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Maintaining the best results requires knowledge and expertise. Our athletes train and so do we, through our professional development program. Meaning that when a practitioner the treats you, they have the most advanced injury care knowledge. Read about what our practitioners are thinking in the injury blogs below.
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The opening of the AFLW season has seen a spate of season ending knee injuries, including Carlton skipper Brianna Davey who ruptured her ACL against the giants last Friday.
Leading sports medico Peter Brukner says women are 5 times more likely to rupture an ACL.
“The main reason is mechanics,” he says. “Females have a wide pelvis and therefore are more bow legged. There’s more of an inclination for their knees to fall in when they twist, so that makes them more susceptible.”
For women and men, an ACL injury can be devastating, writes Physiotherapist Kobi Phelan in her latest blog.
An ACL (Anterior Cruciate Ligament) rupture is one of the most debilitating sporting injuries that can see athletes sidelined from nine to 24 months and beyond. ACL injury occurs most commonly during sports that involve sudden changes in direction, sudden stops or jumping such as football, tennis, skiing or basketball.
For many years surgery has been seen as the best management for sufferers of ACL injuries wishing to return to physical activity. However recently there has been a lot of discussion about non-surgical pathways for ACL rehabilitation being equally as successful for certain people.
Surgery versus no surgery depends entirely on your functional requirements, goals and time for rehabilitation. Whatever your choice, it is a long and mentally tough rehabilitation period after ACL injury. With around one in three people never returning to sport after ACL injury, a thorough rehab plan is essential for the best outcome. Regardless of the management strategy, achieving full knee extension, regaining quadriceps activation and reducing knee swelling precedes the all-important strengthening and conditioning phases.
For surgical patients, it has been shown that five weeks of intensive pre-operative rehabilitation with the aim of achieving 90% limb symmetry resulted in better knee function two years after surgery (Grindem et al., 2015). For those who are operated on sooner, it has been shown that completing some pre-op rehab results in a higher likelihood of returning to sport and having better knee function post-op (Mansson et al., 2013).
For both surgical and non-surgical patients, returning to sport should be criteria as opposed to time-based. This means, achieving key milestones before progressing to the next level.
Returning to running is only a small component of the overall picture and requires adequate strength and single leg balance prior to being attempted.
I follow a criteria based program by Randall Cooper because it ensures patients achieve Phase 1 functional goals prior to progressing to Phase 2, and so on. Results indicate that of those who met the key goals in Phase 3, only 5 per cent sustained a second ACL injury (Grindem et al., 2016) after returning to sport in Phase 4.
For the best outcomes after an ACL injury it is important to consult a physiotherapist and discuss the most appropriate pathway for you. If you have recently had an ACL injury, come in and see one of our physiotherapists. We will help guide you through your rehabilitation, whether it be pre-surgery, post-surgery or no surgery at all.
Filbay, S. R., Ackerman, I. N., Russell, T. G., & Crossley, K. M. (2017). Return to sport matters—longer‐term quality of life after ACL reconstruction in people with knee difficulties. Scandinavian journal of medicine & science in sports, 27(5), 514-524.
Grindem, H., Granan, L. P., Risberg, M. A., Engebretsen, L., Snyder-Mackler, L., & Eitzen, I. (2015). How does a combined preoperative and postoperative rehabilitation programme influence the outcome of ACL reconstruction 2 years after surgery? A comparison between patients in the Delaware-Oslo ACL Cohort and the Norwegian National Knee Ligament Registry. Br J Sports Med, 49(6), 385-389.
Grindem, H., Snyder-Mackler, L., Moksnes, H., Engebretsen, L., & Risberg, M. A. (2016). Simple decision rules can reduce reinjury risk by 84% after ACL reconstruction: the Delaware-Oslo ACL cohort study. Br J Sports Med, 50(13), 804-808.
Månsson, O., Kartus, J., & Sernert, N. (2013). Pre‐operative factors predicting good outcome in terms of health‐related quality of life after ACL reconstruction. Scandinavian journal of medicine & science in sports, 23(1), 15-22.
Sanders, T. L., Maradit Kremers, H., Bryan, A. J., Larson, D. R., Dahm, D. L., Levy, B. A., ... & Krych, A. J. (2016). Incidence of anterior cruciate ligament tears and reconstruction: a 21-year population-based study. The American journal of sports medicine, 44(6), 1502-1507.
Waldén, M., Hägglund, M., Magnusson, H., & Ekstrand, J. (2016). ACL injuries in men9s professional football: a 15-year prospective study on time trends and return-to-play rates reveals only 65% of players still play at the top level 3 years after ACL rupture. Br J Sports Med, 50(12), 744-750.
With textbooks, computers, lunch and sporting equipment, backpacks can be heavy. This is particularly concerning for junior students as the spine is at a critical stage of development between 12 and 14 years of age.
According to the Australian Physiotherapy Association, 70 per cent of children will suffer back pain because of heavy backpacks.
Backpacks should weigh no more than 10 per cent of a child’s weight. However, recent studies have shown that the school bags of more than half (61%) of school aged children exceed that.
Studies have reported the highest level of discomfort is in the shoulders and back as well as the neck.
In extreme cases, overloaded backpacks can cause headaches, pins and needles and numbness in the arms.
Ideally, you want to lower the backpack weight but here are a few things you can do to eliminate discomfort and injury:
-Get organised. Only take the books you need for that day and leave the rest at school or in a locker.
-The ideal school bag is a backpack with wide shoulder straps that are comfortable and sit well on the shoulder and a padded back support that fits snugly on the back.
-Parents should look for bags with compartments that allow you to pack the heaviest items at the base of the bag closest to the spine.
-Don’t make the mistake of thinking your child will grow into a backpack. The backpack shouldn’t sit higher than the child’s shoulders when sitting down.
-The straps should be shortened until the bottom of the backpack is just above the child’s waist, and not sitting on their buttocks.
Our team is more than happy to answer any questions or help to fit a backpack properly.
It’s back to school time! Hard to believe the summer break is already over! Parents - it’s time to check up on all things uniform based, seeing how much kids have grown over the break and whether or not they still fit in their shoes!
Getting the right school shoe can be tricky, some are too heavy, some are too bulky and some are too expensive. We’re here to help put you on the right track, to not only get the best value for money, but to get the right fit for your child.
Before you purchase the shoes, ask your child:
-How much running do they do in their shoes?
-How many days per week do they wear them?
-And how old are their school shoes?
It’s important to ask these questions, as shoe technology has improved significantly over the previous couple of years. Companies such as Ascent are making school shoes with running shoe technology to increase movement efficiency and decrease the overall weight of the shoe, whilst still sticking to uniform guidelines. The only issue is with these shoes is that they do wear out in less time than traditional shoes. So be aware when purchasing.
It’s common for parents to purchase shoes so that children “will grow in to them” which is a big NO! Having a shoe that is too big can lead to blisters and musculoskeletal conditions of the foot and lower leg, which can lead to big problems going forward. A perfect shoe fit is 0.5-1 size on top of your measured foot size to allow for the foot to swell during activity without restricting motion.
Here’s an exercise for you: head down to your local oval and use the boundary line and run directly along it. If you notice your feet crossing over the boundary line to the other side of your body, you are most likely crossing the midline of your body. This may be a result of muscle tightness/weakness across the pelvic and hip region or could be coming from your foot posture. Persistent crossing the midline in association with loading increases have shown to increase your chances of lower limb injury, and may require intervention.
Crossing the midline is also referred to having a “narrow base of gait” which identifies that rather than having your feet strike the ground in alignment with your lower limb, you become more ‘adducted’ and have both feet strike the ground closer towards, or cross over the midline of your body (an imaginary line from the top of your head, dissecting the body in to two). Overloaded foot structure from pronation can be made worse for lower limb function if you have a narrow base of gait, and can lead to increases in the average vertical rate of force in the body (Napier et al., 2015).
