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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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We at CSSM were lucky enough to have Andrew Russell join us as a guest presenter at our recent Run Long Run Strong information evening. As Hawthorn’s Elite Performance Manager, Andrew has played a major role in Hawthorn’s premiership three-peat and has a track record of 4 premierships in 11 years at Hawthorn.
His wealth of knowledge in the areas of maximising performance, strength and conditioning as well as the psychological aspects of elite sport was showcased throughout his captivating presentation.
Some of the very interesting and thought-provoking topics Andrew discussed were:
1) The way you perform on the training track makes only a small contribution towards your overall success as an athlete. The sacrifices you make outside of training (diet/lifestyle) increase your emotional commitment to success and play a much greater role.
2) The way you think influences your actions, your actions then develop into habits, and your habits harden into character.
3) Stress has a negative effect on the mind and the body. The most important factor in decreasing your stress response is having a sense of control over all parts of your life. Create strong social support networks.
An inspirational and hair-tingling video of Stephen Curry’s journey towards being one of the best shooters in the NBA was used to demonstrate the power of sacrifice, commitment and pure determination. A quote from this video that has stuck with me was, “Are the habits that you have today, on par with the dreams that you have for tomorrow?” …. Are they?
As Elite Performance Manager, Andrew ensures all players know exactly what is ahead of them at each training. He does not believe in throwing in any unexpected “lemon twisters”, valuing the trust that the players have in him each day. The players train hard, but recover even harder.
In pre-season Andrew designs the programs to have more extreme variations in training loads, with importance placed on pure speed and pure endurance early on, funnelling towards repeat efforts as the weeks progress. The importance of a strong preseason was portrayed in a ‘Games played vs % pre-season’ graph. The players that completed an average of 87% of the pre-season program, played on average 23 games with no injuries. Those who completed an average of 65% of the pre-season, played on average 16 or fewer games. The average group percentage of pre-season completed in 2008, and 2013-2015 was over 80%. These same years Hawthorn went on to win the AFL Premiership. Need any more motivation for a solid pre-season?
The Run Long, Run Strong education evenings are held to support CSSM’s preferred charity the Indigenous Marathon Foundation anf their Indigenous Marathon Project. CSSM was proud to donate $520 as the proceeds of this event.
Posted February 17th
Physiotherapists have been trained to treat a variety of conditions. We are commonly known for our expertise in treating musculoskeletal conditions and sports injuries, however we also work in conjunction with other medical professionals to help manage various neurological, cardiovascular and genetic disorders.
Parkinsons Disease Boxing legend Muhammad Ali was perhaps the most well known Parkinsons Disease (PD) patient, but approximately 70,000 Australians are living with Parkinsons (Parkinson’s Australia, 2015). Parkinsonism is characterised by a disorder of movement consisting of tremor, rigidity or increased stiffness in joints, slowness of movement, slowness in initiating movement and freezing while moving (Carr and Shepherd, 2010). The role of physiotherapy in the early stages of PD is promoting physical activity as a means of maintaining an active lifestyle, a flexible neuromusculoskeletal system, cardiorespiratory fitness, muscle strength and balance. In the middle stage of the disease, cueing and cognitive strategies are of greatest importance for optimising the performance of everyday tasks. The appropriate prescription of gait aids is also necessary when moving from the middle to later stages of the disease (Carr and Shepherd, 2010).
Walking The benefits of walking practice have been well established for people with PD (Carr and Shepherd, 2010). The aim of walking practice is to increase the stride length in order to increase overall walking speed, as opposed to increasing the cadence (amount of steps). In the early to middle stages of PD, moderate to high intensity walking may also have positive effects on maintaining muscle length and cardiovascular fitness. Given that in PD walking speed and stride length is most greatly affected under more complex walking conditions, incorporating backwards walking, dual tasking and negotiating obstacles is recommended.
Treadmill walking has been found to have an immediate effect of promoting a walking consistency significantly greater than that for normal overground walking (Frenkel-Toledo et al 2005; Bello et al 2008). Upon the completion of a treadmill-walking programme, several studies have found people with PD have gained the ability to walk faster and further (Miyai et al 2000, 2002; Cakit et al 2007).
Balance Training to improve balance involves methods that safely challenge a persons ability to make postural adjustments. Since impairment of reactive postural adjustments is a problem for people with PD, specific training is recommended in order to decrease the occurrence of falls. This type of training is however difficult to do at home without the supervision of physiotherapists due to safety concerns.:paragraph!Standing up and sitting down People with PD are slow to stand up from sitting. Physiotherapists help people with PD use cognitive strategies and cues to train a more effective motor pattern. Improvements in time to stand up, peak horizontal and vertical speeds have been found in PD patients who participate in motor skill therapy with cueing (Mak & Hui-Chan 2008).
http://www.parkinsons.org.au/what-is-parkinsons Bello, O., Sanchez, J. A., & Fernandez‐del‐Olmo, M. (2008). Treadmill walking in Parkinsons disease patients: adaptation and generalization effect. Movement Disorders, 23(9), 1243-1249. Carr, J. H. (2010). Neurological Rehabilitation, Optimizing motor performance. Elsevier India. Cakit, B. D., Saracoglu, M., Genc, H., Erdem, H. R., & Inan, L. (2007). The effects of incremental speed-dependent treadmill training on postural instability and fear of falling in Parkinsons disease. Clinical Rehabilitation, 21(8), 698-705. Frenkel‐Toledo, S., Giladi, N., Peretz, C., Herman, T., Gruendlinger, L., & Hausdorff, J. M. (2005). Treadmill walking as an external pacemaker to improve gait rhythm and stability in Parkinsons disease. Movement Disorders, 20(9), 1109-1114. Mak, M. K., & Hui‐Chan, C. W. (2008). Cued task‐specific training is better than exercise in improving sit‐to‐stand in patients with Parkinsons disease: A randomized controlled trial. Movement Disorders, 23(4), 501-509. Miyai, I., Fujimoto, Y., Ueda, Y., Yamamoto, H., Nozaki, S., Saito, T., & Kang, J. (2000). Treadmill training with body weight support: its effect on Parkinsons disease. Archives of physical medicine and rehabilitation, 81(7), 849-852. Miyai, I., Fujimoto, Y., Yamamoto, H., Ueda, Y., Saito, T., Nozaki, S., & Kang, J. (2002). Long-term effect of body weight–supported treadmill training in Parkinsons disease: A randomized controlled trial. Archives of physical medicine and rehabilitation, 83(10), 1370-1373.
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.
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.
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 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?
What are the risk factors?
What should I do if I think my child has patella tendinopathy?
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.
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.