Sonia Dunne was diagnosed with Rheumatoid Arthritis while training for the 2014 Ironman Melbourne. Despite her diagnosis, she still competed the 3.8km swim, 180km bike ride and a 42.2km marathon! It’s this determination that saw her accepted into CSSM’S Athlete Sponsorship Program.

Sonia talks about how rheumatoid arthritis has affected her life and training and how she plans to achieve her goals for 2018.

 

Rheumatoid Arthritis is an autoimmune disorder that causes pain and swelling of the joints. For me to cross the Ironman Melbourne finish line in a very respectable 14 hours and 7 minutes was a HUGE accomplishment to say the least, especially given sufferers of RA at my level are rarely able to get out of bed in the morning and end up with severe depression from the pain associated with the disorder. I did actually end up in hospital at the completion of the event for a week and a half due to the fact that I pushed myself above and beyond in order to make the finish line and become an IRONMAN. Unfortunately, I have paid the price for my sheer determination to cross that finishing line and since then I have seen some very trying times.

I am not a quitter and I refuse to give up often to my own detriment. No matter how hard and crappy my RA is, I always manage to keep a positive attitude in all that I do, and I inspire others around me. The overwhelming symptom I have is pain and stiffness, sometimes it lasts 4 hrs and sometimes it last all day but the mornings are generally the worst. I remember once trying to get out of bed and the pain was so great that I collapsed and my body went into shock and I had a fit. That was probably the disease at its worst. Now, with the treatment I am receiving, I still get pain but it is far more manageable.

My knees, lower back, feet and hands are most effected. My knees of late are causing me the greatest about of pain, so much so that I rarely walk without pain anymore. It often takes me 30 seconds or so to stand up from a seated position and move making running pretty much impossible.

I receive treatment monthly in the form of a drug called Tocilizumab that requires admission to day oncology. In the next few weeks, I am also going to be admitted to hospital to have Yttrium Radio Synovectomy Therapy which is a treatment that destroys painful tissue, stops fluid secretion and reduces joint inflammation on the knees.

Strangely, exercise helps! I'm unclear as to whether that is mind related or mobility related but if I don’t exercise I find myself being very short and irritable. Does it help the pain? Probably not, although I like to say it does but the issue then becomes working out what is RA pain and what is general muscle soreness. The challenge you have with someone like me is that exercise is not going for a walk or an easy swim, exercise is  running 21kms or exercising to max capability for 45 min or riding for 4hrs + anyway you get the idea!

Exercise brings so much more benefit for me other than keeping fit, keeping the weight off etc….its an outlet. It’s something I use to clear my head, digest the day and make a plan for what's next. That is invaluable.

I have certainly not done another Ironman - but I will one day. I have done two ultra marathons, two half IM's and two half marathons and one Olympic distance triathlon over the past two years. Of late, I’ve taken up Functional 45 Training with F45 Oakleigh and this I really love. I am learning so much about the importance of balance as opposed to just run, ride, swim and the strive to beat yourself, I just love it. I have found myself participating in sports that are far less weight bearing on my joints, and shorter time span to avoid stress and fatigue on my body. I can't say I am convinced as I have been programmed for so long to do endurance.

I am also on the Triathlon Victoria Board - VP. This helps me remain connected to the sport I love and enables me to give back in a way that I can manage and that suits my skill set. It also helps me develop both personally and in my career. One day I will race again, but in the meantime this is a great compromise. There is so much that can be done and gained from volunteering in sport.

Diet - clean eating with my disease is a must. I feel it in myself and my body when I don’t eat well. Lots of fish for essential oils and lots of green vegetables and minimising sugar. F45 has also been a huge help with this, it has transformed the way I see food. I have also found wine to be a trigger.

Home - we have had to make a few modifications to make life a little more bearable. Pull taps instead of turn taps, walk in shower recesses as opposed to the old step over the bath style and importantly, we have a furry family member - Molly which I found also helped a lot as the focus shifts from you to her.