Intervention programs can involve stretch and strengthening, dynamic exercise prescription, gait retraining or even the use of orthotic devices to prevent you overloading from midline infringements.
Every runner is different. We all have different styles, strike patterns and muscular status. If you’re wanting to get the best out of your running to propel you to the next level, getting your technique analysed is the best way to get to the bottom of any issues and help your program for the future.
We offer a Running Gait Analysis’ at CSSM.
Napier C, Cochrane CK, Taunton JE, et al. Gait modifications to change lower extremity gait biomechanics in runners: a systematic review. Br J Sports Med 2015;49:1382-1388.
Part 3: Heavy Heel Striking
Are you wearing out of the rear of your runners much more quickly than the rest of your shoe? You may have a heavy heel strike in your running style. This is commonly paired with a very “loud” running style, where you can commonly hear the contact that you make with the ground. So take out your headphones, and listen to your style!
Heavy heel striking is not only unattractive to watch when observing gait, it is extremely taxing on the body. That large impact sends load through the posterior leg and can lead to longstanding conditions such as ankle instability, shin splints, muscular overload and even stress fractures. It even relates to the topic we covered in the last blog in this series - looking at how overstriding can affect your gait. If you are a chronic overstrider, you may also be contributing to your injury risk heavily loading on the rear-foot.
Research conducted at Curtin University in Perth looked at the relationship between “running quietly” and vertical ground reaction forces (how much load is impacting the body during ground contact). Their study found, particularly with male participants, their peak loading rates and forces were reduced when asked to “run quietly.” This important piece of research backs up many coaches and health professional’s beliefs that potentially altering a runner away from a heavy heel striking gait, can help to prevent further injury.
This is not to say that heel striking is a terrible gait characteristic. A large percentage of the population do run with a heel strike style gait, and can be seen in many endurance athletes across the world. What is important to remember is that any type of instability associated with the rear foot can largely effect how we manage the increased load of running through the lower limbs.
To assess the effect of this characteristic, having your running technique analysed by a running coach or health professional is the best way to prevent any injuries that may develop.
About the Author
James Unkles is a Podiatrist at CSSM, who enjoys running as part of a balanced lifestyle. His passion in biomechanical analysis will help you get the most out of your running.
Xuan Phan, Tiffany L. Grisbrook, Kevin Wernli, Sarah M. Stearne , Paul Davey & Leo Ng (2017) Running quietly reduces ground reaction force and vertical loading rate and alters foot strike technique, Journal of Sports Sciences, 35:16, 1636-1642, DOI: 10.1080/02640414.2016.1227466
BLOG SERIES: Part 2 Overstriding
Technique in running is something that is often overlooked in the casual competitive runner, and in many cases can lead to the development of an overuse injury. In terms of gait (running movement) patterns, maximising your efficiency during gait will prevent joint overloading and thus prevent the onset of load induced injury. In this blog series, we have already gone through running lingo - this week we look at overstriding.
As the term indicates, overstriding is where our stride length (the distance between the same feet contacting the ground in one stride) is influencing our ground contact. If there is excessive stride length and our ground contact is occurring well out in front of our body, by contacting the ground in front of our body, our ability to hold the load changes as we are unable to recruit the knee and the hip to manage the load and notoriously the muscles below the knee must take the load.
This can cause overuse injuries such as Medial Tibial Stress Syndrome (MTSS-Shin Splints) as the anterior leg musculature overreacts to the load and can cause irritation to the tibia bone. Patella-femoral joint pain is also common with an over-strider not being able to utilise the upper leg complex to process the body weight load as it meets the ground reaction forces. Calf, achilles and hamstring injuries can all be related back to overstriding.
These conditions unfortunately are not quick fixes, and can take time to repair and rehabilitate.
So how do you know if you're overstriding? The best way is through video analysis. Whether that be through a directed video gait analysis with a trained professional, or getting a mate to take a video on their smart phone of you running along from the side. You may also know by symptoms of pain just below or behind the knee cap, anterior leg soreness or inflammation of the lower leg.
Treatment for overstriding involves including some gait retraining cues to decrease the impact of overstriding and look at greater efficiency, potentially soft tissue work depending on the health of your lower limb and occasionally orthotics to alter the mechanics. For something that can seem so miniscule, the reality of the situation is that it can cause chronic activity pain. By working through these difficulties we can get long term outcomes, which not only resolve your pain, but can keep you running for longer and help you hit your targets!
About the author
James Unkles is one of our Podiatrists here at Camberwell Sports & Spinal Medicine. A casual runner in his spare time, he understands the nature of the industry and how little imperfections can become big issues.
Rowlands, A., Eston, R., & Tilzey, C. (2001). Effect of stride length manipulation on symptoms of exercise-induced muscle damage and the repeated bout effect. Journal of Sports Sciences, 19(5), 333-340.
Next week: Heavy heel striking. Stay tuned!
Technique in running is something that is often overlooked in the casual competitive runner, and in many cases can lead to the development of an overuse injury. In gait (running movement) patterns, maximising your efficiency during gait will prevent joint overloading and thus prevent the onset of load induced injury.
Common technique habits that can increase your risk of injury include overstriding, heavy heel striking and crossing the mid line of your body. Those might all seem slightly complicated to diagnose when heading out for your daily run.
Over a four part series, we will look at some common running technique mistakes and how they can affect you putting one foot in front of the other!
It is quite common in the running game to use certain terms to describe your running pattern and the impact you have with your technique. All over the internet you will find running blogs which implement different terms and try and guide you in the right direction, but we’re here to help you understand and use this information to become a better runner.
The actual impact from one foot meeting the ground, transferring through the foot, taking off, swinging though and contacting the ground again.
The distance of one stride, generally measured from initial contact point to initial contact point on the same leg.
In health terms, we use this term to describe your movement style. It encompasses both walking and running, both foot contact and flight time.
The stage in your gait where your foot is flat on the ground, and taking the full weight of your body. This time in your gait cycle is commonly where compensations can occur through your foot, knee or hip.
The propulsion phase where your foot leaves the ground.
The initial ground contact generally made by rearfoot and midfoot runners.
Commonly referred as “training load” it refers to the forces coming through the body.
Now you know the lingo, next week in Part 2 we will delve into Overstriding. Watch this space!
October has been World Osteoporosis Awareness Month. Most people understand what osteoporosis is and what it means in relation to bone health. However despite promising evidence, there is something of a knowledge gap amongst the general public in terms of what can be done through diet and exercise to minimize and prevent the risk of osteoporosis.
According to the Australian Bureau of Statistics as many as 4 out of 5 people with osteoporosis are unaware they have it, despite being at risk of fracture. 4.74 million Australians over the age of 50 either have osteopenia or osteoporosis. And by 2022 it is anticipated that there will be a fracture every 2.9 minutes associated with poor bone health in Australia.
Osteoporosis is a condition affecting the structure and metabolic health of bones, in essence making bones weaker and decreasing their ability to absorb impacts. The spine, hip, and wrists are most commonly affected and are often sites of fractures for the elderly. This is important, because as we age, decreased bone mineral density predisposes an individual to an osteoporotic fracture. With fractures in this age group contributing significantly to morbidity and decreased quality of life, it highlights the importance of implementing strategies to successfully manage osteoporosis.
A randomized control trial by Bailey and Brooke-Wavell examined the effects of performing 50 hops per day in 61 premenopausal women. Over 6 months, those who performed 50 hops seven times per week increased their bone mineral density by 1.8%, whilst those performing 2 or fewer sessions a week showed no change or even a loss in bone mineral density. Similar results have also been replicated in post-menopausal women. These findings highlights that weight bearing impact exercises are effective in improving and minimizing the effect of age related bone mineral density loss. And that exercise is a powerful stimulus for good bone health in both young and older individuals irrespective of current bone health.
