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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.

Running biomechanics and muscle strength

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Running physiotherapy injury

 

Biomechanics refers to how we are built and how we move. Some of us have legs that bow out (varus alignment) and others have knock knees (valgus alignment) which relates to the shape of our bone structure. It is a combination of our bony structure and how well our muscles work that can increase the likelihood of injury with running. This blog is looking at key areas of muscle weakness that alter our biomechanics and lead to injury. Your bony structure can’t be changed but improving your strength in the right areas can be achieved within 6 weeks of an exercise program that is designed for you. Assessing the biomechanics of the body combined with a basic understanding of your running style is important if you are serious about running.

A biomechanical physiotherapy assessment considers whether you have sufficient strength and mobility in the right places for running. The muscles in the back of the leg (calf, hamstring and gluteal) are important to maintain strength for running. Weakness in these muscles often leads to pain and injury in runners.

  • Calf muscle and Achilles tendon strength – it is important to understand that both muscles and tendons can respond to the loads we put on them. A simple test and exercise for the calf and achilles is the calf raise. If you can’t do a repeated full height single leg calf raise of more than 6 reps than you probably don’t have enough strength. I encourage people to get to 15 reps and be able to repeat 3 sets as a baseline but there isn’t a magic number here because it also depends on your running style. If you are about to change your style and get further forwards on the forefoot then check your calf and achilles strength first to minimise the chance of getting achilles tendon problems.

calf raise

  • Hamstring strength is essential for fast running but a base level of strength is also important for your park runners to 10km distances. Clearly the most functional way to strengthen the hamstrings for running is to gradually increase the distance and intensity of your running sessions. If you can’t do a hamstring bridge exercise or it takes considerable effort then you need to get stronger. Caution with doing this exercise – if it causes back pain then stop and discuss with one of our physio’s.

hamstring bridge

  • Gluteal (buttock muscle) strength allows for a stable pelvis during running. If you don’t have adequate gluteal strength it puts extra load on the knees, hips and lower back. Unless you have had a biomechanical physio assessment you probably don’t know if your glut’s are working well enough. A glute bridge is similar to a hamstring bridge but the knees are bent at approximately 90°. By bending the knees it makes it harder to use the hamstrings to lift the bottom and thus challenges the gluteal muscles more. Again if you have back pain stop and get some advice.

glute bridge

  • A squat is another good exercise to get the glute muscles working for runners but it needs to be done correctly. Keeping the back straight and bending at both the knees and hips gets the gluteal muscles working. Once you have been taught to do a squat correctly the challenge is a single leg squat with letting the knee drop in valgus collapse.

Squat exercise

Hope you have enjoyed reading about good strength exercises for runners. Thanks to Pete for his stick figure art which has been enjoyed by his clients for many years.

 

Running injuries – How to avoid them

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running

There is a lot of expert opinion on running technique for performance and injury but its complex and sometimes contradictory. When we look at running without injury what helps one person often doesn’t for the next. Pain is not uncommon with running so for this article lets define an injury as when pain influences your running. This article is running advice that often does help get you running pain free …

Planning your approach to running is important but most of us just run when we get the time.

How often should I run is a great question with many possible answers. Let’s start with why you run? Having a goal is an important part of getting started. What do you want to achieve by running: increase fitness, lose weight, do a 5km park run, improve your time for running a set distance, complete a half or full marathon or simply feel better mentally and physically. Let’s aim to minimise or avoid muscle or joint pain that stops you from continuing to run.

How often (runs per week) and how long (distance)?

This depends on whether you have been running lately or not. If you haven’t run in the past 12 months then you need to start slower and less frequently then increase more gradually. There are apps such as couch to 5kms that can help guide you with graded increases. If you already have a base level of running fitness then you can progress more quickly.

Starting with 2 runs per week and working up to 4 per week is a good guide for frequency but it depends on how far you are running and you base running fitness. Starting with 3km walk / jog progressing to continuous jogging then working towards 5km (park run distance) is a good place for those who haven’t run recently.

One of the most common mistakes leading to joint or tendon pain is just doing too much too soon.

If you have had running injuries such as back or hip pain, shin splints or knee pain previously then a physio assessment is recommended before you start. This will identify stretches and strength exercises that will help and provide a guide to how often and how far you run when getting started.