Lifestyle - bring back the flats and joggers! Unfortunately, I am not going to win awards for the "style master of the year " at work or heading out as I can only wear flat shoes or when the pain is unbearable, joggers but everyone is used to that now and it suits my lifestyle. The other big change I have made is to prioirtise sleep. Fatigue comes as a symptom of the disease but the more sleep you get the easier things are to bare so I try to get at least 8 hrs sleep a night.

I utilise Remedial Massage, Pilates and core and lower back strengthening exercises thanks to Kobe at CSSM. I had really not maintained my body proactively at all until I was lucky enough to be selected as an ambassador and now I do it all the time. More importantly, I understand why I'm doing it and what I am affecting. Looking after your body is so important. I now believe that if you are good to your body it will be good to you.

The best advice I’ve been given is stop and listen to your body. By nature, I just push and push and push I have learnt that there is only so much your body can take and that is why I am where I am today. Hopefully, others can learn from this.

I have a very supportive specialist who is very keen to support me in achieving my goals whilst also managing the impact on my body and the expectations that I have. At this stage, all I am doing is F45, focussing on strengthening my body through pilates and weights.

My goals for 2018:

Compete in the Kokoda Ultra Trial Marathon

Compete in the Noosa Triathlon

To get a 6 pack!

During nine months of pregnancy, the female body undergoes several structural and physiological changes and this can lead to compensatory patterns in movement with the potential to cause restriction and pain. As Osteopaths we are trained to assist you in your overall movement and well-being.

The most common body adaptions that we see include, 

• Exaggerated spinal curves with changes in pelvic tilt, causing some muscles to be ‘tight’ and weak, contributing to: 
  • Headaches 
  • Muscle pains 
  • Lower back pain 
  • Posterior pelvic pain 
  • Plantar fasciitis 

 

• The presence of the hormone relaxin, and an increase in progesterone causing an increase in ligament laxity presenting as:
  • Posterior pelvic pain or instability 
  • General spinal pain 
  • Muscle spasm 

 

• An increase in body weight due to the growing foetus and an increase in blood volume, adding further strain to the joints and connective tissue 

 

• Interstitial fluid retention impacting lymphatic flow, causing: 
  • Thoracic Outlet Syndrome
  • Carpal Tunnel Syndrome 
  • Peripheral oedema/swelling in legs and/or arms 

 

• An increase in baby size (especially in the third trimester), causing: 
  • Reflux (heartburn)
  • Shortness of breath 
  • Intercostal neuralgia (pain around the ribs)  

 

At CSSM, we ensure a careful selection of hands-on techniques to best suit your condition, as well as your stage of pregnancy for safe and effective management. This may involve soft tissue massage, joint articulation and stretching in order to address affected areas. Spinal manipulation can be utilised if your practitioner deems it safe and appropriate for your condition. Your Osteopath will then take time to educate you on ways to manage your pain for the remainder of the pregnancy and also following delivery when your newborn arrives. 

Osteopaths are Government registered allied health practitioners with five years of university education behind them studying anatomy, pathology, physiology, pharmacology and clinical application. If you want to find out how an Osteopath can make your pregnancy more comfortable, make an appointment at cssm.com.au.

 

Caroline Sanguinetti is an Osteopath who specilaises in pregnancy care. 

Jumper’s knee

With winter just around the corner, the sporting seasons are now in full swing. Many teens and pre-teens are involved in multiple sports, both in school and club teams resulting in a surprisingly large training load. A particularly common complaint we are treating is knee pain, more specifically patella tendinopathy or “jumper’s knee”.

Patella tendinopathy is a condition that develops in adolescents, more commonly in boys who participate in sports such as basketball, volleyball, football, and other sports requiring repetitive jumping. Prior to puberty, the patella tendon is not fully attached to the knee cap and excessive load during this period can change some of the fundamental characteristics of the tendon. 