Whilst ‘impact’ exercise may seem counter-intuitive and perhaps harmful for those with weakened bones. It is important to understand that bone, like muscle, requires a level of stimulation to increase metabolic and cell activity. With muscle we can do this through resistance exercise, and this allows our muscles to grow stronger. The same can be done to bone through weight bearing exercise that stimulates bone remodeling and growth. Unlike muscles which adapt quickly, bones don’t have the same blood supply or cellular activity, and as a result bony adaptation is a longer and slower process, with complete skeletal remodeling taking 7+ years.
Current consensus statements from Osteoporosis Australia and Cochrane Reviews support a combination of Vitamin D and calcium supplementation enhancing the effects of impact exercises performed 3-5 times per week, with 50-100 weight bearing impacts per session to create a meaningful improvement in bone mineral density. Supplementation alone is ineffective in creating positive changes in bone mineral density. Exercises can be as simple as step-ups, star jumps, side-side jumping, bounding or stomping. Further exercise including resistance exercise, aerobic exercise, and fall prevention strategies are also recommended to ameliorate and decrease risk of osteoporotic fractures.
If you or someone you know has osteoporosis or are concerned, please speak with your GP to perform all the appropriate checks and discuss a management plan. For those who have osteoporosis, it is critical that advice regarding new exercises is obtained through a qualified health professional to ensure appropriate loading, progression, and safety. The team at CSSM are perfect for that!
For further reading and resources please see Osteoporosis Australia.
About The Author:
Trevor Spencer is a Physiotherapist with a strong interest in exercise rehabilitation for athletes and the general population. In addition to his physiotherapy qualifications, Trevor has qualifications in Exercise and Sports Science.
- Bailey, C. and Brooke-Wavell, K. (2010). Optimum frequency of exercise for bone health: Randomised controlled trial of a high-impact unilateral intervention. Bone, 46(4), pp.1043-1049.
- De Matos, O., Lopes da Silva, D., Martinez de Oliveira, J. and Castelo-Branco, C. (2009). Effect of specific exercise training on bone mineral density in women with postmenopausal osteopenia or osteoporosis. Gynecological Endocrinology, 25(9), pp.616-620.
- Sinaki M, Itoi E, Wahner HW, et al. Stronger back muscles reduce the incidence of vertebral fractures: a prospective10 year follow-up of postmenopausal women. Bone 2002;30:836-41.
- Maddalozzo GF, Snow CM. High intensity resistance training: effects on bone in older men and women. Calcified Tissue Int 2000;66:399-404.
-Howe TE, Shea B, Dawson LJ, et al. Exercise for preventing and treating osteoporosis in postmenopausal women. Cochrane DB Syst Rev 2011, Issue 7. Art. No.: CD000333. DOI: 10.1002/14651858.CD000333.pub2.
- Bass SL, Naughton G, Saxon L, et al. Exercise and calcium combined results in a greater osteogenic effect than either factor alone: a blinded randomized placebo-controlled trial in boys. J Bone Miner Res 2007;22:458-64.
- Allison, S., Folland, J., Rennie, W., Summers, G. and Brooke-Wavell, K. (2013). High impact exercise increased femoral neck bone mineral density in older men: A randomised unilateral intervention. Bone, 53(2), pp.321-328.
Rowing is an incredible sport for many reasons: it is a great way to gain cardiovascular fitness, builds full body muscle strength, promotes weight loss and reduces stress. But due to the nature of rowing, it is also closely associated with a number of injuries. Most rowing injuries are related to overloading and poor biomechanics that can be due to incorrect technique, lack of experience and changing sides that the oar is on (if using a sweep boat).
Why technique is so important:
The rowing stroke is a continuous cycle that is divided into the catch, drive, finish and the recovery. The drive requires the rower to sequentially use their legs, followed by body and then arms while the recovery sequence is the reverse. Incorrect technique can therefore lead to overuse injuries as the rower is repeating incorrect movement patterns. For example, poor technique through the recovery such as lunging too far forward at the catch can put rowers in risk of shoulder and back injuries. While poor technique at the finish such as hunching through the shoulders and leaning too far back can increase pressure through spinal discs.
Common injury sites for rowers:
How to reduce/prevent injury from rowing:
Immediate management for your rowing injury:
At CSSM we are able to assess and treat your rowing injuries as well as use our software to analyse your technique using the ergometer.
1. Rumball JS, Lebrun CM, Di Ciacca SR, Orlando K. Rowing injuries. Sports medicine. 2005;35(6):537-555.
2. Holden DL, Jackson DW. Stress fracture of the ribs in female rowers. The American journal of sports medicine. 1985;13(5):342-348.
3. Hosea TM, Hannafin JA. Rowing injuries. Sports Health. 2012;4(3):236-245.
4. Karlson KA. Rib stress fractures in elite rowers. The American Journal of Sports Medicine. 1998;26(4):516-519.
5. Smoljanovic T, Bojanic I, Hannafin JA, Hren D, Delimar D, Pecina M. Traumatic and overuse injuries among international elite junior rowers. The American journal of sports medicine. 2009;37(6):1193-1199.
Many patients with pain in their lower back are often after treatment and advice on ways to best to manage their condition. Osteopaths and other practitioners are trained in thoroughly assessing and examining someone’s body, and can determine a differential diagnosis that forms the treatment and management plan moving forward.
Every day we are faced with patients wondering whether they should have some sort of investigation into their pain - x-ray, CT or MRI. In respect to the lower back, MRI can be gold standard for diagnostic value, and will therefore identify problems with the vertebrae, intervertebral discs and soft tissues. However what it is not capable of, is determining the structure that is responsible for YOUR pain.
Studies in the field of back pain have revealed that imaging cannot reliably diagnose lower back pain, and often cause more false alarm. False alarms, or ‘Red Herrings’, are known as possible structural irregularities that MAY cause someone pain, however are not clinically diagnostic. This may be features of ‘wear and tear’ within the spine, having occurred over many years of an active or even sedentary life.
While the idea of having an MRI to visualise structures in the back is valuable and extremely tempting, we also must understand the complex outcomes of unnecessary imaging or poor interpretation of results. This can in fact INCREASE patient apprehension and therefore indirectly affect quality of life and lead to a poorer prognosis. It is important for practitioners in the medical industry to accurately relate the MRI findings to clinical symptoms and manage accordingly with treatment techniques and lifestyle advice (Graves et al, 2012).
When your pain is not improving over a period of time, not responding to manual therapy, or if you present with any clinical red flag, then imaging is undoubtedly a valuable tool to use. This will change the way that your practitioner manages your condition, and may refer you on for further intervention or assessment as required.
At CSSM, we encourage patients to discuss their condition with their practitioner. Ensure that you understand YOUR pain, and ways to manage it when conservative treatment is appropriate rather than seeking answers through imaging methods.
Graves et al, Early Lumbar MRI not associated with better outcomes, 2012.
Jensen 2010, Early MRI Use, COCA.
With the Eagles having snuck into the finals for the 2017 AFL season, there has been a lot of speculation about the possible return of star ruckman Nic Naitanui for a run at the finals. Naitanui has missed the 2017 AFL season following a late season ACL injury in 2016.
There has been a lot of evidence around suggesting that “NicNat” has made good progress with his knee rehabilitation, including this video from a US rehab camp in July, which has fed much of this speculation. Eagles coach Adam Simpson has put this speculation to bed during the week by ruling Naitanui out for the season, however with some players over recent years returning from ACL reconstructions in less than 6 months, many are asking, Why so long?
It is a good question and it is a question that we get a lot in the clinic when dealing with injured athletes at a local level. Whilst I do not pretend to have any inside knowledge of NicNat’s progress, nor would I dare second guess the judgement of the Eagles medical team, I do believe that Naitanui’s situation is a perfect example of the old saying, 'just because you can, doesn’t mean that you should.'