What surface (grass, beach, cement, road)?

The surface you run on needs to be considered. If you want to do a half marathon on road and cement then we need to prepare your body for these surfaces. But if you are just getting started grass has the least impact and has most give to reduce impact stress through the legs. Road or tar is next then cement is the most stressful. Beach is obviously going to have less impact but be careful on the wet sand near the water if there is a reasonable side slope as this will quickly lead to pain. Soft sand level running is hard work, fantastic fitness and low impact but again don’t go too hard too soon. If you are prone to foot pain, then you should have shoes on even for beach runs.

What type of shoes?

There is a lot of research being done around shoe types and orthotics. You can read more detail in our running shoes blog but the only accurate advice is once you have found a type of shoe that allows you to run without pain then stay with it. Finding that shoe becomes more difficult and it is recommended that a physio assessment look at your foot type, muscle strength and running style to best advise a starting point.

How should I run (technique)?

There is lots of information about the ideal running technique (such as the ‘pose’ method) but what suits one body may not suit the next. To land on your heel first like when we walk is associated with increased pressure on the joints in our legs. Alternately to land on the forefoot increases loads on the achilles, calf and shin. If someone has a natural preference to one style and doesn’t have any complaints then you are best not to change your style. If you are trying to avoid knee pain by running more on your forefoot you might just develop an achilles problem and then not be able to run. If you do have joint pain and have been advised to change your running style then get advice and make the change very slowly.

If you have any questions in relation to preventing or treating running injuries let us know on admin@numovesphysiotherapy.com.au

 

Stand up and feel better

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newcastle physio stand up desk

Nothing has changed in the last year. The best advice remains to stand up and feel better whenever you can. If you study or work at a desk consider one of the stand desk options to get you on your feet more often.

Ergonomic setup for stand desk is similar with desk height being at approximately elbow height and the top of the screen should be at eye level. A laptop at a standing up desk offers some benefits of standing but the neck and shoulders are likely to get sore with prolonged use. The screen should be directly in front and keyboard / mouse within forearm arc (i.e. the upper arms should stay beside the body and not reach out). The main point for success of a stand desk is you need to be able to stand comfortably for periods of 20 mins or more. Let us know if you have any questions on stand desks.

Newcastle physiotherapy standing desk

Staying active with some form of exercise and reduce some of the negative effects of sitting. Find the balance between activity and sedentary and you will feel better. Get a reminder on this topic from one of our previous blogs here.

Groin and adductor pain in sport

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Newcastle physiotherapy for groin and adductor pain in footballThe NU Moves Physio team has recently completed a masterclass debating the best approach to manage and treat adductor pain and tendon problems with footballers. Journal articles were found and discussed relative to the NU Moves approach to diagnosis and treatment.

The following is a summary of the NU Moves masterclass. The current best approach to assist a footballer with pain in the groin or adductor region:

  • Diagnosis is essential: There are many different possible sources of pain into the groin / hip area. Identifying the likelihood of each of these (e.g. osteitis pubis, stress fractures, avulsion fractures, bursitis, tendon strain, hernia, arthritis, lower back referral) via a thorough assessment is essential. Subsequently investigations (Xray, CT scan, MRI, Ultrasound) to confirm or negate are considered. The timing of investigations depends on the risks of the problems and whether treatment is altered because of the investigation findings.
  • Treatment of adductor tendon pathology:
    • Note that this requires consideration and exclusion of all the other potential causes of hip pain.
    • Don’t stretch the adductor muscle area – the right type of strength and functional return to sport exercises will assist recovery of flexibility and stretching is more likely to irritate the problem.
    • Stability is essential – becoming core stable in the pelvis by focussing on strengthening the gluteal and abdominal muscles in sport specific positions (i.e. one leg stand) is the starting point and can often be done very quickly after injury occurs.
    • Strengthening the adductor tendons – when commenced at the correct time after the injury, adductor strength exercise is useful in improving long term outcomes of full pain free return to sport. This could be a ball squeeze between the ankles / knees in lying or a band or cable resistance exercise in standing (as long as the pelvic stability stage has been achieved).
    • Graded return to running: graded return to jogging then running then change of direction exercises is essential. Once the tendon can cope with it and the pelvic / core stability is adequate then a terrific way to strengthen the area for running is to start jogging. The problem is when you go too hard too soon and create a flare-up of pain that lasts several days. Flare-ups are a set back to the eventual goal of return to playing again.
    • Sport specific exercise: kicking / striking / passing the ball in football can all be done lightly and gradually increased in a comparable way to jogging and running. Similarly, once pelvic / core stability and sufficient local strength of adductors is achieved, these are a great way to strength load the area for sport. Again, be wary of flare-ups by progressing too quickly.