Girls have a mature patella tendon by the age of 12-13 years, generally prior to the increased training demands of high school. This puts them at a lower risk of patella tendinopathy. Unfortunately for the boys, they do not develop a mature tendon until 14-16 years. By this age, higher training loads have already commenced, stressing the patella tendon during its critical developmental period. 

How does patella tendinopathy present?

• Localised pain at the base of the patella 
• Increased pain with increased load such as running and jumping 
• Pain may be bilateral, but often one side is worse 

What are the risk factors?

• Male gender
• Repetitive quadriceps contractions (jumping, running)
• Rapid increase in training load 
• Poor calf strength 

What should I do if I think my child has patella tendinopathy?

• Address the pain initially through ice and decreased load (NOT complete rest)
• Anti-inflammatory medication used as directed may be beneficial for your child if tolerated
• See a physiotherapist for assessment and treatment which may include:
  • Soft tissue massage 
  • Taping 
  • Commencement of isometric exercises for pain relief 
  • Assessment of jumping/landing strategies to identify predisposing factors
  • Strengthening and stretching exercises to address the factors identified above

Patella tendinopathy can be a long-term injury that requires optimal load management and patience. There are some simple self-management strategies that can help control pain and improve function, so if you think your child may be suffering from patella tendinopathy come and see one of our physiotherapists here at CSSM to help get them back playing sport pain-free.

 

About the author

Kobi Phelan is a graduate of the Doctor of Physiotherapy program at the University of Melbourne and also holds a Bachelor of Exercise and Sport Science. Kobi places high importance on actively involving her patients in the design and implementation of their injury rehabilitation.

 

References: 

Mascaró, A., Cos, M. À., Morral, A., Roig, A., Purdam, C., & Cook, J. (2018). Load management in tendinopathy: Clinical progression for Achilles and patellar tendinopathy. Apunts. Medicina de l'Esport, 53(197), 19-27.

Getting back from injury can be a long and lonely road. No matter what sport you play or what kind of athlete you are, everyone has setbacks.

I had hip surgery in 2016 after tearing cartilage in my right hip while training for the Cairns Ironman.

It's been tough because I really enjoy the satisfaction that comes from competing in endurance events both from a physical and psychological perspective.

For me, surgery was inevitable. Even though I tried to avoid going under the knife by focusing on glute and core strength work, I was unable to run pain free. As if that wasn’t enough, I also suffered from a frozen shoulder during the same period.

Regular physio and massage has been part of my rehab program. I have worked on changing my running gait to a more mid-foot strike to reduce impact, increase running cadence and extensive core and glute strengthening work.

Rehab has been frustrating. The improvements have been very slow and I have had to manage my expectations carefully and listen to my body. But I believe early intervention has helped minimise the damage and get me active sooner.

I am currently training 6-7 days a week. Generally 2-3 swim sessions, 2 runs and 2-3 rides. This is supplemented by massage focused on my lower back and legs. Dry needling is also a part of the treatment.

The best advice given to me while I've been injured? "Be patient and don’t skip the rehab exercises even if they don’t seem to make a difference."

My goal is to complete a half marathon triathlon again. If you're injured, be patient, listen to your body, be consistent with training, don’t increase the training volume too quickly and utilise massage as a key rehab treatment.”

 

*Peter Hutchings is 54 and is sponsored by CSSM as part of the 2018 Athlete Sponsorship Program. 

He is currently 16 months post-surgery and one of our very determined athletes.

CSSM is proud to work with people like Peter to help them achieve their goals.

 

Camberwell Sports & Spinal Medicine requires a Medical Receptionist to be part of our busy reception/administrative team. Be the smiling face that greets our clientele who come from a vast variety of backgrounds.  The role is a permanent part-time position.

We are seeking a person who thrives on a busy working environment. This person will be highly motivated to have a positive impact of the practice by being organised, proactive, and dedicated to providing patient services support to the highest level.   