We know after many years of following the progress of athletes returning from knee reconstructions that the risk of re-injury increases substantially by a premature return to sport. Much of this knowledge was reinforced by a 2016 study that found that athletes who return to high level sport have a four fold increase in re-injury compared to athletes who do not return to sport1. In fact almost 1 in 3 athletes who returned to high level sports sustain a re-injury within 2 years1. An alarming statistic - but what is most interesting is that this re-injury rate decreased by 51% for each month return to sport was delayed up until 9 months after surgery1.
It seems that 9 months is the magical number – so is it a matter of just waiting? The answer is a resounding no! If wishing to return to sport at any level, effective and specific rehab is important. This rehabilitation program works towards regaining symmetry of muscular strength in the muscle groups around the knee. Effectively retraining the nervous system to build co-ordination and proprioception which increases agility, body awareness and reduces the chances of reinjury2. The rehabilitation program is best designed by your treating practitioner, be it an Osteopath or Physiotherapist in consultation with your orthopedic surgeon.
Return to sport should not be attempted until a criteria of sports specific performance goals are achieved. It is likely that this is an area where the West Coast medical team are at with Naitanui. They will have set performance goals for Nic to achieve at the start of the rehabilitation phase and it may be that he is not quite there yet. Good management can reduce re-injury risk by 84% after ACL reconstruction1. It is unlikely that they will release Nic Naitanui to return to play if there is any doubt about his ability to sustain the load. A re-injury now would potentially risk Nic’s ongoing career.
ACL injuries are distressing and the rehabilitation process is a long one. However, a positive outcome is achievable with careful management and patience.
Should you have any queries about a knee injury you have sustained, feel free to contact the team at CSSM.
About the Author.
Travis Bateman is an Osteopath, trail runner, mountain biker, habitual back of the pack finisher and founder of Camberwell Sports & Spinal Medicine. His clinical interest is in movement analysis and its relationship to injury management, pain and sports performance
Published 1st September 2017
Tendon overuse pain
With the Melbourne Marathon fast approaching and the weather improving we are starting to see more runners out pounding the pavements. Because of this I thought it would be good to address the topic of tendon pain. Tendon overuse injuries or pain account for a large proportion of a sporting clinician’s case load. In other words, we see it a lot. More specifically for runners, Achilles tendinopathies.
Typically, tendon pain tends to be worse on the morning after exercise or activity, is usually pain free at rest, becomes painful with use, and is painful to touch on the effected tendon.
During exercise or training you might experience pain with the first few steps, then warm up with activity to the point of comfort, then it may or may not reappear towards the end of training.
Tendon pain can be broken down into three categories:
The best management for the “reactive” tendon is relative rest, ice and commencing an isometric loading program which your physiotherapist can help you with. Anyone who has suddenly increased their load or training volume can experience this pain, but when identified and addressed early, this type of tendon pain can be relatively easy to settle down.
The disrepair or degenerative tendon rehabilitation requires a little more patience. This tends to be a step-by-step process whereby you would commence a weight based strength program guided by your physiotherapist, work towards gaining full range of motion at the effected joint, and then graduate through a guided walk/jog program. From here your physiotherapist would then introduce power/dynamic loading prior to progressing to sport specific tasks and eventually a full return to sport.
If you are looking to get back into running, or are starting to experience the above described pain, get in touch with one of our physiotherapists and we will help guide you through the process!
Brukner, P. (2012). Brukner & Khan's clinical sports medicine. North Ryde: McGraw-Hill.
Cook, J. (2011). Tendinopathy: no longer a ‘one size fits all’diagnosis.
Cook, J. L., & Purdam, C. R. (2009). Is tendon pathology a continuum? A pathology model to explain the clinical presentation of load-induced tendinopathy. British journal of sports medicine, 43(6), 409-416.
We’ve just wrapped up our 4th Run Long, Run Strong forum here at CSSM with all participants loving the opportunity to pick the brain of one of Australia’s most iconic long distance runners, Steve Moneghetti. A key focus of the evening was how important load management is to managing your running program, and how to prevent injury.
Steve’s a big believer in setting yourself a goal and working towards it, and we could not agree more. Signing yourself up for a running challenge can be daunting, but extremely rewarding if it’s done in the correct manor. Loading up gradually is extremely important, and it’s the number one mistake runners make when commencing a training program. Trying too much, too quickly can often lead to the body breaking down and the onset of injury becoming a reality.
From a planning approach, when training load exceeds load capacity is the moment where we are at risk of developing a load induced injury. Our load capacity will increase and improve with our training program, but researching and implementing other training modalities will improve our running performance.
Through the use of supplementary training you can continue to build not only your cardiovascular fitness but your muscular strength, endurance and power if you utilise the correct formats. Activities such as swimming, deep water running, weights training and Pilates are all great ways of improving your base level of fitness and reducing your chance of load induced injury!
We also spoke on the importance of recovery and allowing time for the body to rejuvenate from training load. From a biological level, allowing time for adaptation to occur is important for good muscular development. Not allowing a rest day in a full training week could allow for an overload on the tissues, and prevent muscles developing to their optimal level.
After another great forum we are already looking towards the next opportunity to help our #teamCSSM runners, so if you have any ideas from who you’d like to hear from in the future, let us know!
About the author.
James Unkles is a Podiatrist who has also completed his Bachelor degree in Exercise and Sport Science, and loves running every week! He can provide expert assistance with managing your running program, gait analysis or explain how the lower limb reacts to aerobic or anaerobic training.
Konopka, A. R., & Harber, M. P. (2014). Skeletal Muscle Hypertrophy after Aerobic Exercise Training. Exercise and Sport Sciences Reviews, 42(2), 53–61. http://doi.org/10.1249/JES.0000000000000007
It is “Severs Season” across Melbourne! As kids are getting involved in winter sport and as training loads increase, we are starting to see some common injuries hindering participation across many different sports. One particular concern for pre-teen athletes is the onset of heel pain, particularly in high impact running sports such as Hockey, Soccer, Basketball, Netball and Australian Rules.
By far the most common cause of heel pain in the early teens is Severs disease or “calcaneal apophysitis”. It is most common in children between the ages of 8-14 and it is generally sporting kids that can suffer from the condition.
As kids go through periods of significant growth, it is not uncommon for the growth plate at the back of the heel to be grabbed, pulled and irritated through the Achilles tendon and related posterior leg muscles. This pain can be so severe that walking can become a challenge and no activity can be completed at all. Pain will normally be felt on the side of heel and in the Achilles tendon.
This condition tends not to affect populations past 14 years old, as the growth plate becomes fully ossified within the calcaneus (heel bone) by that time. Factors that predispose a child to developing Severs include a flat or high-arched foot, tight posterior muscles particularly if they are actively engaging in high impact sports.
What should I do if my child has heel pain?
Heel pain is common in children, and most causes of pain are benign and self-limiting however all pain in children should be assessed. So if your child has heel pain you should:
Severs is something that does resolve with time, and generally does not require any type of surgical intervention. There are simple strategies that can help manage Severs disease, which usually have great results with pain reduction and increased mobility. Kids who show dedication to the treatment program improve rapidly and can be back participating in activity pain free after slight delay and with minimal repercussions.
If you think your child may be suffering from Severs, or other complex foot pain, come and see the Podiatry team at CSSM to help them perform at their best.
About the author – Jim Unkles is a podiatrist at Camberwell Sports and Spinal Medicine. He understands the demands of competitive sport in children through personal experience in representative Hockey and Cricket. He is currently managing several sporting kids experiencing Severs.
Marchick, M., Young, H. and Ryan, M.F. (2015) Sever’s Disease: An Underdiagnosed Foot Injury in the Pediatric Emergency Department. Open Journal of Emergency Medicine, 3, 38-40. http://dx.doi.org/10.4236/ojem.2015.34007
Motivation to exercise during winter can be tough - but sometimes it's easier to get out the door if you are going to meet a friend. From now until the end of winter, CSSM is giving you the chance to "bring a friend for free" to try one of our PilatesFIT or PilatesFIT EXPRESS classes!
