Month: September 2017

Hamstring injury management – A breakdown of the latest research

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Sliding exercise

Athletes rejoice! For decades our understanding of hamstring (HS) injuries has been improving and evolving, yet the frequency of HS injury rates in sport have not declined. Finally, a new paradigm has been developed which consolidates our knowledge of the anatomy and the physiology of this highly prevalent injury, applies effective rehabilitation strategies, accurate return to sport testing and re-injury prevention.

We can broadly define the typical hamstring strain into a sprinting type strain which occurs at high speed running versus a stretch type strain which occurs with high kicking or other stretching movements. Each of these will typically cause an injury to a different muscle in the hamstrings group. They can generally be diagnosed in the clinic without the need for any imaging. The most common type is the sprinting type, frequently seen in football codes, soccer, hockey, athletics and other running sports. The stretch type is more common in dancers, jumpers and hurdlers, although either type can occur in any sport. Knowing the type of injury gives us a chance to apply the right exercise rehab as well as gives a guideline for the return to sport time, which varies enormously between the type, location and grade of strain.

We know that most HS injuries occur when the muscle is working hard in its lengthening phase, therefore it is essential that the rehabilitation program targets this movement at high load. A comprehensive program is undertaken, which incorporates hamstring strength, but also hip, pelvis, trunk and general lower limb strength and stability. This addresses all the factors which will lead to re-injury – that’s not new. What is new is a set of 3 specific exercises, that when applied correctly in soccer players led to a re-injury rate of only 1 in 75 players over 12 months! That’s way down from the average 1 in 4 players with conventional rehab in professional soccer.

The protocol is based on 3 specific lengthening (eccentric) strength exercises and the technique, timing and progressions of these are of critical importance, they need to be integrated and complemented with other exercises and, as a rule, should be pain free. So what can you expect to gain from completing a modern rehab program like the one we provide at NU Moves? A research study by Askling and colleagues found that their protocol of exercises led to an average return to play time of 28 days, compared with 51 days for the conventional group. Combining this with the low reinjury rate means it was proven to be a much better approach to HS rehab. The research also provided an additional return to play testing procedure (H test), which we integrate into our comprehensive existing return to play algorithm in the clinic. It assesses apprehension or feeling of insecurity as well as pain when performing a high load eccentric braking action on the leg, similar to what happens during an injury but in a safe way.

So to put it all together, we have a rehab protocol that fits well with our current understanding of hamstring strains and their risk factors. It is easy and inexpensive to perform once taught. It also reduces the time to return to play and gives better long-term outcomes. If you are ever unlucky enough to be in this position, then things are looking better now than they ever have!

NU Moves physio provides sports physio services to clubs around newcastle. For more information contact us online or give us a call and to view our current sports teams or what services we provide, click here.

Feel better through movement

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Manual physio newcastle

The Uni Physio Clinic on Callaghan campus is located within The Forum Sports Centre. NU Moves has been helping staff and students for more than a decade now, specialising in manual therapy, exercise prescription, and rehabilitation. Our goal is to help you feel better in the short term and increase movement / exercise in the long term.

Are you currently:

  • Sitting most of the day?
  • Not exercising daily?
  • Stressed (workload, interactional, emotional)?
  • Have any neck / shoulder or back / hip pain?

If you answer yes to 3 or 4 of these questions then it’s time to reflect and make some changes to your daily habits now.

If you answer yes to the first 2 questions then consider how you can start to fit a walk or another exercise you enjoy into your day. The goal for long term health and feeling better now is 30 mins of activity per day. It can also help prevent muscular pain associated with excess sitting.

If you have neck & shoulder or back / hip pain, that is when we can help you the most. Physiotherapy has a range of treatment options from massage, spinal manual therapy or dry needling to reduce pain. There should always be advice on activity / exercise or we can design a full exercise program suited to your goals. Assessment of your computer ergonomic setup is essential and advice on simple changes often helps. Occasionally we utilise orthotic prescription but only if it helps you get active with less pain.

To book an appointment with NU Moves call 4921 6879 or email admin@numovesphysiotherapy.com.au

Complex ankle injuries

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Ankle Injuries

It is commonly thought that ankle sprains are a minor injury, which usually resolve fully and quickly. While this is sometimes the case, research shows that 64% of people who sprain their ankle report ongoing problems 12 months later! The main complaints we see for a “problem” ankle are swelling after activity, loss of normal range of movement, recurrent sprains, tendon pain, inability to participate in high level sport and feelings of instability.