The practice is open extended hours with this position including some mid-week evening and weekend commitment.

 Your responsibilities will include:

• Front desk reception
• Meeting and greeting patients – creating a great first impression
• Working with a busy switchboard
• Assisting with patient enquiries
• Scheduling patient appointments
• Prepare and receipt patient accounts
• Data entry with a high level of accuracy
• Filing - scanning (paperless office)
• Organising and liaising with other practices and service providers.
• General administration
• Practitioner support
• Back of house support – Organising linen etc.

 

To be successful in this role you must possess the following:

• High-level computer literacy
• Strong organisational and communication skills with the ability to manage competing demands
• The ability to work within a large team environment and liaise with people on all levels
• Excellent presentation skills
• Professional telephone manner
• A knowledge of Frontdesk Practice Management software would be highly advantageous

 

The position will commence May / June 2018.

 

Resume’s to:

 

Careers@cssm.com.au

 

Low back pain and paracetamol by Osteopath Lachlan White

It is expected that 70-90% of people will suffer from low back pain at some time in their lives. 

Low back pain can be a significantly debilitating experience and commonly affects a person’s ability to complete simple tasks, such as getting dressed, getting out of bed or walking a short distance. It also has the potential to burden those who care for low back pain sufferers. 

Paracetamol is one of the most commonly prescribed medications for relieving low back pain – but is it really effective?

Significant research has recently been conducted in this area and has revealed some surprising insights.  The British Medical Journal (BMJ) found paracetamol to be ineffective for reducing low back pain intensity and improving quality of life. Evidence also indicates that people consuming paracetamol are four times more likely to have altered liver function due to the body’s metabolism of the drug.

When compared to placebo (a dummy pill), paracetamol has been shown to have the same effects on pain, function, sleep and quality of life – no improvement. 

So as a sufferer of low back pain, where does this leave me?

In some cases, anti-inflammatories or other forms of pain medication are more likely to be effective. There are also many other self-management strategies which may assist in managing low back pain. 

Osteopathy is a form of manual therapy within the Allied Health profession which can help diagnose, treat and manage low back pain. By using a range of safe and clinically effective treatment techniques tailored to the individual, it can relieve pain, improve mobility and strength, and increase performance. Osteopaths are also able to prescribe rehabilitation programs, provide advice regarding common medications, prescribe other self-management strategies and assist with any other problems that you may be experiencing.

To discuss this further contact CSSM on 9889 1078.  

About the author:

Lachlan White is a registered Osteopath. He has an interest in treating patients with acute and chronic pain conditions, including headaches, neck and back pain and assisting in the management of chronic and degenerative disease.

References

Back problems. (2017). Australian Institute of Health and Welfare. Retrieved 20 March 2018, from https://www.aihw.gov.au/reports/arthritis-other-musculoskeletal-conditions/back-problems/what-are-back-problems

Machado, G., Maher, C., Ferreira, P., Pinheiro, M., Lin, C., & Day, R. et al. (2015). Efficacy and safety of paracetamol for spinal pain and osteoarthritis: systematic review and meta-analysis of randomised placebo controlled trials. BMJ, 350(mar31 2), h1225-h1225. http://dx.doi.org/10.1136/bmj.h1225

Williams, C., Maher, C., Latimer, J., McLachlan, A., Hancock, M., Day, R., & Lin, C. (2014). Efficacy of paracetamol for acute low-back pain: a double-blind, randomised controlled trial. British Dental Journal, 217(4), 183-183. http://dx.doi.org/10.1038/sj.bdj.2014.732

One of the most common questions we receive from concerned parents about their active children is, “how much is too much?” 

When a child has a healthy interest in sport and has the dedication to be the best that they can be, sometimes it can be difficult to get them off the court and the ball out of their hands.  As with many things in life, balance is important and parents are tasked with the role of trying to encourage the enthusiasm of youth whilst knowing that too much may be putting that child at risk of injury.