PilatesFIT is a dynamic form of Pilates designed for those who are looking to improve their strength, conditioning, flexibility and fitness. Great for everyone of all ages, from beginners, to those more advanced and wanting to try a new, fun and effective form of exercise. Pilates can be an excellent form of general exercise in its own right or can complement other sports and activity perfectly.
We have classes right throughout the week, so find a friend and bring them along to a class and spread the word!
What you have to do
If you’re an existing PilatesFIT client, simply log in to your Mindbody account and book yourself into a class - then phone CSSM to reserve a place for your friend and we will do the rest! Your friend(s) must be booked in prior to attending the class
*Valid for all existing clients. Only valid when friend attending the same class as existing client. 1 free class per friend, can bring up to 3 friends per class. Can be used multiple times for multiple friends! Please contact CSSM if you or your friend is unable to make the class you’ve reserved to ensure someone else is able to attend*
Hawthorn football player James Frawley is out for 8 weeks with a Turf Toe Injury. So, what is turf toe and why does it take so long to heal?
Turf toe is a sprain of the 1st MPJ or the joint where the big toe attaches to the foot. It usually occurs when the big toe is hyperextended or forced upwards. This can occur as the toes push off the ground but can also result from another person stepping on the toes as the foot is moving. Turf toe can be classified as grade 1, 2 or 3 which indicate severity. In the worst cases, the ligament under the toe is torn. Pain is felt each time the toes bend, which is obviously difficult to avoid as this occurs with each step we take. Foot injuries are therefore difficult and can take long periods to heal properly for this very reason. It is very difficult to rest a foot completely unless a plaster cast or a cam boot walker is used.
If a turf toe injury is suspected, treatment should initially involve rest, ice and elevation. Consultation with a podiatrist will ascertain the extent of the injury and guide further treatment. A variety of treatments may be implemented ranging from taping; which can be very effective, right through to surgery in some cases.
If correct treatment is not undertaken there can be a permanent loss of flexibility at this joint. This will cause altered biomechanics and most likely predispose this joint to arthritis and pain in the long term. Correct diagnosis, treatment and adequate rest from sport will reduce the likelihood of long term complications.
We wish James Frawley a speedy recovery.
Clinical Sports Medicines Brukner and Khan 4th edition 2012 McGraw-Hill Education
Podiatry Today: http://www.podiatrytoday.com/article/9063
R.I.C.E. or M.E.T.H.?
By Lisa McInnes
I’ll never forget when one of my lecturers asked, “Isn’t Meth the new Ice?” After a few chuckles he was met with confused faces and a collective "huh?" I didn’t investigate this any further until my interest was recently triggered by seeing a journal article titled “The effects of cold water immersion and active recovery on inflammation and cell stress responses in human skeletal muscle after resistance exercise.” Working with a football club, I was interested and curious as to the practice of icing an injury and the use of ice baths post game for recovery and also as a nurse with occasionally post-operatively applying ice packs to orthopaedic surgical sites (surgeon dependent of course).
The study investigated the current belief of cold water immersion (ice baths) after exercise and its effect on skeletal muscle. It’s believed this reduced inflammation, compared with active recovery such as resistance exercise. Interestingly, the study found there was no human data available to support the theory of cold water immersion after exercise and that it is no more effective than active recovery for minimising the inflammatory and stress responses in muscle after resistance exercise.
So why has it been drummed into us as consumers and practitioners to use ice, even on acute injuries? Most of us are aware of the acronym R.I.C.E. (or R.I.C.E.R.) which stands for Rest, Ice, Compression, Elevation, (Rehab/Referral).
Have you heard of M.E.T.H.? This stands for Movement, Elevation, Traction and Heat and brings us back to the old debate....heat or ice? Does this newer acronym not contradict our current practice and beliefs? Of course it does! So what do we do? I believe the most important question to ask at this point is WHY? Why are we applying heat or ice? What are we actually trying to achieve? What is our purpose? Are we using ice as an attempt to numb the injured area or to reduce the swelling as a direct effect from inflammation?
What were we trying to achieve using ice? For years, with first aid and an acute injury we rested the area so as not to worsen or aggravate the injury further, applied ice to reduce inflammation thereby reducing swelling as this was considered counterproductive. Compression for support and to reduce swelling, elevation to reduce swelling, then rehab to strengthen the injured area. But why do we want to reduce inflammation? The body has an astounding capacity for healing and multiple buffer systems to maintain homeostasis, eg pH levels, water retention and of course conducive environments for healing. Will we really effect it?
So why use M.E.T.H? How does this work in the setting of an acute injury? Mobilising an injury or the tissues around it, with traction, will provide support whilst assisting lymphatic drainage as the muscles compress the lymph nodes moving lymphatic fluid back to the subclavian veins thereby reducing swelling. Elevation helps this process and heat will also increase blood flow enhancing the healing environment.
There are three phases of healing - inflammation, proliferation and maturation or remodelling (Physiopaedia.com). Without inflammation, the next two phases of healing are affected and impeded, the body cannot skip a stage. If this is so, then why are we trying to prevent it?
Current practice is slowly changing and is starting to gain momentum. As Elle’s blog ‘Ankle Sprains: Is Rest Really Best?’ explains, the benefits and importance of early implementation of therapeutic exercise in the successful rehabilitation of ankle sprains. Rest is not really best! Ice is following this path…
Gary Reinl, author of Iced: The Illusionary Treatment Option discusses there can be inflammation without healing but there cannot be healing without inflammation.
Have a look at the video below featuring Kelly Starrett and Gary Reinl about the change in culture for the elite sportsperson in America and their move away from the use of ice with improved outcomes for those athletes.
Very importantly, Gary mentions we need to keep in mind our purpose for using ice. If we want to numb the area to assist with pain relief then by all means use ice, but if our purpose is to reduce inflammation then we need to reassess our practices.
So what should we do from here? There are many blog posts and opinions on moving away from ice and using heat but what we really need are further clinical studies and research evidence so as practitioners we are using best practice to ensure our clients are receiving the best treatment to help them reach their goals and potential. Remember, if you have any questions contact your practitioner for further advice.
Reinl, Gary Iced: The illusionary treatment option. 2nd edn
Peake J, Roberts L, Figueiredo V, Egner I, Krog S, Aas S, Suzuki K, Markworth J, Coombes J, Cameron-Smith D, Raastad T, The effects of cold water immersion and active recovery on inflammation and cell stress responses in human skeletal muscle after resistance exercise. The Journal of Physiology, 2013 Nov, Vol 595 (3), p695-711
For a long time running has received a lot of bad press with regards to its relationship with back pain and other “wear and tear” injuries such as knee osteoarthritis.
It does seem to make logical sense that the cumulative effects of high intensity activity, where forces of up to four times the normal body weight are driven through the joints of the body, would have a detrimental effect on those joints. It is certainly a theme that sports shoe companies have perpetuated and made billions from each time they advertise their latest advance in shock absorbing footwear, be it airTM gelTM or even the - you couldn’t make up if you tried - BioMoGoTM - not sure what happened to that.
The concept that “high impact” equals “bad” is certainly one that has penetrated the mindset of many of the patients that I see. Many of these patients I see as an Osteopath, who frequently have back pain of some sort, have either stopped running as a result or are considering changing the type of activity they do.
My response to these patients is on several levels.
The first is that maintaining some sort of activity when suffering back pain is vital. Both for the recovery and rehabilitation of the current injury and for the prevention of further injury.
Secondly, notwithstanding the common consensus and the logical connection, there is little quality evidence to suggest that running is bad for backs (or knees or ankles for that matter). In fact there is a growing body of research and knowledge that suggests the complete opposite. It is a counterintuitive position that reminds me of one of my favorite quotes:
"For every complex problem there is an answer that is clear, simple, and wrong." H. L. Mencken
It is a growing belief that running is in no way detrimental to the health of joints and the spine and in fact may enhance spinal health. A report of research conducted by Deakin University published just this month online at www.nature.com adds weight to this argument.