Why? The list of possible injuries that can come from rolling an ankle is rather long, both for acute injuries and persistent ankle pain … tears of the 3 outside ankle ligaments (ATFL, CFL, PTFL) or the inside ankle deltoid ligament; osteochondral lesion (bony / cartilage bruising) of the talus; high ankle sprain (syndesmosis injury); fractures of the ankle malleoli, navicular or base of the 5th metatarsal;  tendon strains or rupture/dislocation of tibialis posterior or peroneal tendons; chronic instability; subtalar joint sprain; joint synovitis; tenosynovitis; sinus tarsi syndrome; anterior/posterior impingement.

Most people don’t get the right diagnosis (or any diagnosis) or just get an incomplete one on the sideline immediately after the injury. Fortunately, with the correct diagnosis and treatment the majority of ankle injuries can be treated non-surgically by physiotherapy. Early intervention is the best management. Unfortunately a lot of poorly managed or misdiagnosed ankle injuries present to our clinic, often months or years after the initial injury. These people have ongoing symptoms and limitations, which leads to frustrated and uncertainty about why it isn’t getting better. The main problem is difficulty competing in sport or doing regular exercise.

There is hope! We can help you accurately diagnose the problem and design a specific intervention. Many of our problem ankle cases have had a full resolution and are now symptom free. So if it’s you, a team mate, friend or family who are struggling with a non-resolving ankle injury get it assessed – get it treated – get back to sport and exercise!

To read more about foot and ankle pain click here.

ACL Reconstruction – When is best?

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ACL reconstruction

The NU Moves team recently did a masterclass session into the research associated with ACL tears and reconstructions. The questions we raised were based on a randomised trial published in BMJ in 2013 and several papers this year from Assoc Prof Richard Frobell and collaborates*.

Do you always need to have an ACL reconstruction?

Surgical repair of the ACL depends on the presence of instability and your specific goals. If you want to play sport involving change of direction (football, netball, basketball, etc) then surgery is recommended. However, having surgery in all cases is not as clear as it was 10 years ago. If you only want to walk and cycle then in some cases it’s possible to rehab the knee to an adequate level of stability. Persistent feelings of instability or giving way after rehab would warrant consideration of surgical intervention in any case, even if you don’t want to play sport.

When is the best time to have an ACL reconstruction post injury?

Current evidence clearly shows better outcomes are achieved if the patient undergoes an initial period of rehab prior to surgical intervention, deciding when and whether to have ACL surgery can be made once you have completed your rehab. A 12-week rehab period should be used to reduce swelling and regain strength and stability.

What should you do before ACL reconstructive surgery?

You must have a physiotherapy assessment and intervention. When we refer to rehabilitation following an ACL injury it involves strategies directed at reducing pain and swelling from the initial injury; regaining mobility and muscle length; and mostly importantly strengthening all the muscles of the legs to provide stability at the knee. These factors are the most relevant factors influencing your functional outcome, should you undergo ACL reconstruction.

Do you need to have an MRI?

Yes. If you have a suspected ACL tear then you should have an MRI to investigate, your doctor or physiotherapist can arrange this. The extent of ACL injury and other cartilage damage that can occur with ACL injuries are best identified via MRI. If there is significant meniscal or other cartilage damage then it needs to be considered relative to the rehab management and sometimes earlier surgery.

Do you always need to see an orthopaedic specialist?

Yes. They are the specialists of ACL surgery. Alternatively you could see a sports physician for a non-surgical opinion. There is now debate around the prevention of arthritic changes in the knee by undergoing ACL reconstruction surgery, evidence of its effectiveness is still valid but not as clear cut as it was 10 years ago. Studies over longer periods of time are still required to fully answer the question of whether surgery is better than conservative rehabilitation to delay or avoid arthritic change in the ACL injured knee. Getting a good orthopaedic opinion relative to your injury and goals is advised. For isolated ACL injuries it is now clear that better outcomes are achieved after a 3 month pre operative rehab period. So get the rehab started and then organise an orthopaedic referral at a time that suits you.

If you have any questions or have injured your ACL contact us to organise a time to start your rehab. Read more about knee rehab here.

* Articles reviewed:

  1. Treatment for acute anterior cruciate ligament tear: five year outcome of randomised trial. Frobell et al. BMJ Jan 2013.
  2. Lower extremity performance following ACL rehabilitation in the KANON trial. Ericsson et al. Br J Sp Med 2013.
  3. Delaying ACL reconstruction and treating with exercise therapy alone may alter prognostic factors for 5 year outcome. Filbay et al. Br J Sp Med 2017.
  4. Surgical reconstruction of ruptured ACL prolongs trauma induced increase of inflammatory cytokines in synovial fluid. Larsson et al. Osteoarthritis and cartilage 2017

Avoiding Pre-season Injury

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pre-season injuries

If you want avoid pre-season training injuries – start to plan your pre-season program now! This is good advice if you are between seasons or starting a sport again after a period of not playing. It is also good for trainers / coaches to consider when running a pre-season fitness program for a team.