This issue becomes more apparent as the “professionalism” of sport filters into the junior ranks.  In some sports, athletes can now receive national rankings from the age of 10 and athletes are encouraged into single sport specialisation together with high intensities and volumes of training at increasingly younger ages.  

Undoubtably, the biggest consideration when dealing with junior athletes is injury prevention. With young age, sport specialisation and high training volumes - they are at high risk. 

An article from 2017 in the Strength and Conditioning Journal discussed this dilemma.  How much is too much?

Interestingly, the article concluded that junior athletes tolerate surprisingly high volumes of sport - but only if the load was tempered by significant rest periods between seasons and a limit on sports specialisation until the late teens.  

Of importance was the finding that injury prevention strategies and conditioning should form part of the training program.  

The recommendations of this study outline that a mixture of structured sports and unstructured play is very important in junior athletes. The study found the time spent playing structured sport should be no more than twice the time spent participating in unstructured play.  

In terms of the total volume of the number of hours spent playing structured sport (training plus match play) - it should be less than the child’s age in years and should not exceed 16 hours per week for late teens.  So a ten year old athlete can play up to 10 hours of structured sport a week, but an 18 year old should not exceed 16 hours.  

Time off is very important.  The recommendations within this research suggests that time off between seasons and time off through the year is vital.  The findings suggest that junior athletes should have at least 3 months away from structured sport each year (not necessarily in a row) and at least one month between seasons for the best outcomes with regard to injury prevention.  

When it comes to specialisation, the research suggests that this should be limited until the athlete reaches late teens. Athletes should participate in different sports throughout the year, but not necessarily more than one sport at a time.  

Clearly, the recommendations in the paper are one view and general in nature.  Recommendations will change based on numerous individual variables including gender, developmental progression and the actual sports involved.  Should you have any queries about your child’s participation in sport and injury prevention, please talk to our team at Camberwell Sports and Spinal Medicine.  

About the Author

Travis Bateman is an Osteopath, trail runner, mountain biker, habitual back of the pack finisher and founder of Camberwell Sports and Spinal Medicine.  His clinical interest is in movement analysis and its relationship to injury management, pain and sports performance.

 

Reference

Jayanthi, Neeru A. MD; Dugas, Lara R. PhD, MPH, 2017, The Risks of Sports Specialization in the Adolescent Female Athlete, Strength & Conditioning Journal: April 2017 - Volume 39 - Issue 2 - p 20–26

The jury is out on which is better. Standing all day is no better than sitting. This is because, by standing all day, a variety of new risk factors are introduced such as increasing compression through the spine which can lead to low back pain. It may also increase the risk of developing varicose veins and other cardiovascular problems as the body has to work against gravity to return blood flow back to the heart.

What experts do agree on is that the body was designed primarily for movement, so sitting or standing statically for extended periods is counterproductive.  Therefore, a combination of alternating between sitting and standing is most likely to be the healthiest option. So instead of forking out thousands of dollars on a sit-stand desk, try the obvious solution first –stand up and move as often as possible at work.

The term ‘ergonomics’ is derived from the Greek language and translates as ‘how to work according to nature’. Put simply, it is the interaction between a person and their environment.

In Australia, 45% of all employed adults work in a sedentary job where they spend most of their time sitting. Prolonged periods of sitting not only increases the risk of diabetes, heart disease and obesity, but may result in the development of numerous musculoskeletal disorders and discomfort. Ergonomic adjustment to the workplace environment may increase comfort and productivity, and decrease the risk of chronic injury and disease.

Some basic tips to improve desk ergonomics include:

• Feet flat on the ground
• Knees and hips at 90 degrees
• Hips slightly above knee height
• Hips positioned in the back of the chair
• Backrest slightly reclined to 10-20 degrees from vertical 
• Forearms approximately level with the desk, keyboard and mouse within close distance of each other
• Computer screen is at arms length from the head, with eye line falling within the upper 1/3 of the screen
• Sit up tall, chest out, shoulders back and remain upright.