This is perhaps the first scientific evidence that exercise can be beneficial for the intervertabral disc (IVD) in the spine. This research identified that running programs, over extended periods of time, had positive effects on the composition of the disc. It also showed that higher intensity activity such as fast walking and slow running had more positive effects than slow walking or static positions.
If you are currently suffering back pain, this is not a recommendation to throw the shoes on (even if they are BioMoGoTM equipped) and go out for a run. You should always make these decisions in consultation with your Osteopath or Physio.
What this research does do (and it is certainly not conclusive evidence at this point), is give us reason to change the way we look at moderating our activity with the long term view to preventing spinal injury and back pain. We will keep abreast of what changes this and similar research directs the way we do things. Until then keep running, keep moving and enjoy yourself.
About the Author.
Travis Bateman is an Osteopath, trail runner, mountain biker, habitual back of the pack finisher and founder of Camberwell Sports & Spinal Medicine. His clinical interest is in movement analysis and its relationship to injury, pain and sports performance.
Belavý, D. L. et al. Running exercise strengthens the intervertebral disc. Sci. Rep. 7, 45975; doi: 10.1038/srep45975 (2017).
I rolled my ankle, AGAIN!
Ankle sprains are the most common type of ankle injury and can account for up to 20% of all sporting injuries (Fong, Hong, Chan, Yung, & Chan, 2007). Poor management and insufficient rehabilitation can lead to recurrent ankle sprains, impairment of athletic performance (Yeung, Chan, So, & Yuan, 1994) and persistent disability (Petersen et al., 2013).
What happens when you roll your ankle?
An ankle sprain occurs when the foot rolls inwards, causing over stretching or tearing to the ligaments on the outside of the ankle.
Fig 1 Inversion injury of the ankle showing damage to the lateral ankle ligaments.
How bad is it?
There are 3 types of sprains which are defined by the extent of damage to the ligaments.
Grade 1: Stretched ligaments
Ligaments are stretched during a slight ankle roll. Common versions of this occur when running onto a patch of uneven grass or during an over step in tennis. You may immediately experience mild pain and a small limp. After a few minutes of rest, most people are usually able to continue their activity. Some swelling may occur within 24 hours and with appropriate management, you can expect return to preinjury state within 1-2 weeks.
Grade 2: Partial thickness tear of ligament
Ligament tearing occurs when the ankle rolls further than the ligaments can stretch. You may experience moderate pain, a limp and usually cannot continue to play. Swelling and bruising may occur within 24 hrs and weight baring is particularly painful. If you experience these symptoms, you should seek medical advice to determine the extent of damage. Depending on this, recovery can take between 2 - 6 weeks.
Grade 3: Complete rupture of ligament
Complete ligament rupture is a progression of grade two and occurs when the ankle has rolled beyond its normal limits. Initially, individuals are unable to walk on the effected ankle and can complain of it feeling “unstable”. Excess swelling and dark bruising would be expected 24 hours after injury. On a case by case basis, grade 3 sprains may require surgical intervention or up to 12 weeks of rehabilitation.
So you’ve sprained your ankle, what to do now?
After following the basic “RICE” principles (rest, ice, compress and elevation), you should seek medical advice from a physiotherapist as soon as possible. Physiotherapists are highly trained health professions who specialise in the assessment, diagnosis and management of ankle injuries.
What to expect when your see the physio?
Your physiotherapist will ask you questions regarding your injury and what symptoms you are experiencing. If pain allows, an assessment will be performed to diagnose your injury and explain the extent of damage. An accurate diagnosis is crucial in ensuring appropriate management and treatment can be provided. (Wolfe, Uhl, Mattacola, & McCluskey, 2001).
Firstly, pain and swelling management is commenced. This may involve icing, taping, bracing, crutches or a moon boot. Secondly, your physiotherapist will discuss your diagnosis and expected recovery time, as well as appropriate activity modification. Thirdly, pain free range of motion and strength exercises can commence. Fourthly, an individualised rehabilitation program will be developed and implemented. Goals and sport specific tasks will be incorporated once adequate function has been regained. Completion of your rehabilitation program results in positive outcome measures, optimal recovery and reduced risk of chronic ankle instability (Mattacola & Dwyer, 2002).
But don’t I need an x-ray?
Physiotherapists follow a set of guidelines called the Ottawa Ankle Rules that are used to determine whether a fracture is suspected (Ivins, 2006). These guidelines have an extremely high sensitivity and are used to reduce the number of unnecessary radiographs by 30-40% (Bachmann, Kolb, Koller, Steurer, & ter Riet, 2003) (Dowling et al., 2009). If your physiotherapist suspects a fracture, an x-ray will be organised.
Can I stop this from happening again?
Extensive research demonstrates that individuals who adhered to a rehabilitation program involving balance and proprioceptive training were significantly less likely to experience a recurrent ankle sprain (Petersen et al., 2013) (Hupperets, Verhagen, & van Mechelen, 2009) (Postle, Pak, & Smith, 2012). While the risk of re-injury can be reduced, unfortunately accidents can still happen.
Bachmann, L. M., Kolb, E., Koller, M. T., Steurer, J., & ter Riet, G. (2003). Accuracy of Ottawa ankle rules to exclude fractures of the ankle and mid-foot: systematic review. BMJ, 326(7386), 417. doi:10.1136/bmj.326.7386.417
Dowling, S., Spooner, C. H., Liang, Y., Dryden, D. M., Friesen, C., Klassen, T. P., & Wright, R. B. (2009). Accuracy of Ottawa Ankle Rules to exclude fractures of the ankle and midfoot in children: a meta-analysis. Acad Emerg Med, 16(4), 277-287. doi:10.1111/j.1553-2712.2008.00333.x
Fong, D. T., Hong, Y., Chan, L. K., Yung, P. S., & Chan, K. M. (2007). A systematic review on ankle injury and ankle sprain in sports. Sports Med, 37(1), 73-94.
Hupperets, M. D., Verhagen, E. A., & van Mechelen, W. (2009). Effect of unsupervised home based proprioceptive training on recurrences of ankle sprain: randomised controlled trial. BMJ, 339, b2684. doi:10.1136/bmj.b2684
Ivins, D. (2006). Acute ankle sprain: an update. Am Fam Physician, 74(10), 1714-1720.
Mattacola, C. G., & Dwyer, M. K. (2002). Rehabilitation of the Ankle After Acute Sprain or Chronic Instability. J Athl Train, 37(4), 413-429.
Petersen, W., Rembitzki, I. V., Koppenburg, A. G., Ellermann, A., Liebau, C., Bruggemann, G. P., & Best, R. (2013). Treatment of acute ankle ligament injuries: a systematic review. Arch Orthop Trauma Surg, 133(8), 1129-1141. doi:10.1007/s00402-013-1742-5
Postle, K., Pak, D., & Smith, T. O. (2012). Effectiveness of proprioceptive exercises for ankle ligament injury in adults: a systematic literature and meta-analysis. Man Ther, 17(4), 285-291. doi:10.1016/j.math.2012.02.016
Wolfe, M. W., Uhl, T. L., Mattacola, C. G., & McCluskey, L. C. (2001). Management of ankle sprains. Am Fam Physician, 63(1), 93-104.
Yeung, M. S., Chan, K. M., So, C. H., & Yuan, W. Y. (1994). An epidemiological survey on ankle sprain. Br J Sports Med, 28(2), 112-116.
The Benefits of Early Morning Exercise
Who doesn’t love the idea of being an early riser? You’re up before sunrise, into the clinic, Pilates class done, and then home in time for a quick shower and breakfast before work.
But when the alarm goes off at 5.30am, there’s easy temptation to stay under the doona. So how can you motivate yourself to get up and going before the crack of dawn? Is there any additional benefit to exercise in the morning, as opposed to late evening after work? If you’re looking to decrease stress, increase quality of sleep and boost your energy levels then read on.
