the patella from extreme lateral displacement which is why we find that in the majority of dislocation cases it is disrupted.

Patients usually complain of the knee suddenly giving way while jumping or running/twisting and the subsequent development of severe pain. A feeling of something “moving out of place” or “popping” is quite common. Often the dislocation reduces spontaneously with knee extension. But, swelling develops almost immediately.

It is common to mistake this injury for an Anterior Cruciate Ligament ( ACL)  rupture as both conditions have similar mechanisms of injury with an audible “pop” and giving way of the leg as well as a quick development of swelling. But, on examination of a patellar dislocation there is usually gross swelling, marked tenderness over the medial (inside) border of the patella and when attempting to push the patella in a lateral direction the patient experiences pain or apprehension. Quadriceps muscle contraction aggravates the pain.

Most first-time dislocations are treated without surgery, with pain relief medication, immobilization of your knee with an extension splint for 2-3 weeks. During this time period you should be using crutches, and be following a rehabilitation program.

The most important aim of rehabilitation after such an injury is to reduce the chances of a recurrence. Hence the rehab program is lengthy and emphasizes core stability, vastus medialis obliquus strength, and stretching of the lateral structures when tight.

Surgery is indicated for second dislocations, or in patients not improving with appropriate rehabilitation (the re-dislocation rate after primary patellar dislocation managed non-operatively is anywhere between 15-44%). Medial patellofemoral surgery has become the surgery of choice.

So if you find yourself “buckled at the knees”, follow the RICE principle in the acute stage (Rest, Ice, Compression and Elevation) and seek treatment from your physiotherapist and/or orthopaedic doctor.

Andrew@PhysioPRO