The adductor tendon strain is a frequent problem in sport and particularly in football. The best advice is to get an accurate diagnosis first then an active exercise program including 3 parts: the pelvic / core stability, the adductor tendons themselves, and a sport specific program. Getting the right level of loads on the area during each phase of recovery is essential to the process. That is where we help the best.

If you want the best diagnosis and treatment then call us at NU Moves if you have groin pain or a known adductor problem. If you have a friend or family member needing advice to get back to sport then recommend us.

MRI scans for low back pain

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MRI scans for low back pain – when are they useful.

Lower back pain is common with almost all of us suffering from it at some stage in our life. Most times it settles fairly quickly and other times it responds to treatment. Scans or investigations usually in the form of MRI or CT are recommended when it doesn’t settle in an acceptable timeframe or your physio and doctor indicate it is recommended earlier.

low back pain scans and diagnosis newcastle physiotherapy

The purpose of this blog is to reduce fear or concern if you have scans that show pathology. Although any pathology seen on imaging can be responsible for your pain, it doesn’t have to cause pain. The following table is from a systematic review in the American Journal of Neuroradiology. It looks at lots of research studies where they have scanned the lower back in people who don’t have any pain. The table below shows the % of people that when they had scans they found pathology BUT these people did not have any symptoms or low back pain. In other words pathology is a common finding in people who do not have lower back pain.

20yrs 30yrs 40yrs 50yrs 60yrs
Disc Degeneration 37% 52% 68% 80% 88%
Disc Bulge 30% 40% 50% 60% 69%
Disc Protrusion 29% 31% 33% 36% 38%
Disc Annular Fissure 19% 20% 22% 23% 25%
Facet joint Degeneration 4% 9% 18% 32% 50%
Brinjikji et al, 2015. Systematic Literature Review of Imaging Features of Spinal Degeneration in Asymptomatic Populations. Am J Neuroradiol 36:811–16 Apr

The highlights in the table show that 37% of those in their 20’s had some disc degeneration but no pain. In the 30s age group it had increased to 52% but again no pain. If a scan is likely to show normal pathology associated with age but doesn’t mean you will have pain and it’s also not going to change the treatment, then scans are not recommended. So if you do have lower back pain, scans are not usually recommended in the early stage.

If you have low back pain, firstly you should manage the pain with simple analgesics such as paracetamol; stay active as tolerated and occasionally use positions that offer short term relief. In acute low back pain, physio can help with the posture and movement means to reduce pain.

There are times when you do need to have scans straight away and your doctor or physio will identify those occasions. For example if your pain is severe, worsening or if you experience neurological symptoms such as weakness, tingling or numbness, then you need to be assessed by your physio or doctor.

If you have back pain and it is affecting your ability to be active then contact us for an appointment. We believe in an active approach to treating low back pain. Contact us on 4921 6879.

Lifting children and low back pain

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A lifting tip for our parents with kids under 5. Did you know the level of load when NSW WorkCover injuries are reported to occur with a seated lift? Anything above 4.5kg! Translate that to the average weight of a 2 year old child who we often lift onto our laps when we are seated. The risk of hurting your back when lifting is relative to many factors including how much bending and lifting you have done lately; how much or little exercise; and your level of stress. If we can advise one thing to reduce the chance of back injury it relates to not lifting from the side in a seated position. This creates a twist or rotation force whilst lifting a load in a bent back (seated) position and has much greater forces on the lower back. Lifting children and low back pain are commonly associated but can be managed better with good movement habits.

Higher risk
Consider changing your habits when lifting your kids. Do they have to be lifted? If so, stand up or kneel onto one knee if possible; let then climb up if they can rather than you lift them; or turn towards your child or get them to come directly in front when lifting – chest and hips facing the same direction to avoid twisting the back.
Less risk
Simple strategies work the best to prevent lifting related low back pain. However the stress of looking after children sometimes also makes it hard to think about the simple strategies. That is when taking some time for yourself to go for a walk is important.