We all know the importance of a good night’s sleep. But we don’t often associate the connection between exercise and sleep behaviours. A study in the US from Appalachian State University found participants who exercised early in the morning had increased levels of mental alertness and felt more energised than their evening counterparts. The same study looked at participant’s sleeping patterns. It found participants who exercised regularly at 7am or earlier, reduced their blood pressure by an average of 10% which carried through the remainder of the day. They also had an average 25% dip in blood pressure at night, slept longer and had better quality sleep cycles than those participants who exercised later in the day. Morning movers are also at an advantage over their evening counterparts as some forms of high intensity exercise 2-3 hours before bedtime is known to disrupt sleep. Simply said, the early risers were more energised during the day, and slept better at night.
One of the most important benefits of exercise, is the role it plays with our Endocrine (Hormonal) System. Our Endocrine system is responsible for the regulation of stress hormones, appetite control and immune function. The primary hormone responsible for stress is cortisol. Cortisol is secreted from the adrenal gland and is known for increasing heart rate & blood pressure, storing fat, increasing appetite, breaking down muscle tissue and suppressing immune function. We can’t always remove the factors that cause stress, but we can control how we respond to these triggers. It’s commonly known that exercise increases our endorphins. Endorphins are released from the pituitary gland and are commonly known as that ‘rush’ of energy and satisfaction post exercise. The effect of endorphins can counteract the effects of cortisol, by decreasing appetite, and reducing tension & anxiety. Endorphins also interact with the receptors in our brain that control our perception of pain, which is why exercise is known to improve our moods. Making time for exercise in the morning, means we feel these benefits throughout the day, when we need them most.
Morning exercises are also at a greater advantage as testosterone levels are typically higher in the morning than they are in the evening. Testosterone is essential for optimal bone health, as well as being responsible for muscle growth and health. Exercising in the morning means you are using this natural fluctuation of testosterone to your advantage.
As we move past holidays and summer social events, setting goals for the year ahead becomes more crucial. We are often setting intentions to improve our physical and mental health, without the proper commitment or motivation to ensure these goals are met. Making time for a morning workout means you are setting aside time at the start of your day, ensuring that the rest of your day is free for other responsibilities. With any goal, consistency is key. Why not set yourself a new goal for the year, and see why the early birds really do get the worm!
The shoulder joint is a complex ball and socket joint that allows 180 degrees of movement. Shoulder impingement occurs when the rotator cuff tendons or bursa (a fluid filled sack) are repetitively compressed in the subacromial space (see image below).
This compression can cause localised inflammation and results in painful movements of the shoulder. It is one of the most common conditions we see in the clinic, especially coming into tennis and cricket season.
The impingement can be “primary” resulting from a structural narrowing of the space or “secondary” due to poor biomechanics and movement patterns of the shoulder. Some of us are born with smaller subacromial spaces or develop bony spurs over time. Secondary impingement can be a result of impaired scapula control, poor posture, or increased mobility in the shoulder joint (Holmgren et al, 2012).
Patients with subacromial impingement may experience pain when sleeping on the effected side, weakness when reaching and lifting and/or an ache referring from the shoulder down the outside of the arm.
Shoulder impingement is classified as a symptom, with many causative factors, rather than a diagnosis (Kibler et al, 2013). It is essential that your physiotherapist acknowledges the concepts of mechanical, movement-related impingement which may in hand prevent the potential for inappropriate surgical interventions (Braman et al, 2014).
The scapula is controlled by a pulley system comprised of muscles attaching to the spine, thorax and arm. Optimal shoulder posture, movement, stability and muscular control are heavily dependent on scapula performance (Kibler et al, 2013). Each muscle has a specific role in helping to tilt and rotate the shoulder blade to allow movements of the arm. The 2013 scapula summit defined altered scapula movement and position as “scapula dyskinesis”. If taping or gentle manual assistance to correct your scapula dyskinesis relieves your shoulder pain this is a fabulous indicator that you are an ideal candidate for rehabilitation and can avoid going under the knife.
As discussed, impingement is caused by a myriad of factors. Traditional treatment involved corticosteroid injections and surgical subacromial decompressions.
Recent evidence has found that exercise management for subacromial impingement is as effective as surgery at 1, 2, 4 and 5 year follow ups (Haahr et al. 2005, Haahr & Andersen (2006), Ketola et al. 2009 and Ketola et al. 2013). This is an exciting revelation in shoulder treatment, showing that a specific exercise program focusing on scapula muscle control, is effective in reducing shoulder pain and improving shoulder function (Holmgren et al, 2012). Exercise management has reduced the need for sub-acromial impingement surgery by up to 80% (Holmgren et al, 2012).
If you are experiencing shoulder pain we recommend you seek a thorough assessment to determine whether your injury will respond to a specific, personalised exercise program to avoid the need for surgical intervention.
Braman, J.P., Zhau, K.D., Lawrence, R.L., Harrison, A. K., & Ludewig, P. M. (2014). Shoulder impingement revisited: evidence of diagnostic understanding in orthopaedic surgery and physical therapy. Medical & biological engineering & computing, 52(3), 211 – 219.
Haahr, J.P., Ostergaard, S., Dalsgaard, J., Norup, K., Frost, P., Lausen, S., Holm, E.A., & Anderson, J.H. (2005). Exercises versus arthroscopic decompression in patients with subacromial impingement: a randomised, controlled study in 90 cases with a one year follow up. Ann Rheum Dis, 64(5), 760 – 764.
Haahr, J.P., Andersen, J.H. (2006). Exercise may be as efficient as subacromial decompression in patients with subacromial stage II impingement: 4 –8- years’ follow-up in a prospective, randomized study. Scand J Rheumato, 35(3), 224-8.
Holmgren, T., Hallgren, H.B., Oberg, B., Adolfsson, L. (2012). Effect of specific exercise strategy on need for surgery in patients with subacromial impingement syndrome: randomised controlled study. British Journal of sports medicine, bjsports-2012.
Ketola, S., Lehtinen, J., Arnala, I., Nissinan, M., Westenius, H., … & Rousi, T. (2009). Does arthroscopic acromioplasty provide any additional value in the treatment of shoulder impingement syndrome?: a two-year randomised controlled trial. J Bone Joint Surg Br, 91(10), 1326-34.
Ketola, S., Lehtinen, J., Rousi, T., Nissinen, M., Huhtala, H., Konttinen, Y. T., & Arnala, I. (2013). No evidence of long-term benefits of arthroscopic acromioplasty in the treatment of shoulder impingement syndrome. Bone and Joint Research, 2(7),132-139.
Kibler, W. B., Sciascia, A.D., Bak, K., Ebaugh, D., Ludewig, P., Kuhn, J., … & Cote, M. (2013). Clinical implications of scapula dyskinesis in shoulder injury: the 2013 consensus statement from the ‘scapular summit’ report of 2013. British Journal of sports medicine, bjsports-2013.
There is a large amount of evidence surrounding the importance of gluteal strength as a protective factor for many musculoskeletal conditions.
A significant weakness in hip abduction (movement out to the side), extension (movement backwards) and external rotation (movement turning out away from the body), with associated hip adduction and internal rotation during functional tasks has been identified in people with patellofemoral pain compared to pain free individuals (Selkowitz et al., 2013).
In other words, people with anterior knee pain were found to have weaker gluteal muscles compared to people without any pain.
Abnormal hip mechanics has also been linked with Iliotibial Band Syndrome (ITBS). As the gluteus medius muscle is the prime hip abductor, weakness in this muscle can lead to greater angles of hip adduction therefore potentially increasing the strain placed on the ITB. It was found that runners with ITBS had greater deficits in gluteal muscle strength on the side of the affected limb, compared to the unaffected limb (Fredericson et al., 2000; Niemuth et al., 2005).