 

Image sourced from: http://www.sittingergonomics.com/

 

Is there anything else I can do to assist my workplace health?

Yes there is. Movement is the key to rejuvenating the neurological system by activating fatigued and ineffective muscles, and allowing fluid movement to keep the spine healthy. Workers should be moving every 25-30 minutes. Get a drink of water at the water fountain, take the stairs instead of the lift or speak to a colleague face to face instead of using email!

Simple stretches can also be completed to assist with pain prevention. These are a few examples of stretches that can be completed whilst sitting: 

 

 

Image sourced from: https://equilibriumnaturalhealth.com/2016/12/01/seated-stretches/

For more information, contact one of our Osteopaths here.

About the author:

Lachlan White is a registered Osteopath. He has an interest in treating patients with acute and chronic pain conditions, including headaches, neck and back pain and assisting in the management of chronic and degenerative disease.

 

References

Australia Bureau of Statistics. (2011). 4835.0.55.001 - Physical Activity in Australia: A Snapshot, 2007-08. [online] Available at: http://www.abs.gov.au/ausstats/abs@.nsf/Lookup/4835.0.55.001main+features32007-08 [Accessed 20 Mar. 2018].

Chu, A., Ng, S., Tan, C., Win, A., Koh, D. and Müller-Riemenschneider, F. (2016). A systematic review and meta-analysis of workplace intervention strategies to reduce sedentary time in white-collar workers. Obesity Reviews, [online] 17(5), pp.467-481. Available at: https://onlinelibrary.wiley.com/doi/abs/10.1111/obr.12388 [Accessed 20 Mar. 2018].

Feet are funny things.  26 Bones, 33 Joints, over 100 muscles, tendons and ligaments.  That is a lot that can go wrong. 

Too often at CSSM we see patients who present with long standing foot pain. Invariably this pain starts as a little niggle, which progresses to pain that doesn’t go away and eventually can become quite painful and disabling.

Now we understand when people say, “It didn’t seem too bad so I didn’t bother to get it checked out,” however identifying issues before they become a problem is a key philosophy of CSSM. With this in mind Camberwell Sports & Spinal Medicine is giving you the opportunity to quiz our experts and receive a free foot check. It is time to get those little niggles checked out!

The Free Foot Checks are conducted by our Podiatry team. The assessment involves a half hour session and will include a biomechanical and video gait analysis. Suitable for children and adults alike, these sessions are focussed on giving the participant a clear understanding of how their foot functions, outlining any evident biomechanical issues, the cause to these problems and suggestions on various management options all with a written report. Designed to answer any questions that you may have, we can also give other specific advice regarding shoe selection and self-management of foot conditions. This will all be provided free of charge with no obligation.

Servicing the general public and athletes from recreational to elite, our podiatrists pride themselves on providing services which have measurable outcomes.

The Free Foot Checks are available until April 15^th 2018. Sessions are by appointment only, with only limited spaces available each day. 

Free Foot Check Appointments cannot be made online.

Find out more about the podiatry services available at CSSM on our website www.cssm.com.au/podiatry

*The Small Print:

• This offer is obligation and commitment free.
• This offer is available for a single use only and is open to both new and existing patients of Camberwell Sports & Spinal Medicine.
• Free Foot Checks are a temporary service available from Camberwell Sports & Spinal Medicine until 15th April 2018.   
• This offer can only be redeemed by calling Camberwell Sports & Spinal Medicine for an appointment on 03 9889 1078.  Free Foot Check Appointments cannot be made online. 
• The purpose of this offer is to enable patients to access the Podiatry services of Camberwell Sports of Medicine and to experience our philosophy on injury management.
• Camberwell Sports & Spinal Medicine reserves the right to amend these terms and conditions without prior notice.
• In the event of any dispute, the decision of Camberwell Sports & Spinal Medicine is final.