Shoulder dyskinesia – does it cause shoulder pain?

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shoulder pain and dyskinesia

Shoulder pain is a common problem. It is one of the top four reasons why people see their physiotherapist. The scapula (shoulder blade) is commonly blamed for causing someone’s shoulder pain. However, our understanding about the relationship between shoulder pain and scapula motion has since improved with new research findings.

When you perform a shoulder movement, the scapula follows the arm bone in a particular pattern of motion. Scapula dyskinesia is when this pattern is considered abnormal. When it gets tricky is when we try to determine what exactly defines ‘normal’ movement of the scapula. Our current understanding of ‘normal’ has been developed based on studying people with non-painful shoulders. It was thought for a long time that scapula dyskinesia causes the shoulder pain, but it might not always be the case, in fact it could be the other way around!

The research has been able to consistently show us that shoulder pain can actually cause dyskinesia. That is, people who had no pain and no dyskinesia were injected with a painful substance and this then led to those funny looking movements of the scapula. Therefore, scapula dyskinesia may in some cases be a short term response to acute shoulder pain. When the pain persists beyond the acute phase, the presence of scapula dyskinesia might actually be causing more problems, preventing the shoulder pain from improving.

Our physios believe that an important part of the shoulder examination includes assessment of scapula movement to determine if it is a contributing factor to the patient’s pain. If the scapula is found to be a contributor, treatment can be directed towards it and may involve:

  • Manual therapy to correct tightness that might affect scapula movement
  • Exercises that teach you how to change the way you move your scapula
  • Taping the scapula to help it move differently
  • Strengthening exercises for the scapula and rotator cuff muscles
  • A functional exercise program that helps you achieve your goals

But what if you have scapula dyskinesia and no pain?
The research is not yet clear whether scapula dyskinesia causes pain in the general population. There are some studies in high level, finely tuned athletes that show that the presence of scapula dyskinesia is linked to developing pain in the future. Clinical experience says that if one scapula moves differently to the other, consider trying to change it with some strengthening exercises that lower your risk of developing shoulder pain in the future.

Key points:

  • Pain can cause scapula dyskinesia
  • If you have pain and want to know if your scapula motion is contributing or…
  • If you know you have a scapula that moves in a funny way and you’d like to know more about it:

Then call us on 49216879 and we can advise what is the best way to manage it.

Low back pain … learning to take control yourself

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Low back pain

A recent journal article in the Medical Journal of Australia* prompted this blog to encourage our clients to learn more about how they can take control of back pain. Low back pain gets 80% of us over our lifetime. It often resolves without treatment in the first week or two but recurs in up to 70% of cases. It is also common in adolescence (up to 50%). The assessment of back pain must consider the mechanics or movement relative to the muscles and spine itself however red flags and biopsychosocial factors are equally if not more important.

Red flags are indicators of medical conditions (rather than musculoskeletal cause of back pain) that need to be considered via assessment and sometimes GP referral. The diagnosis process sometimes involves investigations via Xray or MR scans which is important but comes with risks of opening a pandoras box of what may be causing the pain (e.g. knowing there may be a problem with our spine often adds to the psychological side of how pain can persist, when in fact we shouldn’t be worrying about most of the findings on scans). It is generally understood that in a small % of cases (usually <20%) a problem identified on investigations can be related to the cause of a person’s pain. In the rest of people with back pain the findings do not correlate with what is causing their pain.

For the 80% which is the majority, the word biopsychosocial is now generally applied to understanding the reason for a person’s back pain. Yes we still need to rule out the red flag problems and the persistent mechanical back pain coming from the musculoskeletal system. But the 80% of people with low back pain need to consider the many contributors that are often psychological, social and environmental / lifestyle factors. These must be considered in taking control of back pain. Getting a good opinion early on that considers all of these factors is essential but sadly is not common enough.

Good things to remember with low back pain:

  • Getting active helps a lot of people take control of pain. The reason why can be complex but it works … you just have to find the exercise that suits you best.
  • Stress is a big factor with persistent pain. Just considering this is a start towards managing the problem.
  • Surgery is rarely the answer for low back pain.

* Atkinson & Zacest MJA 204 (8), p 299-300, 2 May 2016