Additionally, poor neuromuscular control of the lower limb, in particular excessive dynamic valgus (knee dropping inwards when landing) is one of the primary risk factors for ACL rupture (Hewett, Myer & Ford, 2005). What causes your knee to drop in during landing you ask? The simple answer, weakness in your gluteal muscles.
Due to this apparent association between gluteal muscle weakness or dysfunction and lower extremity injury, there has been an increased focus on gluteal strengthening as part of injury rehabilitation or prevention programs prescribed by Physiotherapists.
As a practitioner prescribing exercises, it is important that we choose the most effective three to five exercises on an individual needs approach. Generally speaking, when doing gluteal strengthening exercises it is not uncommon to experience overactivity of the Tensor Facia Lata (TFL) muscle. The TFL works similar to the middle fibres of the gluteus medius and upper fibres of the gluteus maximum in that they all abduct the hip (movement out to the side). However, the TFL also acts to internally rotate the hip (rotates it inwards) which can exert forces onto the outside of the knee leading to conditions such as patella femoral pain. Due to this it is important we choose exercises that optimise gluteal activation whilst minimising TFL activation.
Selkowitz and colleagues in 2013 used fine wire electode EMG on the TFL and gluteal muscles to measure muscle activation during various commonly used gluteal strengthening exercises.
The clam , crab walk (or side step) , four-point kneeling hip extension with a straight knee , four-point kneeling hip extensions with a bent knee , bilateral bridge , and squat  all showed statistically significant higher gluteal muscle activation than the TFL. The gluteus medius was preferentially recruited during the side-lying hip abduction  and hip hitching , and the superior fibres of gluteus maximus was recruited best during the clam  and unilateral bridge 
If the goal is to preferentially activate the gluteal muscles whilst minimising TFL activation these nine exercises can now be prescribed with confidence, on an individual needs basis.
Fredericson, M., Cookingham, C. L., Chaudhari, A. M., Dowdell, B. C., Oestreicher, N., & Sahrmann, S. A. (2000). Hip abductor weakness in distance runners with iliotibial band syndrome. Clinical Journal of Sport Medicine, 10(3), 169-175.
Hewett, T. E., Myer, G. D., Ford, K. R., Heidt, R. S., Colosimo, A. J., McLean, S. G., ... & Succop, P. (2005). Biomechanical measures of neuromuscular control and valgus loading of the knee predict anterior cruciate ligament injury risk in female athletes a prospective study. The American journal of sports medicine, 33(4), 492-501.
Niemuth, P. E., Johnson, R. J., Myers, M. J., & Thieman, T. J. (2005). Hip muscle weakness and overuse injuries in recreational runners. Clinical Journal of Sport Medicine, 15(1), 14-21.
Selkowitz, D. M., Beneck, G. J., & Powers, C. M. (2013). Which exercises target the gluteal muscles while minimizing activation of the tensor fascia lata? Electromyographic assessment using fine-wire electrodes. journal of orthopaedic & sports physical therapy, 43(2), 54-64.
You may be familiar with the term ‘Fascia’ in relation to a common injury known as ‘Plantar Fasciitis’. However what some people may not know, is that fascia is not only located in the foot but rather, right throughout the body.
Fascia is a strong connective tissue that serves many purposes, mainly compartmentalizing and connecting your muscles forming a body-wide tensional network of fascial continuity (Wilke, J). As with other structures within the body; for example soft tissue, joints and ligaments, fascia can also impact your body and be a source of pain.
For example, lower back pain is a very common complaint that we see every day at CSSM. Injury and subsequent immobility in the area can lead to decreased movement of the thoracolumbar fascia (a term given to the broad, thick diamond-shaped fascia spanning the middle and lower back regions). If this is a chronic problem, adhesions within the fascia can develop leading to long-term issues in the area, meaning that your back may feel ‘stiff and tight’ and therefore be influencing your pain.
Over many years, many physical therapists have started to incorporate assessment and treatment of fascia leading to positive results in terms of symptomatic relief, and injury prevention. You will also be interested to note that some of these techniques can be utilised on a daily basis at home using a foam roller!
A recent study has showed a positive relationship between using the foam roller on the thoracolumbar fascia (Griefahn A, et al). You may be more familiar with the techniques used on your upper back by lying on the roller vertically (along your spine as well) and horizontally, using your legs to push your body back and forth. This in turn will not only help to increase movement in the joints locally, but also reduce tension in the thoracolumbar fascia, therefore having a positive effect throughout the spine.
These treatment principles can also be applied throughout the body with other common conditions such as ‘runner’s knee’, jaw/TMJ pain and more. If you have any questions regarding fascia then do not hesitate to ask your treating practitioner.
Wilke J. 2016, Myofascial Chains Revisited: A Review of Several Suggested Force Transmission Lines from an Evidence-Oriented Perspective with Special Focus on Low Back Stability.
Griefahn A, et Al. 2016, Do Exercises with the Foam Roller have a short impact on the Thoracolumbar Fascia? – A randomized controlled trial
The TGA (Therapeutic Goods Administrator), Australia’s drug regulator has issued a warning to women about the use of anti-inflammatories during pregnancy.
Whilst pregnant women should always speak to their health professional before taking any medication, many women consider anti-inflammatories “harmless” like other drugs such as paracetamol. Anti-inflammatories are marketed as a common remedy for headaches, period pain and other general pains; and many women may take them before they are even aware that they might be pregnant.
Taking anti-inflammatories during early pregnancy has been linked with increased risk of miscarriage.
The TGA is warning all women thinking of conceiving to avoid these popular drugs including Voltaren, Naprosyn and Nurofen; and are in discussion with drug companies to make sure they display obvious warnings on the packaging. The TGA has stated “The data suggests that the risk is greatest when the medicine is taken close to the time of conception."
American researchers interviewed more than 1000 recently pregnant women and found that use of NSAIDs increased the risk of miscarriage by 80 per cent.
There are many studies relating to the use of non-steroidal anti-inflammtory drugs (NSAID) during pregnancy. Antonucci et al outline “Increased risks of miscarriage and malformations are associated with NSAID use in early pregnancy. Conversely, exposure to NSAIDs after 30 weeks' gestation is associated with an increased risk of premature closure of the fetal ductus arteriosus” (part of the developing heart). “Fetal and neonatal adverse effects affecting the brain, kidney, lung, skeleton, gastrointestinal tract and cardiovascular system have also been reported after prenatal exposure to NSAIDs.”
A study by Wiley et al identified “Many pregnant women get prescriptions for NSAIDs during their first trimester, and even more--up to 15 percent--take over-the-counter versions of these drugs.”
The current advice from the TGA is “If you are pregnant, think you may be pregnant or are trying to become pregnant, consult a health professional before using these products and consider using an alternative medicine.”
“TGA pregnancy warning for popular over-the-counter painkillers” The Age Newspaper. October 11, 2016.
Use of non-steroidal anti-inflammatory drugs in pregnancy: impact on the fetus and newborn. NCBI. Antonucci et al. May 2012
First Trimester Use Of NSAIDs Is Associated With Cardiac Abnormalities In Babies. Wiley, John et al. Science Daily. August 25, 2006
Tension headaches are the most common type of headache and affect 36% of men and 42% of women - that's 7 million Australians. Tension headaches usually present with some of the following characteristics:
The causes of tension type headaches are multiple and include different muscular conditions. Excessive muscle contraction such as jaw-clenching and active trigger points or “knots” can induce one. Poor posture, be it at work, in front of the computer or driving, are the other main culprits. Other causes include stress, anxiety and fatigue.
Our myotherapists here at CSSM can help you with a variety of treatments.
Moraska AF, Stenerson L, Butryn N, Krutsch JP, Schmiege SJ, Mann JD. Myofascial trigger point-focused head and neck massage for recurrent tension-type headache: A randomized, placebo-controlled clinical trial. The Clinical journal of pain. 2015;31(2):159-168.