 

It’s time to burst some bubbles, pop the stigma and talk about the really irritating problem of blisters. They’ve been in the news recently with South Korean tennis superstar Hyeon Chung having to retire from his Australian Open semi-final clash with Roger Federer (heard of him?). It has to be a serious blister to cause someone to retire from playing in a grand slam semi-final, but it goes to show how important blister prevention and management can be!

If blisters are left untreated and not offloaded they can eat away at the epidermis (the outermost layer of the skin) and reveal the dermis; a part of the skin that is easily prone to nasty infections. The last thing we want to happen after developing a blister, is to see an infection take over the region on the foot and lead to time off your feet.

With the new football season about to kick off (pun intended) and with events such as the 100km Oxfam Trailwalker happening soon there is a lot of blister talk around the clinic at the moment.  

As most people know, a blister can really ruin your day.  In fact for the Oxfam walkers, blisters are the most common reason that participants seek medical attention or even pull out of the walk, so managing them is super important if going ahead with the challenge.

Tips for Avoiding Blisters

• Wear good quality socks: that form well to the foot and size well.
  In vigorous situations, having a sock too small can increase the area of pressure due to the seam contacting with the foot. Likewise, socks that are oversized can increase the friction over bony landmarks and cause a “hot spot.”
• Wear in your footwear!
  Seems simple, but testing your shoes and gradually wearing them in before vigorous exercise is the best way to avoid blisters. Hiking, construction and leather boots are the main culprits. Preventative taping using sports tape or underwrap (Hypafix or Fixomull) will decrease the friction caused and leave your feet a lot happier.
• Manage hotspots early.
  If you feel the blister starting to form, cease activity and inspect the area. If a fluid sac has not appeared, commence management involving a non-stick dressing over the area and tape it well. Your podiatrist can also help by applying felt offloading padding, particularly for those pesky blisters in the arch and under the big toe.

Managing Blisters Once Formed

• Don’t pop the blister unless you can do in a sterile manner, apply an anti-bacterial agent (such as Betadine) and an appropriate bandage. If not, protect using blister packs for protection and reabsorption. 
• If these can be achieved, create a small insertion to the fluid sac and the most distal point (lowest gravity point) using your sterile implement. Use gauze (or similar products) to absorb the fluid as you gently drain the blister. Once the region is inspected, apply Betadine and dress.
• This is a great time to adjust the lacing on your shoes, or change shoes all-together to protect the area going forward.

Blisters can be detrimental to the best athletes and for the weekend warrior. If you have any further questions, or want advice and strategies to protect yourself in whatever challenge you face, pop in (pun intended) and chat to the Podiatry team at CSSM.

 

About the Author: James Unkles is a Podiatrist who has also completed his Bachelor degree in Exercise and Sport Science. He loves the finer details of running and how it effects the body. He hates blisters with a passion. 

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.

 

References:

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. 

By Kobi Phelan

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.

Key Features:

• Rigid “heel counter” enabling the rear foot to be locked in to the shoe and prevent slippage
• Fixation through laces, or velcro to prevent midfoot movement
• Nil flexibility through rotation of the midsole. In simple terms: not being able to scrunch the shoe in to a ball. A little bit of flex is good, but it should be free moving.
• Width across the forefoot - should not rub on the foot.

Remember to take care of those shoes, get them fitted properly by the experts, and if there’s anything we can do to help, come and see the Podiatry team here at CSSM.

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.

 

About the Author
James Unkles is a Podiatrist who has also completed his Bachelor degree in Exercise and Sport Science, and loves the finer details of running and how it effects the body.

References

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.

References
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.  

Reference

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.

Stride
The actual impact from one foot meeting the ground, transferring through the foot, taking off, swinging though and contacting the ground again.