A few months off regular exercise and training after winter sports is routine and often good for the body. But when pre-season training starts is when our physio clinic starts to fill up with athletes with strains. Here’s a guide to reduce your risk of injury during the next pre-season and regular season.

It starts with understanding injury risk and how we measure it. Why do some people get injured more than others? Can anything be done?

There are a lot of different reasons involved in why an injury may occur and there is no single test that provides an overall level of injury risk. Most professional sporting clubs use a complex battery of preseason testing, but it requires a huge amount of resources, and the chances are your local club doesn’t have that.

Recently a very simple, easy to understand and freely available risk indicator has been researched: The ratio of an athlete’s current exercise load compared to their historical exercise load (current week vs previous four weeks). This has been shown to predict injury risk in Cricket fast bowlers, Australian Rules football players and Rugby League football players. In order to get this ratio, you have to measure exercise load. In professional sport, players will often train with GPS and accelerometers to measure exercise load over the season – large fluctuations in load = higher risk of injury. When those devices aren’t available we have to go back to more simple measures.

Start recording in a diary the type (cardio, speed/sprint, power, strength etc) of exercise you do each day and some indicator of quantity (i.e. distance ran or the total time spent training). Then you need a measure of the intensity of the session which is usually relative to 100% as hard as you could go. If the session varies then record what you think is the average intensity and the amount of time spent at the maximum intensity. The goal of your workload diary is to allow you to plan your workload volume and intensity each week relative to the previous ones to make it a gradual transition during pre-season conditioning. This will avoid large spikes in workload and reduce your injury risk.

So when you get active again make sure you plan what you will do one week to the next and avoid spikes. But if do you get an injury we will be there to get you back on track.

If you want to read more on this see the articles below:

* Hulin BT, Gabbett TJ, Blanch P, et al. Spikes in acute workload are associated with increased injury risk in elite cricket fast bowlers. Br J Sports Med 2014;48: 708–12.

* Hulin BT, Gabbett TJ, Lawson DW, et al. The acute:chronic workload ratio predicts injury: high chronic workload may decrease injury risk in elite rugby league players. Br J Sports Med 2016;50:231–6.

* Murray, N. B., Gabbett, T. J., Townshend, A. D., Hulin, B. T. and McLellan, C. P. (2017), Individual and combined effects of acute and chronic running loads on injury risk in elite Australian footballers. Scand J Med Sci Sports, 27: 990–998. doi:10.1111/sms.12719

Common biomechanical problems with runners – flexibility

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Stretching running physiotherapy

Last week’s blog looked at strength in key muscle groups for runners. This blog is highlighting areas of the body where flexibility is useful at preventing pain associated with running. There has been a lot of research on muscle length / flexibility relative to preventing injuries and the summary is commonly that it doesn’t help. However sometimes the research doesn’t give us the full picture on how to help an individual with pain and that is where having an experienced physio counts. Helping runners return to exercise after pain or injury results in a wealth of experience based knowledge. In relation to muscle length it is that if you don’t have the mobility in the correct places it can lead to injury. An obvious example is a hurdler who tightens up in the hamstring and lacks the flexibility to get the front leg over the bar.  The key area for everyday runners to maintain flexibility is in the front of the hip.

The front of the hip / hip flexors includes 3 muscles, one of which is the TFL (tensor fascia lata) that connects to the ITB (iliotibial band). One example of a common runner’s problem is not having enough hip flexor length which can impair the buttock (gluteal) muscle function and lead to the TFL muscle working harder to stabilise the pelvis whilst running. This can then lead to ITB tightness and pain in runners. Another example is tightness in the hip flexors leading to an increased arch in your back. When this combines with the glut’s switching off hip or back pain are common.

hip flexor tightness and low back pain
Tight hip flexors

Correctly stretching your hip flexors should be comfortable. It is possible to make short lasting improvements in muscle length so if you are tight you need to stretch before you run (despite some research assumptions!). Don’t forget to control the pelvis when stretching.

hip flexor stretch
hip flexor stretch – pelvic tilt / roll

The best plan is if you have pain then get one of the experienced NU Moves physio’s to assess and determine if that’s what you need to get you back to running pain free.