Stride Length
The distance of one stride, generally measured from initial contact point to initial contact point on the same leg. 

Gait
In health terms, we use this term to describe your movement style. It encompasses both walking and running, both foot contact and flight time.

Midstance

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.

Toe-Off

The propulsion phase where your foot leaves the ground.

Heel Strike

The initial ground contact generally made by rearfoot and midfoot runners. 

Load

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.  

 

 

References:
- www.osteoporosis.org.au/sites/default/files/files/Burden%20of%20Disease%20Analysis%202012-2022.pdf

- 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:

• Wrist and hand  
• Forearm 
• Shoulder
• Rib stress fractures
• Hip
• Knee
• Back

How to reduce/prevent injury from rowing: 

• Maintain correct technique
• Good general health
• Make sure you warm up sufficiently 
• Stretch afterwards – particularly hamstring and hip flexor muscle groups
• Improve posture both during rowing and during study or work

Immediate management for your rowing injury: 

• Stop what you are doing, rowing through pain can make your injury worse! 
• For soft tissue injuries use RICE (rest, ice, compression, elevation) until you have the opportunity to see a healthcare professional. 
• Seek treatment from a health care professional as soon as possible. Early management will help your condition heal quicker and reduce your time spent away from rowing. 
• Correct any technique errors prior to graded return to rowing.
• If you are experiencing discomfort in your chest and suspect a rib stress fracture in line with the Rowing Australia guidelines, 4 days of no water training is highly recommended. 

 

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. 

 

References^1-5

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.  

 

Resources:
Graves et al, Early Lumbar MRI not associated with better outcomes, 2012.
Jensen 2010, Early MRI Use, COCA.
https://www.painscience.com/articles/mri-and-x-ray-almost-useless-for-back-pain.php 

 

 

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

1. Grindem H, Snyder-Mackler L, Moksnes H, et al  Simple decision rules can reduce reinjury risk by 84% after ACL reconstruction: the Delaware-Oslo ACL cohort study Br J Sports Med 2016;50:804-808. 
2. Rambaud AJM, Semay B, Samozino P, et al. Criteria for Return to Sport after Anterior Cruciate Ligament reconstruction with lower reinjury risk (CR’STAL study): protocol for a prospective observational study in France. BMJ Open 2017;7:e015087. doi:10.1136/ bmjopen-2016-015087

_{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:

1. Reactive Tendinopathy: Cells within a tendon respond to increases in load (i.e. running) and become activated. These activated cells can then produce pain receptors, and you as the runner start to feel acute pain in the tendon. These cells need calming down, in other words, rest. If these cells continue to detect tendon overload, they produce certain proteins which swell the tendon. This then leads into phase 2.
2. Tendon Disrepair: Increases in the aforementioned proteins causing the tendon to swell eventually leads to the breakdown of the connective tissue matrix. Matrix breakdown allows for more space for blood vessels to grow into.
3. Tendon degeneration: Cells become quite passive. This phase is characterised by a “grumbly tendon”. It can be a little sore in the morning but usually settles down ok. People with tendons in the degeneration phase don’t usually present as often to physio as their pain doesn’t seem to bother them too much day to day.

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!

 

References:

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 4^th 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.

References

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:

• Address the pain initially through the use of Ice and Rest
• Anti-Inflammatory medication used as directed may be of benefit (if tolerated by your child)
• See a Podiatrist for assessment and treatment options which may include
  • Ensuring appropriate footwear with rearfoot support
  • Stretches or strengthening program
  • In some cases orthotic devices may be recommended. 

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.

 

References

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

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 1^st 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.

 

REFERENCES

Clinical Sports Medicines Brukner and Khan 4th edition 2012 McGraw-Hill Education

Podiatry Today: http://www.podiatrytoday.com/article/9063

http://www.medicinenet.com/turf_toe_symptoms_causes_and_treatments/article.htm